Cocaine-Related Disorders Clinical Trial
Official title:
Treatment of Heroin and Cocaine With Methadone Maintenance and Contingency Management
Background:
- The treatment of addiction often hinges on preventing relapse into drug-using behaviors,
which occurs at high rates even after prolonged abstinence. Some methadone patients continue
to abuse cocaine and heroin during treatment, even with extensive psychosocial services. More
research is needed to look at the results from earlier studies of continued drug use during
methadone treatment, focusing on the results of fixed vs. flexible doses of methadone to
reduce the likelihood of continued drug use and the role of monetary vouchers as an incentive
to continue abstinence from illicit substances.
Objectives:
- To determine if the combination of flexible methadone dosing and voucher-based contingency
management can improve rates of abstinence from heroin and cocaine.
Eligibility:
- Individuals between 18 and 65 years of age or older who are dependent on opioids (cocaine
and/or heroin).
Design:
- The study will last 40 weeks. After the initial screening, participants will receive
daily methadone and weekly drug counseling sessions that will continue throughout the
study.
- After 6 weeks of methadone treatment, participants who continue to use heroin and
cocaine will be randomized to one of four groups for 16 weeks of study. Each group will
receive a flexible or fixed dose of methadone, and one of two contingency management
conditions.
- Flexible-dose participants will receive individualized dose increases, based on drug use
and withdrawal. Fixed-dose participants will be set at a specific dose of methadone that
will not be changed.
- The two contingency management conditions will be monetary vouchers given for regular
cocaine-negative urine samples, or vouchers independent of urine cocaine screen results.
- After the study phase, participants will have 10 weeks of standard individual counseling
and stable doses of methadone. Urine samples will continue to be collected, but no
vouchers will be given.
- At the end of the study, participants will have the choice of transferring to a
community clinic or undergoing a 10-week taper from methadone.
Scientific goals. The primary goal is to determine if simultaneous abstinence from heroin and
cocaine can be elicited by combining two approaches: flexible methadone dosing and
voucher-based CM. Secondary goals include: 1) comparing saliva and plasma levels of
methadone, cortisol, and prolactin as predictors of treatment outcome; and 2) evaluating the
impact of methadone maintenance on renal function, lipid profile, and cardiac function.
Methods. During an initial 6-week baseline phase, cocaine-abusing opioid-dependent outpatient
participants (300 enrolled; 180 evaluable) will be stabilized on methadone 70 mg/day. At the
end of baseline, participants who continue to use heroin and cocaine will be randomized to
one of two dosing regimens and one of two CM conditions. In the flexible-dose regimen,
participants will receive individualized dose increases (15 mg/day) to a maximum of 190 mg
/day, based on heroin use and withdrawal. In the fixed-dose regimen, participants methadone
dose will be increased to 100 mg/day and remain fixed there. Dose-group assignment will be
double-blind: investigators will determine participants individualized dose increases, but
only the pharmacists will know which participants actually receive them. The two CM
conditions will be: vouchers contingent on cocaine-negative urine specimens, or noncontingent
vouchers (i.e., vouchers independent of urine cocaine screen results). The main outcome
measure will be the percentage of urines simultaneously negative for both cocaine and illicit
opiates during treatment. For the concurrently run pharmacokinetic-pharmacodynamic portion,
saliva and blood samples will be taken at regular intervals to determine levels of methadone,
cortisol, and prolactin as predictors of treatment outcome. For the concurrently run
medical-outcomes portion, urine (renal function), blood (lipid profile), and ECGs (cardiac
function),will be obtained at set intervals.
Hypothesis. Flexible methadone dosing and voucher-based CM will be safe and result in greater
simultaneous abstinence from heroin and cocaine, higher treatment retention, and higher
health-related QOL when compared to fixed methadone dosing and the absence of CM.
Benefits. Participants will receive methadone, counseling, and some medical care at no
charge. The methadone and voucher interventions are likely to reduce participants' use of
heroin and cocaine. Counseling will include management of HIV risk behaviors. The study
incorporates participant safety monitoring and will provide information relevant to improving
the health and safety of community methadone-maintenance patients. The
pharmacokinetic-pharmacodynamic part of the study does not benefit participants directly, but
may lead to the development of more useful and less invasive drug-monitoring methods.
Risks. Participants may experience side effects from methadone, discomfort during methadone
withdrawal, and discomfort (or, rarely syncope) from blood draws.
;
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