1 University of Pennsylvania School of Medicine, Department of Psychiatry, Treatment Research Center, 3900 Chestnut Street, Philadelphia, Pennsylvania 19104.2 Veterans Affairs Medical Center Philadelphia, Pennsylvania.3 Statistics Department, Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania.
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Recent papers have reported good results for several relatively intensive and costly psychosocial treatments for cocaine dependence (Alterman et al., 1994; Carroll et al., 1993; Higgins et al., 1993). It would be important to determine to what extent less costly psychosocial treatments might be effective, recognizing that earlier studies have reported limited success for low intensity treatments for cocaine dependence, i.e., 4 or fewer hours weekly (Higgins et al., 1993; Kang et al., 1991). We compared a 12-hour per week day hospital program (DHP12), which was a scaled-down version of a 27-hour per week day hospital program previously shown to be effective (Alterman et al., 1994), with a further scaled down 6-hour per week outpatient program (OP6). Both programs were administered at the same site. The DHP12 was evaluated from July 1992 to December 1993, and the OP6 was evaluated from December 1992 to December 1993.MethodsSubjects. The research subjects were 50 cocaine-dependent male veterans in the Philadelphia Veterans Affairs Medical Center's Addiction Recovery Program. Thirty subjects were treated in the DHP12 and 20 were treated in the OP6. A cocaine dependence diagnosis was made by a unit psychiatrist using DSM-III-R criteria. Patients experiencing severe psychiatric or medical problems were excluded from the study. Thirty-nine patients treated in the DHP12 who concurrently participated in a study of the drug ritanserin were excluded from the analysis based on possible effects that could have resulted from such participation (although analyses that included these patients resulted in similar outcomes). Full informed consent procedures were followed.Treatments. Before entry into either program, patients spent 1 to 2 weeks in an orientation program consisting of 1 hour of group treatment twice weekly. The primary treatments lasted 4 weeks and comprised: group and educational therapy, individual counseling/case management, availability of psychiatric and medical services, and required attendance in community self-help groups (Alterman et al., 1994).The DHP12 included 7 hours of group treatment over 5 weekdays, 3 hours of educational therapy, and 2 hours of counseling/case management. The OP6 included 4 hours of group treatment over 3 weekdays (Monday, Wednesday, and Friday), 1 hour of educational therapy, and 1 hour of counseling/case management. Both programs treated cocaine- and alcohol-dependent patients together. Both were directed by a senior psychiatrist and staffed by counselors/social workers. Supervised urine samples were taken twice weekly and random breath monitoring was implemented.Treatment completion required regular attendance and participation, clean urine samples for the past 2 weeks, and self-help group attendance. Repeated noncompliance was ground for suspension.Research assessments. The Addiction Severity Index (ASI; McLellan et al., 1985) was administered by a research technician prior to treatment entry. Attendance and urine data were derived from program records. A follow-up ASI and a urine sample were obtained 3 months after treatment entry. Subjects were compensated $10 for the follow-up ASI.ResultsBaseline comparisons. Although group assignment was not random, no significant baseline group differences in background or problem levels were revealed using the Wilcoxon rank-sum test (Hollander and Wolfe, 1973; Table 1). The subjects were primarily urban, lower socioeconomic (28% working; $207 monthly income), African American (92%) male veterans (100%). The average age was 39 years.Treatment attendance/completion. No significant differences (t =.59, df = 48, NS) were found in the duration of treatment for the DHP12 (22.50 calendar days; SD = 9.7) and the OP6 (24.35 calendar days; SD = 12.5) groups.