Evaluating the efficacy of contingency management in a standard open treatment facility for individuals with crack dependence disorder

Abstract

Crack addiction has became a sever health problem in Brazil. Data from the second national epidemiologic survey points that 0.7% of all Brazilians have at least once smoked crack and that 0.2% are currently abusing from crack use. Although numbers related to crack use may look small, it is, for all illicit drugs, the substance which demands for treatment has had the highest growth in the last 10 years. Today, crack addiction is the primary cause for inpatient treatment (voluntary or not) for all illicit substances (losing only for alcohol addiction). When compared to cocaine, crack users develop much faster diagnoses for crack dependence (mean of 5 month after first use), show a more compulsive pattern of use, have higher probability of living or have lived in the streets, and of engaging in illegal activities. Consequently to this, mortality of crack addicts is 7 times higher than for the rest of the population. Despite all efforts being made for the development of effective pharmacological treatments for stimulant addiction (crack included), up to today, there is no robust evidence of efficacy of any pharmacological treatment. For that reason, the use of evidence based psychosocial interventions is so important for treating this population. Although today open treatment facilities in Brazil are more and more starting to use evidence based interventions such as motivational interviewing, cognitive behavior therapy, relapse prevention and coping skills, such treatments present very modest results when treating crack addiction. The biggest difficulties encountered when treating this population are maintaining patients in treatment and achieving continued abstinence from crack. A psychosocial treatment based in behavioral principals' named Contingency Management (CM) is widely applied in the USA and some countries in Europe. In resume, CM interventions deliver systematic rewards (like vouchers with monetary value) contingent to specific target behaviors (such as objective verification of abstinence). These specific behaviors are most often incompatible with drug like behaviors (being abstinent is incompatible with using crack). Hence, by reinforcing one healthy behavior, there is also a reduction in the probability of emission of drug use behaviors. Recent meta-analyses and review studies present robust evidence that, when applied alone or in adjunction with other psychosocial and pharmacological treatment, CM is the most effective treatment for what regards, treatment retention and promoting continued abstinence. CM studies present rigorous methodology, and have been shown effective in the treatment for a great number of substances (crack included) in different populations. Although CM is highly applied in the USA, up to today there is no study on CM in the Brazilian population with substance use disorders. Also, professionals in the area are not familiar with this intervention, and hence, CM is not yet applied in Brazilian treatment facilities. The objective of our study, is to develop the first randomized controlled trial of CM for substance use disorders in the Brazilian population. In this case, specifically targeting crack addiction. If the results encountered in this study resemble those achieved by studies present in the literature, it will bring immense contribution for what regards effective treatment for crack addiction for the Brazilian population as well as disseminating knowledge on CM for professionals of these area. (AU)