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Computer-Assisted Delivery of Cognitive-Behavioral Therapy: Efficacy and Durability of CBT4CBT Among Cocaine-Dependent Individuals Maintained on Methadone
Kathleen M. Carroll, Ph.D.; Brian D. Kiluk, Ph.D.; Charla Nich, M.S.; Melissa A. Gordon, M.A.; Galina A. Portnoy, M.S.; Daniel R. Marino, B.A; Samuel A. Ball, Ph.D.
Am J Psychiatry 2014;171:436-444. doi:10.1176/appi.ajp.2013.13070987
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Supported by National Institute on Drug Abuse grants R37-DA 015969 and P50-DA09241.

Dr. Carroll is a consultant to CBT4CBT LLC, which makes CBT4CBT available to qualified clinical providers and organizations on a commercial basis. Dr. Carroll works with Yale University to manage any potential conflicts of interest. The other authors report no financial relationships with commercial interests.

Clinicaltrials.gov ID number NCT00350610.

From the Department of Psychiatry, Yale University School of Medicine, New Haven, Conn.

Address correspondence to Dr. Carroll (kathleen.carroll@yale.edu).

Copyright © 2014 by the American Psychiatric Association

Received July 27, 2013; Revised October 07, 2013; November 12, 2013; Accepted November 25, 2013.

Abstract

Objective  A previous pilot trial evaluating computer-based training for cognitive-behavioral therapy (CBT4CBT) in 77 heterogeneous substance users (alcohol, marijuana, cocaine, and opioids) demonstrated preliminary support for its efficacy in the context of a community-based outpatient clinic. The authors conducted a more definitive trial in a larger, more homogeneous sample.

Method  In this randomized clinical trial, 101 cocaine-dependent individuals maintained on methadone were randomly assigned to standard methadone maintenance or methadone maintenance with weekly access to CBT4CBT, with seven modules delivered within an 8-week trial.

Results  Treatment retention and data availability were high and comparable across the treatment conditions. Participants assigned to the CBT4CBT condition were significantly more likely to attain 3 or more consecutive weeks of abstinence from cocaine (36% compared with 17%; p<0.05, odds ratio=0.36). The group assigned to CBT4CBT also had better outcomes on most dimensions, including urine specimens negative for all drugs, but these reached statistical significance only for individuals completing the 8-week trial (N=69). Follow-up data collected 6 months after treatment termination were available for 93% of the randomized sample; these data indicate continued improvement for those assigned to the CBT4CBT group, replicating previous findings regarding its durability.

Conclusions  This trial replicates earlier findings indicating that CBT4CBT is an effective adjunct to addiction treatment with durable effects. CBT4CBT is an easily disseminable strategy for broadening the availability of CBT, even in challenging populations such as cocaine-dependent individuals enrolled in methadone maintenance programs.

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FIGURE 1. CONSORT Diagram of Participants in a Study of Computer-Assisted Delivery of Cognitive-Behavioral Therapy

a One additional individual did not proceed to random treatment assignment as a result of uncertain eligibility.

FIGURE 2. Frequency of Cocaine Use by Months Within Treatment (Months 0–2) and Follow-Up (Months 3–8)a

a Estimates from random regression analyses by treatment assignment.

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TABLE 1.Baseline Variables by Treatment Assignment in a Study of Computer-Assisted Delivery of Cognitive-Behavioral Therapy (N=101)
Table Footer Note

a All statistical tests are two tailed.

Table Footer Note

b CBT4CBT indicates access to the computer program in addition to standard methadone maintenance and counseling.

Table Footer Note

c Treatment as usual indicates standard methadone maintenance and counseling.

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d Diagnosis from Structured Clinical Interview for DSM-IV interviews.

Table Footer Note

e Addiction Severity Index composite score. Scores range from 0 to 1, with higher scores indicating greater severity of problems.

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TABLE 2.Treatment Process Variables and Serious Adverse Events By Treatment Assignment
Table Footer Note

a Serious adverse events included medical hospitalizations (asthma or heart conditions) or brief inpatient substance use detoxification or stabilization.

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TABLE 3.Primary Outcomes: Cocaine and Other Drug Use Within Treatment by Random Treatment Assignment
Table Footer Note

a Indicates effect size expressed as Cohen’s d for means and odds ratio for proportions. (Proportion of sample attaining 3 or more weeks of abstinence).

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b The intention-to-treat sample had 47 in the CBT4CBT group and 54 in the treatment-as-usual group.

Table Footer Note

c The individuals who completed treatment had 34 in the CBT4CBT group and 35 in the treatment-as-usual group.

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