Combined Pharmacotherapies and Behavioral Interventions for Alcohol Dependence (The COMBINE Study): Examination of Posttreatment Drinking Outcomes
ABSTRACT The aim of this study was to examine the efficacy of pharmacological and behavioral interventions across 1 year posttreatment in the COMBINE (Combining Medications and Behavioral Interventions) Study.
Alcohol-dependent individuals (N = 1,383; 428 women) recruited at 11 outpatient academic alcoholism-treatment clinics across the United States participated in a randomized, double-blind, placebo-controlled trial. They received 16 weeks of naltrexone (Revia) or acamprosate (Campral) or both medications and/or placebos in combination with medical management (MM), with or without combined behavioral intervention (CBI); one group received CBI without pills or MM. Drinking behavior and clinical status were assessed at the end of treatment (Week 16) and at Weeks 26, 52, and 68.
Prior treatment with active naltrexone, without active acamprosate or CBI or with active acamprosate plus CBI, and CBI with double placebo resulted in a significantly higher percentage of days abstinent than double placebos with no CBI (p < .05). Having received CBI was associated with positive clinical response posttreatment, compared with not having received CBI. Prior treatment with naltrexone increased the time to the first heavy-drinking day posttreatment (p = .03). No differences were found between patients who had received CBI without MM or pills and those having received MM and double placebo with or without CBI. No significant main effects for acamprosate were found on any of the outcome measures.
Previous treatment with MM and either CBI or naltrexone, or both, but not acamprosate, was associated with sustained efficacy beyond discontinuation. Reasons for the maintained treatment gains with naltrexone and/or CBI and potential methods to extend them are discussed.
- SourceAvailable from: David J Nutt
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- "Early studies of naltrexone suggest its beneficial effects did not persist for 14 or 16 weeks after stopping (Anton et al., 2001; O'Malley et al., 1996) (Ib). However, more recent evidence from the COMBINE study reported continued benefit persisting for up to a year (Donovan et al., 2008) (Ib). "
ABSTRACT: The British Association for Psychopharmacology guidelines for the treatment of substance abuse, harmful use, addiction and comorbidity with psychiatric disorders primarily focus on their pharmacological management. They are based explicitly on the available evidence and presented as recommendations to aid clinical decision making for practitioners alongside a detailed review of the evidence. A consensus meeting, involving experts in the treatment of these disorders, reviewed key areas and considered the strength of the evidence and clinical implications. The guidelines were drawn up after feedback from participants. The guidelines primarily cover the pharmacological management of withdrawal, short- and long-term substitution, maintenance of abstinence and prevention of complications, where appropriate, for substance abuse or harmful use or addiction as well management in pregnancy, comorbidity with psychiatric disorders and in younger and older people.Journal of Psychopharmacology 05/2012; 26(7):899-952. DOI:10.1177/0269881112444324 · 3.59 Impact Factor
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- "He was also concerned about over-reliance on pharmacotherapy, noting that behavioral relapse processes require behavioral intervention to produce enduring change. It is of note in this regard that the COMBINE study, (Anton et al., 2006), while demonstrating the efficacy of naltrexone on reducing drinking during the active treatment phase, found an emergent effect for the Combined Behavioral Intervention (CBI), which incorporated a number of components from RP, during the follow-up period (Donovan et al., 2008); participants who had received CBI, regardless of their medication condition, were approximately 20% more likely to have had a good clinical outcome over the 1-year post-treatment period than individuals who did RELAPSE PREVENTION "
ABSTRACT: The term “relapse prevention” drew great criticism and was not generally accepted when it was initially introduced in the early 1980s. The idea of talking with clients about the possibility of relapse was an incredibly radical idea until the pioneering work on relapse prevention by Alan Marlatt and his colleagues challenged the prevailing disease conceptualization of addictions and provided a revolutionary perspective that focused on understanding the factors contributing to and maintaining addiction. Today, relapse prevention is both a manualized treatment and a general treatment strategy that has been implemented in addiction treatment centers around the world. The theory and practice of relapse prevention has emerged as one of the most prominent and pervasive approaches in the treatment of addictive behaviors and stands as one of Alan Marlatt's most notable and longest-lasting contributions to the field. This article provides a review of the development, adaptation, and dissemination of relapse prevention over the past 30 years and also provides some ideas for the future of relapse prevention in research and treatment.Addiction Research and Theory 04/2012; 20(3):204-217. DOI:10.3109/16066359.2011.647133 · 1.03 Impact Factor
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- "The primary limitation in determining clinical findings for treatment planning for comorbid patients from the alcohol literature is that the samples were selected to exclude comorbidity (Donovan et al., 2008). Notwithstanding this issue, Longabaugh and colleagues (2009) conducted one study of a psychotherapy, Broad Spectrum Treatment (BST) that was developed to include elements of CBT, MET and 12-Step Facilitation. "
ABSTRACT: To update clinicians on the latest in evidence-based treatments for substance use disorders (SUD) and non-substance use disorders among adults and suggest how these treatments can be combined into an evidence-based process that enhances treatment effectiveness in comorbid patients. Articles were extracted from Pubmed using the search terms "dual diagnosis," "comorbidity" and "co-occurring" and were reviewed for evidence of effectiveness for pharmacologic and psychotherapeutic treatments of comorbidity. Twenty-four research reviews and 43 research trials were reviewed. The preponderance of the evidence suggests that antidepressants prescribed to improve substance-related symptoms among patients with mood and anxiety disorders are either not highly effective or involve risk due to high side-effect profiles or toxicity. Second generation antipsychotics are more effective for treatment of schizophrenia and comorbid substance abuse and current evidence suggests clozapine, olanzapine and risperidone are among the best. Clozapine appears to be the most effective of the antipsychotics for reducing alcohol, cocaine and cannabis abuse among patients with schizophrenia. Motivational interviewing has robust support as a highly effective psychotherapy for establishing a therapeutic alliance. This finding is critical since retention in treatment is essential for maintaining effectiveness. Highly structured therapy programs that integrate intensive outpatient treatments, case management services and behavioral therapies such as Contingency Management (CM) are most effective for treatment of severe comorbid conditions. Creative combinations of psychotherapies, behavioral and pharmacological interventions offer the most effective treatment for comorbidity. Intensity of treatment must be increased for severe comorbid conditions such as the schizophrenia/cannabis dependence comorbidity due to the limitations of pharmacological treatments.Addictive behaviors 01/2012; 37(1):11-24. DOI:10.1016/j.addbeh.2011.09.010 · 2.76 Impact Factor