Combining bupropion with behavioral therapy that reinforces a drug-free
lifestyle may significantly reduce cocaine use in those in a
methadone-maintenance program, according to Yale University researchers.
The combination of treatments worked better than either alone, according to
findings published in the February Archives of General
Researchers recruited 106 people who met DSM criteria for opiate
and cocaine dependence through ads in a New Haven, Conn., community paper and
assessed them from September 2001 to November 2003.
The article noted that combined opioid and cocaine use is not uncommon and
that some studies have even shown that cocaine use increases in some people
who begin receiving methadone for the treatment of opiate addiction.
Study subjects were randomized to receive one of four treatments for 25
weeks. A nurse administered methadone to each of the participants for the
duration of the study. An initial dose of 30 mg was increased to a target dose
of 60 mg by the end of the first week of the study.
The first group received "contingency management" and
bupropion, and the second received contingency management and placebo.
Those randomized to contingency management received vouchers for submitting
cocaine- and opiate-free urine samples three times a week. For example, the
vouchers could be exchanged for a gift card to Wal-Mart and clothes or be used
toward a down payment on a car or a rent payment.
Each time subjects submitted a clean urine sample, they received a $3
voucher. This amount increased by $1 for each subsequent clean urine sample to
a maximum of $15 per sample. Neither of the latter two groups received the
In addition, those in the contingency management groups also received
vouchers for completing steps that were meant to help them remain drug free,
such as attending meetings of 12-step programs or working toward the
completion of a General Educational Development equivalency exam.
The other subjects were randomized to either the third or fourth group. The
former received vouchers with an increasing dollar amount for each urine
sample submitted, no matter what the results, plus a placebo pill, while those
in the latter group received vouchers under the same conditions, along with
The two groups assigned to receive bupropion took an initial dose of 75 mg
a day, with the dose increased to the target dose of 300 mg a day by the end
of the second week.
James Poling, Ph.D., the study's lead investigator, found that in the group
assigned to contingency management plus bupropion, the proportion of
cocaine-positive urine samples decreased significantly between the third and
15th week of the study (p<.001) and remained low for the remainder of the
In contrast, the groups that received vouchers and bupropion or vouchers
and placebo showed no significant reduction in cocaine use.
Poling, an assistant professor of psychiatry at Yale, told Psychiatric
News that because "there is currently no effective medication for
the treatment of cocaine abuse," it is excellent news that when combined
with contingency management, bupropion helps to reduce cocaine use.
Thomas Kosten, M.D., who obtained a grant from the National Institute on
Drug Abuse to conduct the study, explained why bupropion and contingency
management may work so well together.
Kosten is a professor of psychiatry and medicine at Yale and deputy chief
of psychiatry at the VA Connecticut Healthcare System.
Chronic cocaine use disrupts a person's ability to experience the pleasure
he or she would normally experience upon redeeming the reward vouchers, he
explained, because repeated cocaine use leads to a marked reduction in
dopamine receptors. "The neurobiology of this reduction in pleasure...
occurs through an abnormally low level of stimulation of the dopamine
Bupropion combined with this behavioral therapy "were synergistic due
to the ability of bupropion to help subjects experience the pleasure of
successful and rewarded drug abstinence," he said.
In acknowledging that drug-treatment programs in many community settings
don't have the money to implement contingency management rewards on the scale
of this study, Poling mentioned research by Nancy Petry, Ph.D., of the
University of Connecticut Health Center, who has found that low-cost
contingency management can also be effective in reducing drug addiction.
Poling said that future research should explore the issue of whether
bupropion and contingency management can successfully reduce cocaine use
beyond the 25-week study period and whether contingency management can be
paired with another behavioral intervention, such as cognitive-behavioral
therapy, for lasting effects.
An abstract of "Six-Month Trial of Bupropion With Contingency
Management With Cocaine Dependence in a Methadone-Maintained Population"
is posted at<http://archpsyc.ama-assn.org/cgi/content/abstract/63/2/219>.▪
Arch Gen Psychiatry