This article describes the treatment of depression in low-

Context:No effective pharmacotherapies exist for cocaine dependence, although contingency management (CM) has demonstrated efficacy.Objective: To compare the efficacy of bupropion hydrochloride and CM for reducing cocaine use in methadone hydrochloride-maintained individuals.Design: This 25-week, placebo-controlled, doubleblind trial randomly assigned participants to 1 of 4 treatment conditions: CM and placebo (CMP), CM and 300 mg/d of bupropion hydrochloride (CMB), voucher control and placebo (VCP), or voucher control and bupropion (VCB).Setting: Outpatient clinic at the Veterans Affairs Connecticut Healthcare System. Participants: A total of 106 opiate-dependent, cocaineabusing individuals.Interventions: All study participants received methadone hydrochloride (range, 60-120 mg). Participants receiving bupropion hydrochloride were given 300 mg/d beginning at week 3. In the CM conditions, each urine sample negative for both opioids and cocaine resulted in a monetary-based voucher that increased for consecutively drug-free urine samples during weeks 1 to 13. Completion of abstinence-related activities also resulted in a voucher. During weeks 14 to 25, only completion of activities was reinforced in the CM group, regardless of sample results. The voucher control groups received vouchers for submitting urine samples, regardless of results, throughout the study.Main Outcome Measure: Thrice-weekly urine toxicologic test results for cocaine and heroin.Results: Groups did not differ in baseline characteristics or retention rates. Opiate use decreased significantly, with all treatment groups attaining equivalent amounts of opiate use at the end of the study. In the CMB group, the proportion of cocaine-positive samples significantly decreased during weeks 3 to 13 (PϽ.001) relative to week 3 and remained low during weeks 14 to 25. In the CMP group, cocaine use significantly increased during weeks 3 to 13 (PϽ.001) relative to week 3, but then cocaine use significantly decreased relative to the initial slope during weeks 14 to 25 (PϽ.001). In contrast, by treatment end, the VCB and VCP groups showed no significant improvement in cocaine use. Conclusion:These findings suggest that combining CM with bupropion for the treatment of cocaine addiction may significantly improve outcomes relative to bupropion alone.

Homeless persons with dual diagnoses had poorer adjustment on most baseline measures and experienced significantly less clinical improvement than those without dual diagnoses. However, those with dual diagnoses who received extensive substance abuse treatment showed improvement similar to those without at 12 months.

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