Full Text DA-94-002

BEHAVIORAL THERAPIES DEVELOPMENT PROGRAM

NIH GUIDE, Volume 22, Number 41, November 12, 1993

RFA:  DA-94-002

P.T. 34

Keywords: 
  Drugs/Drug Abuse 
  Behavioral/Social Studies/Service 


National Institute on Drug Abuse

Letter of Intent Receipt Date:  February 11, 1994
Application Receipt Date:  March 11, 1994

PURPOSE

Behavioral therapies are frequently the only treatments available to
drug-dependent individuals.  (The term, "behavioral therapies," is
used here in a broad sense and includes various forms of
psychotherapy, behavior therapy, skills training, counseling, and
other rehabilitative therapies.)  Even where medications are
available, behavioral therapies are an integral component of
treatment.  Considerable progress has been made over the past decade
in developing effective behavioral therapies for drug abuse and
dependence.  These recent research advances suggest that the field is
ready to move ahead with a major initiative in this area.
Recognizing the importance of behavioral therapies for drug abuse and
dependence, the National Institute on Drug Abuse (NIDA) is launching
a Behavioral Therapies Development Program.  It is intended to:  (1)
complement and dramatically expand work underway within the Clinical
and Experimental Therapeutics Research Branch, Division of Clinical
Research, NIDA and (2) parallel NIDA's Medications Development
Program.  The release of this Request for Applications (RFA)
coincides with the commencement of NIDA's Behavioral Therapies
Development Program and represents NIDA's ongoing commitment to
support behavioral therapy drug abuse and dependence research.  It is
NIDA's intention to support scientifically sound and clinically
relevant behavioral therapy research that will potentially have a
meaningful impact on the efficacy of drug abuse/dependence treatment.
Through the Behavioral Therapies Development Program, support may be
sought to identify, evaluate, and standardize behavioral therapies
for the treatment of drug abuse and dependence.  Ultimately,
therapies found to be efficacious through rigorous testing, will be
disseminated to clinicians.  Although substantial work has already
been done, this initiative will target for funding, in a systematic
way, essential research on behavioral therapies for drug abuse and
dependence.  This will include, in particular, critical areas of
research that have been overlooked in the past.

The purpose of this RFA is to introduce a major research effort on
behavioral therapies for drug abuse and dependence.  Behavioral
therapy research has been conceptualized, for the purposes of this
initiative, to consist of three phases.  For the Behavioral Therapies
Development Program to succeed, it is essential that all three phases
of behavioral therapy research receive appropriate support.
Therefore, it is NIDA's intention to support:  (1) Phase I research
(including the development, refinement, and pilot efficacy testing of
behavioral interventions for drug dependence); (2) Phase II research
(efficacy testing and replication of promising piloted behavioral
therapies; and (3) Phase III research (studies to test the
generalizability and transferability of behavioral therapies proven
efficacious in Phase II studies).

HEALTHY PEOPLE 2000

The Public Health Service (PHS) is committed to achieving the health
promotion and disease prevention objectives of "Healthy People 2000,"
a PHS-led national activity for setting priority areas.  This RFA,
Behavioral Therapies Development Program for Drug Abuse and
Dependence, is related to the priority area of alcohol and other
drugs.  Potential applicants may obtain a copy of "Healthy People
2000" (Full Report:  Stock No. 017-001-00474-0 or Summary Report:
Stock No. 017-001-00473-1) through the Superintendent of Documents,
Government Printing Office, Washington, DC 20402-9325 (telephone
202-783-3238).

ELIGIBILITY REQUIREMENTS

Applications may be submitted by foreign and domestic, for-profit and
non-profit organization, public and private, such as universities,
colleges, hospitals, laboratories, units of State and local
governments, and eligible agencies of the Federal government.
Applications from minority individuals and women are encouraged.
Foreign institutions are not eligible for First Independent Research
Support and Transition (FIRST) (R29) Awards.

MECHANISM OF SUPPORT

Support mechanisms include:  Research projects grants (R01), small
grants (R03), and FIRST awards (R29).  Investigators may also respond
to this RFA under the Interactive Research Project Grant (IRPG)
mechanism.  Additional requirements for the IRPG mechanism are
described in PA-93-078.  Most investigator-initiated research is
supported by regular research grants.  Research grants are awarded to
institutions on behalf of Principal Investigators who have designed
and will direct a specific project or set of projects.

FUNDS AVAILABLE

It is anticipated that approximately $3 million will be available to
support the first year of the behavioral therapies research program.
Because the nature and scope of the research proposed in response to
this RFA may vary, the size of an award will also vary.  However, it
is anticipated that approximately eight new awards will be made under
this announcement.

RESEARCH OBJECTIVES

Background and Rationale

Recent results from research studies indicate great promise for the
efficacy of behavioral therapies for drug dependence.  For example,
Higgins and Budney (1993) reported using the community reinforcement
approach (Hunt and Azrin, 1973; Azrin, 1976) to treat
cocaine-dependent individuals.  Their results were extremely
encouraging, with a large number of subjects achieving initial
abstinence from cocaine.  Carroll et al. (1993) found evidence that
while a behavioral therapy (as compared to standard treatment without
the behavioral therapy) does not always increase an individual's
ability to maintain abstinence from drugs while the patient is in
treatment, behavioral interventions may, indeed, help patients
maintain the gains that they have made after they are out of
treatment.  Specifically, they found that whether cocaine abusers
were provided relapse prevention or clinical management, they all
improved during treatment.  However, at 6 and 12-month followup, only
those who had received the relapse prevention were able to maintain
the gains they made in treatment.

While considerable progress has been made, engagement and retention
in treatment and relapse following treatment remain concerns.  NIDA
is undertaking the Behavioral Therapies Development Program with the
goal of addressing these concerns and substantially improving the
efficacy of behavioral treatments for drug abuse.  NIDA's Behavioral
Therapies Development Program delineates three phases of behavioral
therapy research.  Phase I, the earliest phase of behavioral therapy
research, therapy development, is viewed as a multi-stage process.
It involves identifying promising clinical and research findings
relevant to drug abuse treatment, generating and formulating new
behavioral therapies, operationally defining the therapies in
manuals, and pilot testing and refining the therapies.  With the
Behavioral Therapies Development Program, support for Phase I
research is intended to continue and intensify.

Phase II research consists of small-scale efficacy testing of
promising therapies identified in Phase I, as well as studies
examining the efficacy of components of therapies.  Most of the
behavioral treatment research that NIDA has supported in the past has
been of this type.  Phase II also involves the replication, at other
sites, of efficacy studies with positive results.  Under the
Behavioral Therapies Development Program, Phase II clinical trials
and component analysis studies will be emphasized more strongly, as
is the case for replication studies.

Phase III entails the testing of therapies that have been shown to be
efficacious in more than one controlled Phase II clinical trial.
This involves establishing the generalizability and transferability
of these therapies, and determining their usefulness within
community-based treatment programs.

For drug abuse treatment to succeed, it is essential that all phases
of behavioral therapy research receive sufficient emphasis and
support.  Through the Behavioral Therapies Development Program, NIDA
will greatly increase its support of the early phases of behavioral
therapy development, small-scale controlled clinical trials of fully
developed therapies (including replications), and studies in
community-based treatment programs of the most promising therapies
identified in the Phase II clinical trials.  This RFA is intended to
introduce this initiative by encouraging research grant applications
in any one of the three phases of behavioral therapy research.

Specific Areas of Interest

Areas of interest include, but are not limited to, the following:

Phase I Research:  Investigators are encouraged to submit
applications to develop new or modify existing behavioral therapies
that:  (1) appear promising for the treatment of drug-dependent and
abusing individuals; and (2) have a convincing rationale or
theoretical basis.  Therapies of interest include but are not limited
to the following:

1.  Discrete therapy modules that address specific problems common
among drug-dependent individuals, and that can be implemented in
conjunction with other therapeutic services.  For example, an
investigator may wish to develop a four-session, highly focused,
job-seeking skills module that can be easily implemented by a wide
range of practitioners, to effectively increase appropriate
job-seeking behavior.  Other examples include, but are not limited
to, modules to engage ambivalent drug- dependent individuals in
treatment, to address "denial," or to increase assertiveness in
female drug addicts who feel pressured by others to use drugs.

2.  Therapies designed specifically to engage and retain individuals
in treatment.  An example could be a therapy that:  (1) is sensitive
to the motivational level of the client, (2) is specifically designed
to respond to the needs of the individual, whatever his or her
motivational level might be, and (3) actively works to increase an
individual's desire to remain in treatment.

3.  Therapies to impact specific client characteristics.  Such
therapies are based upon theories regarding measurable psychological,
behavioral, or interpersonal constructs.  Examples include therapies
to overcome cognitive deficits, family dysfunction, or social skill
deficiencies, where these constructs are hypothesized to be causally
related to drug abuse and where they may be quantified.
Investigators may propose the development of measures where relevant
to the development and assessment of the therapy.

4.  Therapies for abusers of specific drugs.  This may include, but
is not limited to, therapies to treat cocaine, heroin, benzodiazepine
dependence, or dependence upon several drugs.

5.  Therapies to treat comorbid populations.  This may include
therapies to treat drug abuse/dependence in individuals who have, for
example, psychotic, mood, anxiety, personality disorders, or one of
the disruptive behavior disorders of childhood and adolescence such
as an attention-deficit/hyperactivity, conduct, or oppositional
defiant disorder.  This may also include behavioral therapies aimed
at integrating drug dependence and mental health treatment approaches
in dually diagnosed populations, where the ultimate goal of the
therapy is to decrease drug use.

6.  Therapies for specific ethnic, racial, or cultural groups.  This
includes therapies that are culturally sensitive and address the
unique needs and perspectives of minorities or cultural groups.

7.  Therapies for women.  Such therapies may be aimed, for example,
at meeting the emotional and cognitive needs of drug-abusing pregnant
or parenting women, or of women who have or are experiencing
physical/sexual abuse.

8.  Therapies for adolescents.  Such therapies may be aimed, for
example, at addressing the problems associated with active drug abuse
or dependence on the part of the youth during the early, middle,
and/or late adolescent stages of development.

9.  Therapies for families.  Such therapies should address drug abuse
from the perspective of the whole family rather than from the
viewpoint of an individual family member.

10.  Therapies for use in community settings.  Therapies need to be
developed for use in outreach programs and other non-traditional
settings that access drug abusers who avoid the formal drug abuse
treatment system.

An application for a grant to develop a therapy should include an
explicit, logical, consistent, and coherent statement describing the
theoretical basis for that therapy, and the population for whom it is
intended.  A thorough literature review documenting relevant research
and clinical findings should also be included.  Although, of course,
a manual for a therapy will not exist prior to an application to
develop such a manual, the nature of the therapy to be developed
should be described in as much detail as possible in the application.
Components of the psychotherapy, behavior therapy, or drug counseling
approach to be developed should be operationally defined wherever
possible.

Applicants proposing client characteristic specific therapies, should
address the issue of whether theoretically based diagnostic systems
or client assessment scales tailored to their therapy need
development.  If one theorizes, for example, that certain heroin
addicts either began or maintained heroin use due to interpersonal
conflicts, and that the resolution of these conflicts will decrease
drug use, a measure of interpersonal conflicts should either exist,
or be developed with a therapy based upon treating these conflicts.
The development of a theoretically based therapy should include
measures of client attributes directly related to that therapy.
Where necessary, investigators may develop new or refine existing
client assessment scales to measure the impact of the proposed
theoretically-based therapy. Methods that will be used to develop
these instruments should be described in detail.  Close attention
should be paid to the psychometric characteristics of these measures
(i.e., validity, internal consistency, inter-rater and test-retest
reliability).

Applicants should also address the issue of how they intend to
measure what is actually occurring in the therapy they are proposing
to develop.  The credibility of any treatment research depends on the
ability to determine the extent to which that treatment was actually
administered, and administered correctly.  In the development of any
therapy, therefore, emphasis should be placed upon the development of
psychometrically sound therapist competence and adherence scales,
process measures, and instruments measuring the integrity and
fidelity of the therapy.  Applicants should describe the instruments
they intend to develop, and the methods that they will use to ensure
they are developing valid and reliable measures.

In the development of a new therapy for drug dependence, a broad
range of issues relevant to efficacy and safety must be addressed.
Pilot efficacy testing of newly developed/modified therapies,
therefore, should be considered an integral part of any therapy
development process.  The applicant should describe, in detail, the
nature of any pilot testing intended.  Any pilot testing proposed
should be based upon sound, scientific methods.

Phase II Research

Phase II research establishes the efficacy of therapies, and the
efficacious components of therapies.  In Phase II research control
and comparison groups are operationally defined, standardized, and
manualized.  However, early in Phase II, it may be appropriate to
compare a therapy with "treatment as usual."  Investigators should
have clearly delineated research questions, and should carefully
choose their control/comparison groups to answer those questions.  It
is appropriate, but not required, that investigators design studies
to answer not only if their therapy works, but why it works.
Specific areas of Phase II research include, but are not limited to:

1.  Comparative Behavioral Therapy Research.  Controlled clinical
trials that examine the relative efficacy of behavioral therapies and
attempt to determine which therapies are best for which individuals,
and under what conditions, are encouraged.  Studies that investigate
the relative efficacy of individual, group, or family psychotherapy;
behavior therapy; skills training; drug abuse counseling; or other
rehabilitative approaches in various special populations are also
encouraged.

Applicants proposing comparative behavioral therapy research studies
are encouraged to examine the interactions of relevant
therapist/patient characteristics with therapy type and to assess the
relative contribution of therapist, patient, and type of therapy to
outcome.  For example, contingency management has been shown to be
efficacious for some individuals, but not for others (Stitzer et al.,
1993). Investigators proposing a clinical trial using contingency
management in one group may wish, therefore, to design the study such
that they may determine the characteristics of patients for whom this
intervention is or is not helpful.  (This type of study may be done,
of course, within or outside the context of a comparative clinical
trial).  Another example of a study examining client characteristics
is a study which attempts to determine the relative efficacy of a
cognitive therapy in individuals with varying levels of cognitive
ability.

For these studies, it is imperative that investigators accurately
measure and control for the psychiatric diagnosis and problem
severity level of the patients.  It is also necessary that clear
definitions of outcome variables be specified, and that valid and
reliable measures of outcome be used.  It is important that
therapists/counselors providing the therapy be systematically
trained, that manuals be used to guide the therapies, that valid and
reliable therapist competence and adherence scales be used, and that
the treatment process be measured accurately. For all efficacy
studies, it is expected that adequate followup assessments be
planned.  It is also important that these studies use procedures and
methods that can be replicated.  It is strongly suggested that pilot
data showing that a counseling or psychotherapy strategy is promising
be provided when proposing comparative research involving this
therapy.  These pilot data should indicate that the utilization of
the therapy approach shows promise in its ability to produce a
decrease in drug use, dropout rate, or psychiatric symptoms.

2.  Research To Integrate Behavioral Therapies with
Pharmacotherapies. Where effective pharmacotherapies are available,
research projects that attempt to maximize the efficacy of that
pharmacotherapy through integration with behavioral therapy, or vice
versa, are encouraged.

3.  Component Analysis Research.  Knowing the effective components of
treatment can greatly aid in improving the quality of treatment.
Theoretically based research that attempts to determine the effective
components or combination of components in drug dependence
psychotherapies, behavior therapies, or counseling strategies is
encouraged.

4.  Replications.  Applications that propose to replicate a
behavioral therapy for drug abuse/dependence study that has positive
findings are strongly encouraged.  Applications that propose to
generalize the efficacy of a promising therapy in another population
are also encouraged. Where the investigator believes that significant
modification of the therapy is needed before it can be tested in
another population, investigators are referred to the section of this
RFA entitled, "Phase I Research."

It is recognized that for many research questions asked in the field
of psychotherapy, behavior therapy, and counseling, no perfect
research design may exist.  Where there is more than one way to
answer a proposed research question, investigators are urged to state
their theoretical, ethical, and practical reasons for choosing one
control group or one research design over another (see Borkovec,
1990, 1993).  Investigators are also encouraged to address the issues
of selection bias and attrition (Howard et al., 1990; Howard et al.,
1993), and any other pertinent methodological issues.

Phase III Research.  Where behavioral therapies have been shown to be
efficacious in a clinical trial, and where replication has borne out
the contention that the therapy is, indeed, efficacious,
investigators may propose to carry out a study to address the
therapy's transferability, generalizability to other populations, and
applicability in community-based drug abuse treatment programs.

It is incumbent upon the applicant proposing any Phase III research
to review the relevant literature on the behavioral therapy to be
researched, and to clearly delineate the reasons that it is ready for
a Phase III study.

An example of a Phase III study might involve an investigator using a
therapy that has been rigorously tested in a replicated controlled
clinical trial, packaging that therapy, including development of
training manuals and other training materials, to be used in a
community setting.  The investigator might then pilot the therapy in
the community clinic, refine the therapy package, and ultimately test
the usefulness of the packaged therapy in the community setting.

Applicants are expected to develop applications that are focused on
one phase; that is, investigators may choose to focus on either Phase
I, Phase II or Phase III research.  However, where it is justifiable,
investigators may develop proposals to include a research component
consistent with another phase (e.g., a Phase II research application
may include a small Phase I component).

If a subject is identified as being at risk for HIV acquisition
and/or transmission, HIV testing and counseling should be offered to
the subject in accordance with current guidelines.  Furthermore, in
high-risk populations, investigators are encouraged to assess the
effect of the new therapy on the acquisition/transmission of
associated infectious disease, including HIV.

STUDY POPULATIONS

SPECIAL INSTRUCTIONS TO APPLICANTS REGARDING IMPLEMENTATION OF NIH
POLICIES CONCERNING INCLUSION OF WOMEN AND MINORITIES IN CLINICAL
RESEARCH STUDY POPULATIONS

NIH policy is that applicants for NIH clinical research grants and
cooperative agreements will be required to include minorities and
women in study populations so that research findings can be of
benefit to all persons at risk of the disease, disorder or condition
under study; special emphasis should be placed on the need for
inclusion of minorities and women in studies of diseases, disorders
and conditions which disproportionately affect them.  This policy is
intended to apply to males and females of all ages.  If women or
minorities are excluded or inadequately represented in clinical
research, particularly in proposed population-based studies, a clear
compelling rationale should be provided.

The composition of the proposed study population must be described in
terms of gender and racial/ethnic group.  In addition, gender and
racial/ethnic issues should be addressed in developing a research
design and sample size appropriate for the scientific objectives of
the study.  This information should be included in the form PHS 398
in Sections 1-4 of the Research Plan AND summarized in Section 5,
Human Subjects.

Applicants are urged to assess carefully the feasibility of including
the broadest possible representation of minority groups.  However,
NIH recognizes that it may not be feasible or appropriate in all
research projects to include representation of the full array of
United States racial/ethnic minority populations (i.e., Native
Americans (including American Indians or Alaskan Natives),
Asian/Pacific Islanders, Blacks, Hispanics).

The rationale for studies on single minority population groups should
be provided.

For the purpose of this policy, clinical research includes human
biomedical and behavioral studies of etiology, epidemiology,
prevention (and preventive strategies), diagnosis, or treatment of
diseases, disorders or conditions, including but not limited to
clinical trials.

The usual NIH policies concerning research on human subjects also
apply.  Basic research or clinical studies in which human tissues
cannot be identified or linked to individuals are excluded.  However,
every effort should be made to include human tissues from women and
racial/ethnic minorities when it is important to apply the results of
the study broadly, and this should be addressed by applicants.

For foreign awards, the policy on inclusion of women applies fully;
since the definition of minority differs in other countries, the
applicant must discuss the relevance of research involving foreign
population groups to the United States' populations, including
minorities.

If the required information is not contained within the application,
the application will be returned.

Peer reviewers will address specifically whether the research plan in
the application conforms to these policies.  If the representation of
women or minorities in a study design is inadequate to answer the
scientific question(s) addressed AND the justification for the
selected study population is inadequate, it will be considered a
scientific weakness or deficiency in the study design and will be
reflected in assigning the priority score to the application.

All applications for clinical research submitted to NIH are required
to address these policies.  NIH funding components will not award
grants or cooperative agreements that do not comply with these
policies.

LETTER OF INTENT

Prospective applicants are asked to submit, by February 11, 1994, a
letter of intent that includes a descriptive title of the proposed
research, the name, address, and telephone number of the Principal
Investigator, the identities of other key personnel and participating
institutions, and the number and title of the RFA in response to
which the application may be submitted.

Although a letter of intent is not required, is not binding, and does
not enter into the review of subsequent applications, the information
that it contains allows NIDA staff to estimate the potential review
workload and to avoid conflict of interest in the review.

The letter of intent is to be sent to:

Director, Office of Extramural Program Review
National Institute on Drug Abuse
5600 Fishers Lane, Room 10-42
Rockville, MD  20857
Telephone:  (301) 443-2755

APPLICATION PROCEDURES

The research grant application form PHS 398 (rev. 9/91) is to be used
in applying for these grants.  These forms are available at most
institutional offices of sponsored research and may be obtained from
the Office of Grant Information, Division of Research Grants,
National Institutes of Health, Westwood Building, Room 240, Bethesda,
MD 20892, telephone 301/710-0267.

The RFA label in the PHS 398 (rev. 9/91) application form must be
affixed to the bottom of the original face page.  Failure to use the
RFA label and to follow instructions could result in delayed
processing of the application such that it may not reach the review
committee in time for review.  In addition, the RFA title and number
must be typed in Item 2a on the face page of the application form and
the YES box must be marked.

Applications for the FIRST Award (R29) must include at least three
sealed letters of reference attached to the face page of the original
application.  FIRST Award (R29) applications submitted without the
required number of reference letters will be considered incomplete
and will be returned without review.

Submit a signed, typewritten original of the application and three
signed photocopies in one package to:

Division of Research Grants
National Institutes of Health
Westwood Building, Room 240
Bethesda, MD  20892**

At the time of submission, two additional copies of the application
must also be sent to:

Director, Office of Extramural Program Review
National Institute on Drug Abuse
5600 Fishers Lane, Room 10-42
Rockville, MD  20857

Applications must be received by March 11, 1994, and will be reviewed
according to the following review schedule:

Application Receipt Date:  March 11, 1994
Initial Review:            June 1994
Advisory Council:          September 1994
Earliest Date of Award:    September 1994

Applications received after the above receipt date will be held for
the next regular receipt date and reviewed under standard
circumstances.  However, such applications may not be considered for
the Fiscal Year 1994 funding set aside under this RFA.

REVIEW CONSIDERATIONS

The Division of Research Grants, NIH, serves as a central point for
receipt of applications for most discretionary DHHS grant programs.
Applications received under this announcement will be assigned to an
initial review group (IRG) convened by the NIDA in accordance with
established PHS referral guidelines.  The IRGs, consisting primarily
of non-Federal scientific and technical experts, will review the
applications for scientific and technical merit in accordance with
the standard NIH peer review procedures.  Notification of the review
recommendations will be sent to the applicant after the initial
review.  Applications will receive a second-level review by the
National Advisory Drug Abuse Council, whose review may be based on
policy considerations as well as scientific merit.  Only applications
recommended for further consideration by the Council may be
considered for funding.

AWARD CRITERIA

The anticipated date of award is September 30, 1994.

Applications recommended for further consideration by an appropriate
Advisory Council will be considered for funding on the basis of
overall scientific and technical merit of the application as
determined by peer review, appropriateness of budget estimates,
program needs and balance, policy considerations, adequacy of
provisions for the protection of human subjects, and availability of
funds.

Upon completion of the project's period of award made under this RFA,
grantees may submit competitive renewal applications.

INQUIRIES

Written and telephone inquiries concerning this RFA are encouraged.
The opportunity to clarify any issues or questions from potential
applicants is welcome.

Direct inquiries regarding programmatic issues to:

Lisa Onken, Ph.D.
National Institute on Drug Abuse
5600 Fishers Lane, Room 10A-30
Rockville, MD  20857
Telephone:  (301) 443-0108

Direct inquiries regarding fiscal matters to:

Gary Fleming, J.D., M.A.
Chief, Grants Management Branch
National Institute on Drug Abuse
5600 Fishers Lane, Room 8A-54
Rockville, MD  20857
Telephone:  (301) 443-6710

AUTHORITY AND REGULATIONS

This program is described in the Catalog of Federal Domestic
Assistance No. 93.279.  Awards are made under authorization of the
Public Health Service Act, Section 301, and administered under PHS
policies and Federal Regulations at Title 42 CFR 52 "Grants for
Research Projects", Title 45 CFR Part 74 & 92, "Administration of
Grants" and 45 CFR Part 46, "Protection of Human Subjects".  Title 42
CFR Part 2, "Confidentiality of Alcohol and Drug Abuse Patient
Records" may also be applicable to these awards.  This program is not
subject to the intergovernmental review requirements of Executive
Order 12372 or Health Systems Agency review.

References

Azrin, N.  "Improvements in the community reinforcement approach to
alcoholism," Behavior Research and Therapy, 14: 339-348, 1976.

Borkovec, T.D.  "Control groups and comparison groups in
psychotherapy outcome research,"  In Onken, L. Simon and Blaine, J.D.
(Eds.)  Psychotherapy and counseling in the treatment of drug abuse,
NIDA Research Monograph #104, Department of Health and Human Services
Publication Number (ADM)90-1722, 1990.

Borkovec, T.D.  "Between-group therapy outcome research:  Design and
methodology,"  In Onken, L. Simon, Blaine, J.D., and Boren, J.J.
(Eds.) Behavioral Treatments for Drug Abuse and Dependence, NIDA
Research Monograph, Department of Health and Human Services, 1993.

Carroll, K.M., Rounsaville, B.J., Nich, C., Gordon, L.T., Wirtz,
P.W., and Gawin, F.H.  "One year follow-up of psychotherapy and
pharmacotherapy for cocaine dependence:  Delayed emergence of
psychotherapy effects."  Submitted for publication.

Higgins, S.T. and Budney, A.J.  "Treatment of cocaine dependence via
the principles of behavior analysis and behavioral pharmacology,"  In
Onken, L. Simon, Blaine, J.D., and Boren, J.J. (Eds.)  Behavioral
Treatments for Drug Abuse and Dependence, NIDA Research Monograph,
Department of Health and Human Services, 1993.

Howard, K.I., Cox, M., and Saunders, S.M.  "Attrition in substance
abuse comparative treatment research:  The illusion of
randomization,"  In Onken, L. Simon and Blaine, J.D. (Eds.)
Psychotherapy and counseling in the treatment of drug abuse, NIDA
Research Monograph #104, Department of Health and Human Services
Publication Number (ADM)90-1722, 1990.

Howard, K.I., Krause, M.S. and Lyons, J.  "When clinical trials fail:
A guide to disaggregation," In Onken, L. Simon, Blaine, J.D., and
Boren, J.J. (Eds.)  Behavioral Treatments for Drug Abuse and
Dependence, NIDA Research Monograph, Department of Health and Human
Services, 1993.

Hunt, G.M., and Azrin, N.  A community reinforcement approach to
alcoholism. Behavior Research and Therapy, 11: 91-104, 1973.

Stitzer, M.L., Iguchi, M.Y., Kidors, M., and Bigelow, G.E.
"Contingency management in methadone treatment:  The case for
positive incentives," In Onken, L. Simon, Blaine, J.D., and Boren,
J.J. (Eds.)  Behavioral Treatments for Drug Abuse and Dependence,
NIDA Research Monograph, Department of Health and Human Services,
1993.

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