Psychosocial Treatments for Cocaine Dependence Grace O’Leary Hennessy, MD, Victoria De Menil, BA, and Roger D. Weiss, MD*
Address *Alcohol and Drug Abuse Treatment Program, McLean Hospital, 115 Mill Street, Belmont, MA 02478, USA. E-mail:
[email protected] Current Psychiatry Reports 2003, 5:362–364 Current Science Inc. ISSN 1523-3812 Copyright © 2003 by Current Science Inc.
Psychosocial treatment remains the predominant modality of treatment for patients with cocaine dependence. This paper reviews several recent studies comparing different types of psychosocial treatments for this population. A number of forms of psychosocial treatment for cocaine dependence have shown promising results, as detailed in the study descriptions.
Introduction Because pharmacologic approaches for the treatment of cocaine dependence have generally been disappointing, psychosocial treatments have been the mainstay for the treatment of this population. In this paper, the authors review the results of recent controlled trials of psychosocial treatments for cocaine dependence.
Treatments The most ambitious controlled psychosocial treatment trial for cocaine dependence was the multisite National Institute on Drug Abuse Collaborative Cocaine Treatment Study (NCCTS) [1], which compared four treatment conditions across two modalities (group and individual therapie s) f or 4 8 7 pa t ie n ts w it h c oca i ne d epe n den c e. Participants were randomly assigned to one of four treatment conditions, all of which included group drug counseling (GDC). For most patients, GDC was paired with disease-model individual drug counseling (IDC) or one of two psychotherapies—cognitive therapy (CT) or psychodynamically oriented supportive expressive therapy (SE). One fourth of the patients received GDC alone. Individual treatment took place twice a week for 3 months, then weekly for 3 months. GDC met once a week for 6 months. The 6 months of active treatment were followed by a 3month “booster” phase with monthly meetings. Patients in each of the four treatment conditions reduced their mean cocaine use; the overall study sample
averaged 10 days of cocaine use in the month before intake, and only 3 days of use in month 6. The best outcomes were seen in the IDC plus GDC group; 40% of these patients used cocaine in month 6 compared with 50% to 58% in the other conditions. No significant difference was found among any of the other treatments. The NCCTS specified two matching hypotheses, namely that psychotherapy would be more effective for people with high levels of psychiatric comorbidity, and that cognitive therapy would fare best for patients with antisocial personality disorder; neither hypothesis was supported. The advantage of the IDC plus GDC group was found despite lower treatment attendance (a mean of 12 IDC sessions vs 16 sessions for all other conditions). One explanation for the success of IDC was its unambiguous focus on the importance of abstinence. Because the primary outcome measures were the number of days of cocaine use and the severity of drug problems (measured by the Addiction Severity Index [2] drug composite score), a treatment aimed directly at stopping drug use would be theoretically more effective in improving these outcomes. With that explanation, one may expect the psychotherapeutic groups to have demonstrated improvements in secondary outcomes, such as psychiatric symptoms, employment, medical, legal, family-social, or interpersonal problems. Another analysis of the NCCTS data [3], however, found no significant differences between treatment groups in these secondary outcomes. This finding failed to confirm not only the hypothesis that psychotherapy would be more effective at treating these associated problems, but also the hypothesis that IDC would have indirectly improved those problems more than other treatments by reducing drug use more successfully. Limitations to the generalizability of the NCCTS may help explain some of its findings. Because patients taking psychotropic medication were excluded from the study, the sample was relatively low in psychiatric severity. It is conceivable that psychotherapy would surpass IDC among a population with more severe psychiatric symptoms. In addition, a 2-week orientation procedure, consisting of assessments and two intake visits, eliminated half of the original sample, suggesting that the degree of cocaine dependence in the study sample may have been less severe compared with that of patients dependent on cocaine presenting for community-based substance abuse treatment.
Psychosocial Treatments for Cocaine Dependence • O’Leary Hennessy et al.
Coviello et al. [4•] more recently examined the role of treatment intensity for standard drug counseling delivered to individuals dependent on cocaine. Ninety-four predominantly African-American war veterans with cocaine dependence were randomized to receive 1 month of a 12-hour per week day hospital program or a 6-hour per week outpatient program. The cohorts received group therapy, individual counseling, and educational sessions; they were also required to attend 12-step self-help groups. The study found no significant differences between groups in any of the primary outcomes (abstinence during treatment, treatment completion, or Addiction Severity Index composite scores). The treatment groups had high abstinence rates, with 62% of the patients abstaining at 7 months of followup, despite an attrition rate of 60%. The authors concluded that 6 hours of weekly outpatient psychosocial treatment for African-American veterans with cocaine dependence was as successful as and more cost effective than 12 hours of the same weekly psychosocial treatment delivered in a day hospital program. Although these findings are promising, more studies with larger sample sizes and the inclusion of non-veterans, women, and individuals from other ethnic backgrounds will be needed to determine the generalizability of the findings. A popular technique for the treatment of other substance-dependent patients is motivational interviewing (MI), in which the therapist uses a nonconfrontational and supportive role to help ambivalent patients increase their readiness to consider change. In a pilot study [5] investigating the efficacy of a brief MI intervention administered during an outpatient cocaine detoxification program (DP) before entry into a subsequent treatment, 105 patients with cocaine dependence entering DP were randomized to receive two hour-long individual MI sessions (MI/DP group) or DP only (DP only group). Although MI/DP patients with lower initial motivation were more likely to complete the detoxification, the addition of MI to DP did not improve retention rates or enhance the achievement of initial abstinence from cocaine in the pilot study. MI did provide benefit to the individuals who completed DP and then participated in a 12-week, randomized clinical trial referred to as the relapse prevention (RP) program. The MI/DP group submitted a higher percentage of cocainenegative urine samples at the initial RP session than the DP-only group (88% vs 62%, respectively). Additionally, the percentage of cocaine-positive urine samples over the RP treatment period was significantly lower for the MI/DP group (18%) than the DP-only group (36%). The authors reported that the generalizability of these results is limited by many factors including the small sample size and the lack of an attention-control group. MI for the treatment of cocaine dependence will require further research to determine its role in the treatment of this population. In addition to formal psychotherapeutic and counseling approaches, an alternative psychosocial treatment of cocaine dependence is a form of behavioral therapy based
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on the theory of replacing the positive reinforcement associated with cocaine use with a different type of positive reinforcement in an attempt to increase abstinence. Kirby et al. [6] conducted two studies examining the effect of a voucher incentive program added to a 12-week standardized cognitive-behavioral treatment for individuals with cocaine dependence. In Experiment 1, 90 individuals with cocaine dependence received counseling. Forty-six received counseling only, and 44 individuals received counseling plus weekly vouchers for cocaine-negative urine drug screens; the vouchers increased in value as the number of consecutive cocaine-negative urine samples increased. No voucher was given for a cocaine-positive sample, and the voucher value after a cocaine-positive sample was reset to the lowest value given at the beginning of the study (Voucher Schedule 1). At the end of the study, counseling plus voucher incentives (using Voucher Schedule 1) did not increase treatment retention rates or improve abstinence from cocaine when compared with counseling alone. Because the vouchers in this experiment were delivered weekly and were of low individual ($5 to $40) and total ($420) value, the investigators conducted a second voucher incentive experiment using the same counseling treatment with a daily (as opposed to a weekly) voucher payment schedule in which the vouchers were of higher value throughout the study than those given according to Voucher Schedule 1. In Experiment 2, 23 patients with cocaine dependence were assigned to a modified version of the 12-week cognitive-behavioral treatment given in Experiment 1. Twelve patients were randomly assigned to Voucher Schedule 1 for cocaine-negative urine samples and 11 were assigned to Voucher Schedule 2 in which the individuals received vouchers of greater monetary value and more immediate reinforcement for submitting cocaine-negative urine samples. Moreover, the voucher values were not lowered for cocainepositive urine screens. Compared with the Voucher Schedule 1 group, the Voucher Schedule 2 group had significantly more cocaine-free urine samples and significantly more weeks of continuous cocaine abstinence during the 12-week treatment period. This study demonstrates that a combination of cognitive-behavioral therapy plus an escalating value voucher incentive program to initiate abstinence can be beneficial to individuals with cocaine dependence. However, the details of the voucher system (eg, voucher value, payment frequency, and escalating schedule) may be critically important in determining the success of the voucher system. Unfortunately, as the cost of the voucher system increases, the likelihood of its implementation in community drug treatment programs declines. Higgins et al. [7] recently studied the effectiveness of another voucher incentive program during a 24-week psychosocial treatment and 1 year of follow-up visits. Seventy individuals with cocaine dependence received a community reinforcement approach that emphasized changes in relationships, leisure activities, and employment. They were then
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randomized to two voucher programs, one of which was contingent on cocaine-negative urine samples and one of which was not contingent on urine drug screen results. For weeks 1 through 12, the contingent condition delivered vouchers of increasing value for each cocaine-negative urine sample, whereas cocaine-positive urine samples reset the vouchers to the lowest value. From weeks 13 through 24, $1.00 lottery tickets replaced vouchers as the reward for cocaine-negative urine samples. Noncontingent condition individuals were all yoked to contingent condition individuals throughout the study so that they received vouchers and lottery tickets when the contingent condition individuals did, regardless of their own urine drug screen results. During the treatment period, a greater percentage of contingent condition individuals attained periods of at least 8, 12, and 16 weeks of continuous abstinence from cocaine, with a significant difference at 12 or more weeks. Additionally, a higher percentage of contingent condition individuals remained continuously abstinent from cocaine from the end of the treatment period through each posttreatment follow-up assessment. No significant differences existed between the two cohorts on treatment retention rates or Addiction Severity Index composite scores during the treatment period or the 1 year of follow-up visits. There was also no difference between the two cohorts in the mean monetary amount of vouchers and lottery tickets the individuals received during the 24-week treatment period. The authors concluded that a voucher-based incentive program may be one effective way to use a reinforcementbased program with other psychosocial treatments for cocaine dependence during active treatment and at posttreatment follow-ups over 1 year. In addition to the controlled clinical trials described herewith, the Drug Abuse Treatment Outcome Study recently reported long-term follow-up data on a large sample of 708 patients with cocaine dependence who had been initially admitted to substance abuse treatment program from 1991 to 1993 [8]. Simpson et al. [9•] found that the reductions in cocaine use reported 1 year after discharge from a substance abuse treatment program were mostly maintained over the 5-year follow-up period. This finding complements the data from the previously described trials, which have the advantage of controlled designs and random patient assignment, but suffer from relatively short follow-up periods. The Drug Abuse Treatment Outcome Study data suggest the gain evident in a 1-year study may have longer-term implications.
Conclusions The encouraging news from these studies is that they generally show that a variety of psychosocial treatments are associated with improved outcomes for cocaine-dependent patients. Moreover, two treatments that are currently in wide-
spread clinical practice, IDC and cognitive-behavioral therapy, have been effective. The recently popular practice of MI has proven useful for the treatment of other substance use disorders, and preliminary research suggests that it may be useful for promoting abstinence in individuals with cocaine dependence with low motivation when entering an outpatient detoxification program. Research studies show that some, though not all, incentive systems are effective in helping people achieving initial and long-term abstinence from cocaine. Finally, the reduction in cocaine use in individuals with dependence that takes place during a relatively short follow-up period may persist for several years. In summary, psychosocial treatments have shown promise for the treatment of cocaine dependence, and future research examining current and new psychosocial treatments should help to further define optimal approaches.
Acknowledgments Supported by grant K02 DA00326 from the National Institute on Drug Abuse and a grant from the Dr. Ralph and Marian C. Falk Medical Research Trust.
References and Recommended Reading Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance 1.
Crits-Christoph P, Siqueland L, Blaine J, et al.: Psychosocial treatments for cocaine dependence: results of the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Arch Gen Psychiatry 1999, 56:493–502. 2. McLellan AT, Kushner H, Metzger D, et al.: The fifth edition of the Addiction Severity Index. J Subst Abuse Treat 1992, 9:199–213. 3. Crits-Christoph P, Siqueland L, McCalmont E, et al.: Impact of psychosocial treatments on associated problems of cocainedependent patients. J Consult Clinical Psychol 2001, 69:825–830. 4.• Coviello DM, Alterman AI, Rutherford MJ, et al.: The effectiveness of two intensities of psychosocial treatment for cocainedependent patients: a pilot study. Drug Alcohol Depend 2001, 62:145–154. A good article. 5. Stotts AL, Schmitz JM, Rhoades HM, Grabowski J: Motivational interviewing with cocaine-dependent patients: a pilot study. J Consult Clin Psychol 2000, 68:858–862. 6. Kirby KC, Marlowe DB, Festinger DS, et al.: Schedule of voucher delivery influences initiation of cocaine abstinence. J Consul Clinical Psychol 1998, 66:761–767. 7. Higgins ST, Wong CJ, Badger GJ, et al.: Contingent reinforcement increases cocaine abstinence during outpatient treatment and 1 year of follow-up. J Consul Clin Psychol 2000, 68:64–72. 8. Simpson DD, Joe GW, Fletcher BW, et al.: A national evaluation of treatment outcomes for cocaine dependence. Arch Gen Psychiatry 1999, 95:507–514. 9.• Simpson DD, Joe GW, Broome KM: A national 5-year followup of treatment outcomes for cocaine dependence. Arch Gen Psychiatry 2002, 59:538–544. A good article.
