Cocaine abuse treatment strategies: Current treatments

2015

Only two comprehensive efforts at cocaine abuse treatment are described in the modern literature. Both are nonpharmacological, but each involves a very different approach to treatment. Anker and Crowley () have adapted the behavioral method of contingency contracting () for cocaine abuse. The contract involves such contingencies as the therapist’s holding letters of notification of cocaine abuse or resignation of professional licenses, written by the patient with content chosen specifically because of severe irrevocable personal effects, and mailing them to drug enforcement authorities, employers, or licensing boards upon finding evidence of cocaine use in urinalysis or after missed urinalysis. Such treatment appears to effectively induce abstinence in those willing to take part. Anker and Crowley report 48% of their sample were willing to engage in this treatment, with over 90% cocaine abstinence during the duration of the “contract.” Over half of these patients relapsed following completion of the “contract” (), however, even though the sample was a presumably well motivated and well educated group. The patients declining “contracts” (52%) were treated with supportive psychotherapy which was also used as an additional intervention in those accepting contracts. All noncontract patients nonetheless dropped out and or resumed cocaine abuse within 2 to 4 weeks. In this case, the consequences used with the behavioral treatment technique may have been unnecessarily punitive and may reduce the clients’ willingness to become involved in treatment. Anker and Crowley present no comparisons of severity of cocaine use and thus ignore the likely possibility that cocaine abusers with severe craving and problems of control recognize their inability to comply and consequently avoid what for them would simply become destructive treatment. In addition to problems of long-term efficacy and possible inapplicability to more severe cocaine abuse, obvious ethical problems exist in those cases where the procedure could have been based on positive reinforcement or on less aversive techniques. That is, when negative rather than positive reinforcement procedures arc applied, an obligation to use the least deleterious technique exists. Variations in “contract” design, such as employing contingencies graduated in severity. or a top contingency level with less drastic consequences, or applying positive contingencies for abstinence (e.g.. starting with a sum of money from the patient and giving part back each week for clean urines) could also circumvent the problems noted. Some cases might optimally need a combination of both positive and negative reinforcement. These variations have not yet been examined in cocaine abuse treatment. Thus, optimal ways of applying the promising approach of contingency contracting will become clear only after further investigation. Broader behavioral intervention techniques have been widely applied and studied in treatment of diverse forms of drug abuse () but other behavioral techniques have not been subject to outcome studies in cocaine abuse. Cocaine abusers are usually treated with more conventional psychotherapies. Except for one description, however. such treatments and their orientations have not been reported in the literature. In the one study reported, Siegel (1982) describes a treatment approach using frequent supportive psychotherapy sessions, self-control strategies, “exercise therapy,” and liberal hospitalization during initial “detoxification.” This treatment aims at initially separating the user from the use-fostering environment via external controls, and then gradually facilitating internalization of controls through psychotherapy. Half of Siegel’s sample of 32 heavy cocaine smokers dropped out, but 80% of those remaining were cocaine-free at 9-month followup.

Almost all psychotherapeutic treatment of cocaine abusers can be organized around three dimensions. These are: (1) To help the abuser recognize deleterious effects of cocaine use and accept the need to stop it. Anker treatment approach emphasizes this area. (2) To help the abuser manage impulsive behavior in general and cocaine use in particular; for example, exploring ways to disassociate the abuser from cocaine use situations and cocaine sources. Such supportive functions are emphasized in Siegel’s treatment approach. (3) To bring the abuser to an understanding of the functions that cocaine has played in his life and to help him serve these functions without drugs. For example, cocaine can serve narcissistic needs through the glamor associated with its use (or by direct pharmacological effects), needs for identity via the social networks and drug-using subculture associated with it and anaclitic needs via possible facilitation of intimate interpersonal interactions among many others. These three dimensions are present, in varying degrees. in virtually all cocaine abuse treatment programs. They correspond closely to behavioral, supportive, and psychodynamic orientations to psychotherapy. The authors feel all three orientations are necessary in the treatment of cocaine abusers, but their admixture is best determined by taking into account the needs of the individual cocaine abuser at the time of seeking treatment rather than by simple program structure. For example, patients in Anker and Crowley’s () study who refused contingency contracts could be approached from psychodynamic or supportive perspectives. The authors’ clinical impression is that severe cocaine abusers acutely attempting abstinence do not respond to psychodynamic interventions while moderate abusers may be more readily able to utilize them. Hence choice of primary therapeutic orientation might shift from behavioral to psychodynamic to supportive as severity increases, The authors’ approach to the psychotherapy of cocaine abusers is described more fully elsewhere (). These notions have not as yet received any empirical testing.

Whether inpatient or outpatient treatment is indicated, and for whom, is also somewhat controversial. Siegel’s study and earlier work in stimulant abuse (AMA Council 1978) both strongly advocate hospitalization for initial detoxification. However, in Anker and Crowley’s () study and Gawin and Kleber’s () study using pharmacological adjuncts, hospitalization was usually not indicated. It is likely that this also reflects severity. Siegel’s subjects were very heavy cocaine smokers who were minimally treated with adjunctive pharmacotherapy and may have been incapable of combating cocaine craving without hospitalization and seclusion from cocaine sources. These circumstances can require hospitalization, as can the existence of severe acute depressive or psychotic symptoms, multiple drug dependence especially involving sedative drugs, and previous failure(s) of the outpatient approach. The question needs to be raised, however, of whether inpatient treatment for the initial treatment of cocaine abuse is not too uniformly employed. It is known that relapse following hospitalization is quite high. This is consistent with studies of animal behavior () and clinical work () with drug abusers that point out the importance of environment and conditioning in drug-taking behavior. Cocaine abusers ultimately have to maintain abstinence within the general setting where abuse developed and our impression is that a period of abstinence within the context of everyday stimuli and stressors, akin to a period of “extinction,” is a necessary prerequisite to consistent long-term reductions in craving. Hospitalization in many cases may thus simply delay confrontation with fundamental issues determining long-term outcome. Also, since many subjects in Gawin and Kleber’s study were also severe abusers but did not require hospitalization, severity alone may not be an index of need for inpatient treatment. This area requires further attention and clarification. The current almost ubiquitous presence of cocaine in many areas of American life makes it unlikely that the former user will simply be able to avoid temptation. Like the former cigarette smoker or alcoholic, the person attempting to give up cocaine must make the drug “psychologically unavailable” since it is so hard to make it physically unavailable.

A final psychological approach to cocaine abuse is the self-help group modeled after A.A. Some former abusers have reported significant help either from A.A. or N.A. (Narcotics Anonymous). Structure group support, a religious tenor, and availability of an around-the-clock helping network have been of important assistance for some abusers. Some inpatient programs combine the confrontation groups long in use at residential therapeutic communities for narcotic addicts such as Daytop Village with heavy N.A. emphasis. No outcome studies of these programs for cocaine abusers have been reported.

Treatment of chronic cocaine abuse as currently practiced is vaguely defined and difficult to evaluate. The more structured treatments of Anker and Crowley () and Siegel (), which are both intensive efforts, can claim long-term effectiveness in 25% and 40% of the total number of patients initially seeking treatment. Most other cocaine abuse treatment presently hoeing conducted has received no systematic evaluation. is based on nonspecific psychological treatments for general substance misuse with no particular attention to the specific difficulties of cocaine abuse, and appears to be even less effective than the treatments reviewed above. Such treatment, focused on simple abstinence and psychotherapeutic management, has been recently characterized as “ineffective and idealistic” (). Treatment strategies for abusers of other stimulants, such as amphetamine (AMA Council 1978) have been similar to the treatment described by Siegel and provide no additional knowledge applicable to cocaine abuse treatment. There thus appears to be a substantial need for new and effective treatments of cocaine abuse.

 

Selections from the book: “Cocaine: Pharmacology, Effects, and Treatment of Abuse”. John Grabowski, Ph.D., ed. Content ranges from an introductory overview through neuropharmacology, pharmacology, animal and human behavioral pharmacology, patterns of use in the natural environment of cocaine users, treatment, through commentary on societal perceptions of use. National Institute on Drug Abuse Research Monograph 50, 1984.