National Institute on Drug Abuse

RESEARCH

MONOGRAPH SERIES

Cocaine

Treatment:

Research and

Clinical

Perspectives

U.S. Department of Health and Human Services • Public Health Service • National Institutes of Health

135
Cocaine Treatment: Research

and Clinical Perspectives

Editors:

Frank M. Tims, Ph.D.

Carl G. Leukefeld, D.S.W.

NIDA Research Monograph 135

1993

U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES

Public Health Service

National Institutes of Health

National Institute on Drug Abuse

5600 Fishers Lane

Rockville, MD 20857
ACKNOWLEDGMENT

This monograph is based on the papers and discussions from a technical

review on “Advances in Cocaine Treatment” held on August 16-17, 1990, in

Bethesda, MD. The technical review was sponsored by the National institute on

Drug Abuse (NIDA).

COPYRIGHT STATUS

NIDA has obtained permission from the copyright holders to reproduce certain

previously published material as noted in the text. Further reproduction of this

copyrighted material is permitted only as part of a reprinting of the entire

publication or chapter. For any other use, the copyright holder’s permission

is required. All other material in this volume except quoted passages from

copyrighted sources is in the public domain and may be used or reproduced

without permission from the institute or the authors. Citation of the source is

appreciated.

Opinions expressed in this volume are those of the authors and do not

necessarily reflect the opinions or official policy of the National institute on Drug

Abuse or any other part of the U.S. Department of Health and Human Services.

The U.S. Government does not endorse or favor any specific commercial

product or company. Trade, proprietary, or company names appearing in this

publication are used only because they are considered essential in the context

of the studies reported herein.

NIDA Research Monographs are indexed in the “index Medicus.” They are

selectively included in the coverage of “American Statistics index,” “BioSciences

information Service,” “Chemical Abstracts,” “Current Contents,” “Psychological

Abstracts,” and “Psychopharmacology Abstracts.”

National institute on Drug Abuse

NIH Publication No. 93-3639

Printed 1993

i i
Contents

Page

Treatment of Cocaine Abusers: Issues and Perspectives 1

Frank M. Tims and Carl G. Leukefeld

Outpatient Treatment of Cocaine and Crack Addiction: A Clinical

Perspective 15

Arnold M. Washton and Nannette Stone-Washton

Comorbid Psychiatric Disorders and Cocaine Abuse 31

Richard Schottenfeld, Kathleen Carroll, and Bruce Rounsaville

Clinical and Research Perspectives on Cocaine Abuse:

The Pharmacotherapy of Cocaine Abuse 48

Thomas R. Kosten

Medications Development at the National Institute on Drug Abuse:

Focus on Cocaine 57

David N. Johnson and Frank J. Vocci

Developing Treatments That Address Classical Conditioning 71

Charles P. O’Brien, Anna Rose Childress, A. Thomas McLellan,

and Ronald Ehrman

Neurobehaviorai Treatment for Cocaine Dependency: A Preliminary

Evaluation 92

Richard A. Rawson, Jeanne L. Obert, Michael J. McCann,

and Walter Ling

iii
Psychotherapeutic Treatment of Cocaine Abuse: Models for its

Evaluation Alone and in Combination With Pharmacotherapy 116

Kathleen M. Carroll

Behavioral Treatments of Cocaine Dependence 133

John Grabowski, Stephen T. Higgins, and Kimberly C. Kirby

Day Hospital vs. inpatient Rehabilitation of Cocaine Abusers:

An interim Report 150

Arthur I. Alterman, Charles P. O’Brien, and Marian Droba

Cocaine Abusers in Therapeutic Community Treatment 163

George De Leon

Community Outreach for injection Drug Users and the Need for

Cocaine Treatment 190

Clyde B. McCoy, James E. Rivers, and Dale D. Chitwood

Relapse to Cocaine Use: Conceptual issues 203

Barbara E. Havassy, David A. Wasserman, and Sharon M. Hall

Pretreatment Natural History of Cocaine Addiction: Preliminary

1-Year Followup Results 218

M. Elena Khalsa, M. Douglas Anglin, Alfonso Paredes,

Penny Potepan, and Carolyn Potter

Combinations of Treatment Modalities and Therapeutic Outcome

for Cocaine Dependence 237

M. Elena Khalsa, Alfonso Paredes, M. Douglas Anglin,

Penny Potepan, and Carolyn Potter

Treatment of Cocaine Abuse and Dependence: Directions and

Recommendations 260

Carl G. Leukefeld and Frank M. Tims

List of NIDA Research Monographs 267

i v
Treatment of Cocaine Abusers:

Issues and Perspectives

Frank M. Tims and Carl G. Leukefeld

INTRODUCTION

The objectives of this monograph are to explore current knowledge

and thinking about major issues in the treatment of cocaine abuse and

dependence, review available findings from studies of treatment of cocaine

clients, and set forth recommendations for research and practice. This

volume is based on a technical review meeting that took place at the

National Institute on Drug Abuse (NIDA) in August 1990 and the subsequent

development of chapters. Leukefeid and Tims present recommendations

from this review meeting in the final chapter of this monograph. Some

studies represented here are completed, others report preliminary results,

and some present treatment perspectives and models. This monograph is

not intended to be comprehensive but rather to provide a survey of promising

avenues of investigation.

The evolution of drug abuse patterns over the past two decades has seen

shifts, from heroin as a primary focus to a drug scene In which poiydrug

abuse patterns are common and new drug abuse problems have emerged.

Cocaine is of particular interest because of its rapid epidemiological spread,

the heterogeneity of its user populations, and the difficulty of developing

adequate treatments. Unlike heroin, for which there are effective agonistand antagonist-based treatments, cocaine has no standard treatment.

There is an array of generic treatments that were largely developed for

treating other drug abuse problems and a research base that is young

but growing in some promising directions. This chapter considers the

present state of knowledge regarding cocaine treatment populations and

comorbidities, pharmacological agents used in the treatment of cocaine

abuse and dependence, NIDA’s medications development program as

it relates to cocaine, the use of behavioral and psychosocial treatment

approaches to treating cocaine abusers, and treatment outcomes.

1
EPIDEMIOLOGY

Prior to 1980, cocaine abuse was considered a minor, albeit serious, drug

abuse problem. Cocaine was identified in admissions to federally funded

treatment as a primary drug of abuse in only 5.8 percent of the cases

reported by the Client-Oriented Data Acquisition Process for 1981 (National

institute on Drug Abuse 1982). In 1990, the percentage of NIDA’s National

Household Survey population 18 to 25 years old having “ever used” cocaine

was 19.4 percent, and 2.2 percent reported having used during the past

30 days (National institute on Drug Abuse 1991), down from 4.5 percent in

1988 (National institute on Drug Abuse 1990). Among those ages 26 to

34 years, the figures are 25.6 percent lifetime and 1.7 percent in the past

30 days, down from 2.6 percent in 1988. The percentage of those ages 16 to

17 having used cocaine in the past 30 days was just less than 1 percent in

1990. Thus, although cocaine use appears to have peaked in the household

survey population, it remains a major problem for which effective treatments

are urgently needed.

When considering the epidemiology of cocaine use, two facts stand out:

first, that cocaine use increased dramatically during the 1980s although it

has apparently peaked, and second, that the use of cocaine is a diversified

phenomenon, both in terms of the populations involved and the patterns of

use. Clayton (1985) called attention to data showing that, in the early 1980s

cocaine use was not concentrated solely in the more affluent social strata but

could be seen as common across classes and occupational groups. Rouse

(1991) examined route of administration and reports that, in 1985, intranasai

use (“snorting”) was overwhelmingly the preferred route among those older

than age 18, whereas smoking or freebasing was reported by 45.6 percent of

the adolescents who had used cocaine. Smoking or freebasing was reported

by about one-fifth of cocaine users age 18 and older. Rouse pointed out that

the advent of smokable “crack” cocaine in the early 1980s eliminated some

of the immediate physical hazards associated with freebasing, and this,

together with the low price of crack cocaine, occasioned the increase in the

popularity of smoked cocaine, especially among the younger population.

Household survey data do not present the complete picture where cocaine

is concerned. Certain subpopulations that are especially deviant have

especially high rates of use—arrestees, for example. Wish and O’Neil (1991)

presented urine test data obtained from arrestees in eight U.S. cities during

1988, with cocaine-positive specimens obtained from more than half the

males in five cities and more than two-thirds of the female arrestees sampled

in those cities. Responses to questions about their preferred route of

administration ranged from 11 percent (Detroit) to 37 percent (Houston)

of the males and from 15 percent (Detroit) to 59 percent (New Orleans)

of female arrestees reporting a preference for injecting cocaine, either alone

2
or in combination with heroin. Both snorting and smoking or freebasing were

also reported by large percentages of males and females.

NATURAL HISTORY

Although knowledge of the natural history of opiate abuse is rich, few studies

have addressed this aspect of nonopiate abuse, particularly cocaine abuse.

The availability of many primary cocaine clients provides the opportunity to

study cocaine abuse careers and develop a body of knowledge essential to

understanding the initiation of, prolonged use of, and treatment outcomes

for cocaine abusers. it has been believed generally that cocaine abusers

typically use the drug for only a few years before entering treatment. Khaisa

and colleagues (Pretreatment . . ., this volume) report data to the contrary.

There is no real knowledge of the extent to which cocaine use careers

continue into middle age or abruptly cease as users mature.

CLINICAL ISSUES

Cocaine is a drug that presents complex and difficult clinical issues. in

an excellent review of the behavioral pharmacology literature on cocaine,

Johanson and Fischman (1989) examined such behavioral effects of cocaine

administration as sensitization, tolerance, and conditioning. Although some

effects of cocaine cannot be ascribed to conditioning, Johanson and

Fischman observed that the overwhelming evidence in the literature is

that cocaine has “extraordinary reinforcing properties.” They also cited the

numerous reports of its toxicity, including cardiovascular changes and crises,

cerebrovascuiar accidents, hyperpyrexia, and cocaine-mediated damage to

other organs or tissues (e.g., gastrointestinal tract, kidneys, and liver) as well

as damage related to route of administration (e.g., nasal passage injuries,

lung abnormalities, and infections acquired through injection with

contaminated needles).

Further complications to providing effective treatment are seen in the variety

of cocaine users, with differences in socioeconomic backgrounds and

lifestyles, as well as involvement with other drugs, impairment of social

functioning, and psychiatric comorbidities. Cocaine use drives and elicits a

variety of behaviors that place individuals at risk in several ways, including

behavior associated with criminality, sexual behavior, perinatal exposure, and

the use (especially intravenous [IV] use) of other drugs. Cocaine has

frequently been cited as associated with compulsive sexual behavior

(Washton and Stone-Washton, this volume) and the exchange of sex for

drugs, particularly crack cocaine.

Despite the numerous risks, recent evidence (Khaisa et al., Pretreatment . . .,

this volume) suggests that many individuals have been long-term users of

3
cocaine prior to entering treatment. In view of these and other data, such

as recent studies reported by De Leon (1989, this volume), Havassy and

Wasserman (1992), and Schottenfeld and colleagues (this volume), it is

not surprising to note numerous physiological, psychiatric, and social

complications presented by those entering treatment for cocaine

dependence.

TREATMENT APPROACHES

Consideration of what treatment strategies are potentially effective for

cocaine-dependent clients must take Into account the biobehavioral nature

of drug dependence: that treatment has several tasks; and that the treated

client must function in a social environment fraught with stresses, social

pressures, and temptations. Just as methadone and naltrexone have

provided useful pharmacological adjuncts for treatment of heroin addicts,

pharmacological treatments may assist in providing relief of craving and the

unpleasant states associated with cocaine withdrawal, retaining clients in

treatment, and preventing relapse. However, treatment must be viewed

as having a structure that integrates stabilization (whether it includes

pharmacological agents), learning, social support, and strategies to prevent

relapse. The client must be withdrawn from the drug and the drug lifestyle,

given a treatment environment that supports recovery, engaged in learning

processes as part of rehabilitation, and provided a continuum of care that

enables the client to function in a drug-free lifestyle after leaving the more

structured phase of treatment.

Given the diversity of clinical and philosophical backgrounds in the drug

abuse treatment field, which is relatively new and evolving, it is not surprising

that models of treatment have emerged in a fragmented way. Researchers

are focused on testing specific interventions, either alone or in combination.

In clinical practice, programs have been developed that draw together

strategies on a pragmatic basis, using elements of cognitive-behavioral

and 12 -step approaches, such as those described by Washton and StoneWashton (this volume). The model of neurobehavioral treatment described

by Rawson and coworkers (this volume) presents an outpatient program

that approaches recovery in stages, each with particular tasks addressed by

therapeutic and educational components, and includes achieving abstinence,

preventing relapse, and working on relationships. Several other models are

described in this volume and elsewhere in the literature, including behavioral

approaches and psychotherapies. Treatments are delivered in a variety

of program environments-inpatient, residential, and outpatient.

4
COCAINE USE BY METHADONE CLIENTS

Cocaine use by methadone clients presents a major problem. In a review by

Condelli and colleagues (1991) various aspects of cocaine abuse by this

population and its treatment are considered. Clients presumably stabilized

and being successfully treated for opiate dependence commonly abuse

several other drugs, especially alcohol and marijuana. Cocaine, although

clearly of concern, was viewed by methadone programs as of secondary

concern prior to the advent of widespread crack cocaine use and IV use

of cocaine. That view is not a valid perspective when considering the

risk of infection to IV cocaine users and the increased sexually transmitted

risk of human immunodeficiency virus common to crack cocaine users

(especially females). Continued cocaine use during methadone maintenance

militates against engagement in a recovery process and is therefore of added

concern. The interaction of cocaine with methadone has been cited as

contributing to increasing cocaine use by this group of clients. Kosten and

coworkers (1988) note that some of their methadone patients apparently

found the combination of methadone and cocaine pleasurable, comparing it

to a “speedball,” and that the clients reported that cocaine had “taken over

their lives” to a greater extent than their previous opioid use. Kosten and

colleagues (1989) also speculate that opioid antagonist treatment may

reduce cocaine use by depriving cocaine-using clients of relief from the

dysphoria, or postcocaine “crash,” which methadone apparently provides.

The reports of high prevalence of antisocial personality disorder among

methadone clients (Kosten et al. 1988; Woody et al. 1985) further point

to difficulty in engaging them in therapeutic alliances. The difficulty in

developing effective interventions for the subset of methadone clients who

use cocaine has been recognized, and two major lines of development of

interventions have been pursued: pharmacological treatment and behavioral

treatments. Kosten (this volume) cites studies of dopamine agonists that

have met with some success and the mixed results in trials of tricyclics.

He also reports that methadone clients who crossed over to buprenorphine

dramatically reduced (and often ceased) their cocaine use, perhaps because

of the opiate antagonist effects. Behavioral approaches such as those

reported by Stitzer and coworkers (1986) and Grabowski and colleagues

(this volume) also may be useful in reducing cocaine use by this population.

PHARMACOLOGICAL TREATMENTS

The search for pharmacological agents useful in treating cocaine withdrawal,

preventing or reducing craving, blocking euphoria, and otherwise stabilizing

clients has attracted widespread attention. Gawin and coworkers (1989)

addressed the problem with a double-blind trial of desipramine hydrochloride

and found substantial reductions in cocaine use as well as in craving for

cocaine in the treated group. Much lower rates of abstinence were found

5
for both lithium carbonate and placebo. Numerous other trials of tricyclic

antidepressants were conducted in the mid- to late-1980s with mixed results

(Kosten, this volume; Carroll, this volume). Other pharmacological agents

have been suggested by researchers as potentially useful, including

dopamine agonists and antagonists, anticonvulsants, and narcotic

antagonists (Kosten, this volume).

NIDA’S MEDICATIONS DEVELOPMENT PROGRAM

NIDA initiated a program in 1988 to systematically identify and test

pharmacological agents potentially useful in the treatment of drug abuse

and dependence. This program was formalized as the Medications

Development Division of NIDA in 1990 (Johnson and Vocci, this volume).

The major objective was to expeditiously support the necessary work to

obtain approval by the U.S. Food and Drug Administration of medications

for treatment of drug dependence. In many cases, these medications

already have been approved for other indications, and thus a major part

of the testing (ie., preclinical studies and safety determination) has been

completed. With this in mind, and with the benefit of numerous open trials

conducted by researchers in the field, NIDA began its search for medications.

BEHAVIORAL APPROACHES

Pharmacological agents are only part of a treatment strategy, and they

address specific aspects (e.g., withdrawal, stabilization, reduction of craving,

or treatment of comorbid conditions) in a program of treatment that must

accomplish a range of tasks, Many of these tasks are addressed by

nonpharmacological (i.e., psychosocial) interventions in programs an

in the community. The acquisition and maintenance of drug dependence

involves learning. At the level of responses to drug stimuli, both classical

and operant paradigms are useful. O’Brien and colleagues (this volume)

have explored the former and have conducted experiments that suggest

that extinction of such conditioning may be a useful approach.

Grabowski and coworkers (this volume) review behavioral treatments, both

in general application to drug abuse treatment and with reference to cocaine.

They suggest that the limited available evidence points to the value of

treatment strategies that involve analysis of client behavior and environment,

identification of sources of reinforcement, and systematic use of behavioral

contingencies that support drug-free lifestyles. They stress the potential

value of behavioral approaches, both in terms of “providing insight into the

behavioral pharmacology of cocaine use and the current problem” and

preparing the field to deal with “future stimulant epidemics.” They identify

the formidable task of altering major events and reinforcers in the patient’s

environment and gaining effective sources of information about events in that

6
environment. Monitoring biological markers is stressed as a valuable

source of clinical and research information, and the feedback provided by

drug screens is cited as both a powerful diagnostic and therapeutic tool.

A recent study of a behavioral intervention using a version of the community

reinforcement approach suggests that this approach holds promise for

helping clients achieve abstinence (Higgins et al. 1991). Grabowski and

colleagues (this volume) also examine the role of pharmacological

adjuncts in behavioral interventions and recommend that the design

of pharmacotherapies take into account their value as reinforcers.

RELAPSE PREVENTION INTERVENTIONS

If drug abuse can be characterized as dysfunctional coping, learning healthier

coping strategies is an approach that has support in the clinical and research

literature. Following the work of Marlatt and Gordon (1984), researchers

such as McAuliffe and coworkers (1991) have employed relapse prevention

approaches that involve acquisition of interpretive skills and learning to

respond to social and environmental cues in ways that support continued

abstinence rather than a return to drug use. Such approaches have been

incorporated in various forms into existing treatment programs and aftercare.

The importance of relapse prevention strategies has been underscored in

the work of such researchers as Wallace (1990). The importance of social

support in maintaining treatment compliance, reducing denial, and

maintaining abstinence is recognized in the social network therapy of

Galanter (1988). Thus, effective relapse prevention approaches may

include both internal and external resources for coping.

PSYCHOTHERAPY AND PHARMACOTHERAPY

It has been suggested, based on work with opiate addicts (Woody et al.

1983) that some classes of drug abusers may benefit from psychotherapy.

Carroll (this volume) examines the use of psychotherapy as a treatment

for cocaine abuse, with attention to types of drug abusers, appropriate

types of psychotherapy, and use of psychotherapy in conjunction with

pharmacotherapy. She reports that, in a trial of two types of psychotherapy,

cocaine clients experienced some improvement, although main effects were

not evident. However, those classified as high-severity cocaine abusers were

more likely to become abstinent when treated with relapse prevention therapy

than when treated with interpersonal psychotherapy. Those classified as lowseverity improved regardless of which therapy was used. The same pattern

was seen with regard to high vs. low severity of psychological symptoms

(based on Addiction Severity Index ratings [McLellan et al. 1985]). Although

overall improvement was noted for the sample, results were in some ways

disappointing. Attrition was a major problem in both conditions. More than

half the clients enrolled in the trials failed to attain stable abstinence during

7
the treatments. Although some findings suggest that psychotherapy may

have value in improving retention in pharmacotherapy, the evidence is too

incomplete to do more than speculate. Carroll suggests that the depression

research literature may offer insights for evaluating psychotherapy (and

pharmacotherapy) for cocaine abusers, Cautioning that the absence of a

standard pharmacotherapy for cocaine abusers is a problem, Carroll points

to the potential value of identifying clinical subtypes based on drug use

and psychiatric severity. The evaluation of psychotherapy in relation to

pharmacotherapy is a complex matter, with potential for clarifying the

response of client types to each and for improving or potentiating response

to pharmacological treatments.

PROGRAMS AND ENVIRONMENTS

lnpatient vs. Day Treatment Modailties

Alterman and colleagues (this volume) also present preliminary results from

a study of inpatient treatment vs. day treatment for a sample of black male

cocaine abusers at the U.S. Department of Veterans Affairs (VA) facilities.

The treatment in both programs consists principally of group counseling

focusing on overcoming denial and coping with problems and stresses

of daily life as well as individual counseling as needed. Psychotropic

medications, when needed, also are available in both modalities. The day

treatment program is available for 27 hours per week during weekdays,

whereas inpatient treatment is on a continuing basis. Clients from each

condition also are encouraged to attend self-help meetings while they are

enrolled in treatment. Assignment to the treatment conditions was random,

and findings were presented for 94 subjects at baseline, 78 at 4-month

followup, and 56 at 7-month followup. Dropout rates were higher in the

day treatment condition, with 87 percent of inpatients vs. 52 percent of day

hospital patients completing treatment. However, both conditions had major

reductions in cocaine use at 4-month followup, with 83 percent of day hospital

subjects and 54.5 percent of inpatients providing negative urine specimens:

at 7-month followup, cocaine-negative urine screens were provided by 57.9

percent of available day treatment subjects and 85 percent for available

inpatient subjects. In addition, significant improvements at the 4- and

7-month followups were found in other (nondrug) areas of functioning,

using the Addiction Severity Index (McLellan et al. 1985). It also was

observed that day treatment subjects entered aftercare treatment

at a rate several times that of the inpatient subjects.

The Matrix Model

The Matrix Model (Rawson et al., this volume) is built on an eclectic,

pragmatic borrowing of concepts and approaches from other researchers

8
and therapists. The intellectual debt owed Washton and others is explicitly

acknowledged. The approach borrows elements from cognitive-behavioral,

psychoeducational, family therapy, and other perspectives and views recovery

as a sequence of stages, each having its own dilemmas, challenges, and

tasks. In particular, the following needs must be addressed: achieve

abstinence and stabilize: deal with the false beliefs regarding abstinence

and the risk of relapse that arise after the early stages of treatment; address

the sources of stress inherent in relationships and everyday life; and relearn

numerous beliefs about life, drugs, stress, and relationships. This is a long

process and requires a major commitment, not only by the individual but also

by the individual’s spouse or significant other. At each stage of recovery,

issues must be addressed on behavioral, cognitive, emotional, and relationship

levels; and issues, beliefs, and behaviors must be clarified and reassessed.

Cocaine Abusers in Therapeutic Communities

Therapeutic community (TC) programs provide treatment for many drug

abuse clients in the United States. De Leon (this volume) reviews available

data from studies of TC clients, with particular focus on clients whose primary

drug abuse problem is identified as cocaine abuse. Although the overall rates

of psychiatric disturbance for crack cocaine users do not appear to be greater

than those of other TC clients, De Leon states that such indicators as suicide

attempts are several times those of other drug abusers. In examining retention

in treatment, De Leon found that the general pattern was similar for primary

cocaine and noncocaine abusers. He suggests that, given the relationship

between time in treatment and outcome, this pattern is indicative of probable

similar treatment outcomes. Treatment outcome studies for cocaine clients

in therapeutic communities are needed.

COMMUNITY OUTREACH AND THE NEED FOR TREATMENT

In considering community outreach to the many IV drug users, many of whom

have never been in treatment, McCoy and coworkers (this volume) report on

cocaine use by injection drug users (IDUs) in treatment (primarily methadone)

and another sample of street IDUs recruited by indigenous outreach workers

as part of the NIDA-sponsored National AIDS Demonstration Research Project

in the Miami area. Sixty percent of those in the street IDU sample reported

having received no drug abuse treatment services at any point during the

5-year period preceding the enrollment interview. Cocaine injection was much

more pronounced among the street IDU sample than among the treatment IDU

sample, and within the street sample, cocaine injection was more prevalent

than heroin injection. The authors report that 90 percent of the street sample

had injected cocaine, 62 percent had injected heroin, and 60 percent had

injected both in combination (i.e., as a speedball). Using a short-term

counseling and training intervention, the researchers were able to follow

9
up both samples of IDUs at 6 and 12 months. Decreased use of cocaine was

reported for both samples, with the largest decrease in the use of speedball,

the most common form of cocaine use, although no reduction was found

for crack cocaine. In addition, the authors report that, during the 6 months

following entry into the study, 11 percent of the street IDU sample gained

admission to treatment. The authors posit that substantial numbers of IDUs

not currently in treatment are, in fact, candidates for treatment and would

be willing to enter if staff resources were made available for placement.

RELAPSE

It has been estimated that two-thirds of relapse in drug abuse clients takes

place within 3 months posttreatment (Leukefeld and Tims 1989). Havassy

and colleagues (this volume) have examined conceptual issues related to

cocaine relapse and reviewed research findings on relapse and its prevention.

Defining relapse involves several conceptual problems, and cocaine is a

particular problem because of the tendency of cocaine users to binge rather

than use continuously. Slips may occur, and criteria of continuous abstinence

may result in erroneously pessimistic reports of outcomes. Moreover, a lapse

to cocaine use may precede long periods of abstinence and may be part of

a learning process in recovery. It is suggested that a standard definition of

relapse include a minimum period of abstinence prior to the lapse and a return

to given levels of use for a specified time. Among factors that have been

suggested as important to relapse are route of administration (cocaine

smokers have a higher relapse tendency than intranasal users), use of

other drugs (especially alcohol), having something to lose, rigorousness

of abstinence goals, and social support. The potential significance of

psychopathology to relapse and the importance of a sense of personal wellbeing also are addressed, as is the need for incorporating social support,

valued relationships, and a sense of well-being into behaviorally based

treatment approaches.

OUTCOME STUDIES

Treatment outcome studies that allow inferences regarding the effectiveness

of treatment programs and modalities are in various stages of implementation

and completion. Large-scale studies of treatment outcome that are presently

available were conducted on treatment cohorts that included relatively few

who could be characterized as cocaine dependent. Large-scale multiprogram

studies of outcome through 1989 were limited largely to opioid and polydrug

abusers (Tims et al. 1991). NIDA has under way a large, national outcome

study of clients with drug abuse diagnoses of cocaine dependence under the

Drug Abuse Treatment Outcome Study program. However, outcome data

from this study will not be available until late 1994.

10
Individual outcome studies presented in this monograph and elsewhere provide

encouraging data pointing to favorable outcome patterns and effectiveness of

programs for treatment of cocaine-dependent clients. Khalsa and coworkers

(Combinations . . . , this volume) report an outcome study of cocaine-dependent

male clients treated in various combinations of VA programs. These included

short-term (21 -day) inpatient programs, outpatient treatments, and referral to

community self-help groups. The inpatient program utilized a 12-step model,

with individual and group counseling, as well as drug education. Outpatient

treatment also used the 1 P-step philosophy, with physician visits followed by

individual and group counseling. Self-help involved attendance at Alcoholics

Anonymous or Cocaine Anonymous meetings. Data collection was at

admission, and at 1 and 2 years postadmission, although only the first-year

postadmission data are reported in this volume. For this group, intranasal

use of cocaine was not common (10 percent pretreatment vs. 5 percent

posttreatment), with crack cocaine smoking being the preferred route of

administration. Overall, dramatic reductions in cocaine use were observed

when the 12-month preadmission period was compared with the 12-month

postadmission period. For the sample, preadmission use of crack cocaine

was approximately 45 to 65 percent of each month during the 1 P-month period

vs. 22 to 37 percent at followup. Similar dramatic reduction in cocaine use

classified as “severe” was reported pretreatment to posttreatment (65 to

75 percent mean time preadmission vs. 17 to 22 percent during followup), and

mean percentage of time not using cocaine increased from 5 to 20 percent

pretreatment to 58 to 69 percent during followup. Also observed were declines

in alcohol and other drug use. However, no statistically significant changes

were found in social behaviors, with the exception of drug dealing, which

decreased dramatically. Regarding time abstinent from cocaine, an increase

was observed in all groups, but the increase was significantly greater in those

whose treatment consisted of either (1) inpatient plus high-intensity outpatient

or self-help or (2) high-intensity outpatient or self-help (although the number

of clients in this group was relatively small). The most commonly selected

treatment combination was the inpatient plus intensive outpatient or intensive

self-help, which also was found to have the best outcomes. Clearly, client

motivation to enter and become engaged in intensive, longer term treatment is

an important area for further study, as are the components of treatment

programs and associated experiences that elicit such engagement and retain

clients for the duration of treatment or return clients to treatment if relapse

occurs.

CONCLUSION

Cocaine abuse and dependence are extreme problems and constitute one of

the central challenges to the drug abuse treatment field. A variety of avenues

of investigation are being pursued in search of knowledge regarding effective

treatments. Some promising leads, pharmacological agents, and techniques

11
that appear to be somewhat effective have been identified and subjected to

systematic testing. Some approaches are believed to be potentially useful in

combination (e.g., psychotherapy and pharmacotherapy), but much remains

to be clarified and resolved. For example, the issue of client subtypes needs

elaboration in relation to available treatments. This monograph examines

some of the major issues and presents a survey of available approaches and

findings,

REFERENCES

Clayton, RR. Cocaine use in the United States: In a blizzard or just being

snowed? In: Kozel, N.J., and Adams, E.H., eds. Cocaine Use in America:

Epidemiologic and Clinical Perspectives. National Institute on Drug Abuse

Research Monograph 61. DHHS Pub. No. (ADM)87-1414. Washington,

DC: Supt. of Dots., U.S. Govt. Print. Off., 1985. pp. 8-34.

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Galanter, M. Social network therapy for cocaine dependence. Adv Alcohol

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consequences of cocaine abuse among opioid addicts: A 2.5 year followup. J Nerv Ment Dis 176:176-181, 1988.

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13
AUTHORS

Frank M. Tims, Ph.D.

Chief

Treatment Services Research Branch

Division of Clinical Research

National Institute on Drug Abuse

National Institutes of Health

Parklawn Building, Room 10A-30

5600 Fishers Lane

Rockville, MD 20857

Carl G. Leukefeld, D.S.W.

Director

Center on Drug and Alcohol Research

University of Kentucky

210 Medical Center Annex II

Lexington, KY 40536

14
Outpatient Treatment of Cocaine

and Crack Addiction: A Clinical

Perspective

Arnold M. Washton and Nannatte Stone-Washton

INTRODUCTION

The treatment of cocaine and crack addiction is one of the most critical

issues facing the substance abuse treatment field today. Unfortunately, the

skyrocketing demand for treatment has made it impossible to wait for results

of carefully controlled research to guide the delivery of treatment services.

Clinicians on the front lines of the treatment delivery system need information

that might assist them in dealing with an increasingly difficult-to-treat patient

population of crack addicts and polydrug abusers. This chapter offers

recommendations for treating cocaine addicts as outpatients and is based

entirely on clinical experience and not on results of carefully controlled research.

Thus, the reader is asked to view the authors’ clinical recommendations within

that context. Clinical issues and techniques discussed in this chapter are

addressed in greater detail in previous publications (Washton 1989 a; Washton

and Stone-Washton 1990).

PROGRAM DESIGN

Structure, intensity, and frequency are the keys to making outpatient treatment

effective. The first goal is to replace the patient’s habitual drug use with habitual

attendance at the program and to make abstinence a singular priority. This

usually requires a highly structured outpatient regimen that combines individual,

group, and family counseling; education; urine testing; and self-help. The

program must provide patients with an enhanced support network to deal with

drug triggers (cues) and to resist the continuous availability of cocaine in their

everyday environment. This requires multiple weekly counseling sessions-at

least four or five per week-to solidly engage the patient and to break the

compulsive cycle of cocaine use.

Dividing an outpatient program into sequential stages helps to structure the

tasks that must be addressed in the natural progression from early abstinence

issues to relapse prevention issues to longer term recovery issues (Washton

15
1989a). Although any such division of the treatment process is somewhat

arbitrary, it provides patients and counselors with a general “roadmap” that

orients them toward achieving specific objectives. Not only does it give shape

and structure to the program, but it also gives patients a sense of

accomplishment when they graduate from each phase.

The Washton Institute’s intensive outpatient program is divided into three

phases, each of which focuses on a specific set of tasks and goals (Washton

1989a). The basic structure and content of these phases are guided by a

series of films (Washton 1987) and workbooks (Washton 1990) that contain

written exercises for the patient and guidelines for the group leader. The first

phase (12 weeks) is devoted to breaking the addictive cycle. The major goals

are to establish initial abstinence, assess the severity of the patient’s problem,

and enhance his or her motivation to change. Patients attend four group

sessions and one individual session per week. In the second phase (4

weeks), the focus shifts toward solidifying abstinence and learning specific

relapse prevention skills (Washton 1988). Patients attend two group sessions

and one individual session per week. The third phase of the program consists

of either (1) a 12-week continuing care group that provides peer support and

focuses on developing a long-range recovery plan or (2) an open-ended,

recovery-oriented psychotherapy group that addresses a range of topics,

including relationships, self-esteem, sexuality, and adult children of alcoholics

issues. Patients decide with the help of their counselor which of these two

alternatives is better suited to their needs. Throughout the entire program, all

patients are urine tested at least twice per week and routinely encouraged to

attend self-help meetings-Cocaine Anonymous (CA), Narcotics Anonymous

(NA), and/or Alcoholics Anonymous (AA). Family members attend an initial 4-

week education group and may elect to enter a longer term codependency

group.

The first stage of treatment, interrupting the compulsive drug use cycle,

must begin in the first session. The job of the evaluating clinician includes

enlisting whatever the patient’s apparent motivation is to quit and to identify

specific measures the patient must take to short-circuit his or her impulses to

continue using cocaine. These early efforts must focus pointedly on basic

habit-breaking strategies to interrupt the cycle of use. Before the first interview

ends, the counselor and patient should have jointly formulated a very specific

and detailed 24-hour abstinence plan for avoiding exposure to drugs, drug

users, and dealers. This means constructing a structured, moment-bymoment plan of how to spend time, whom to spend it with, and what to say to

anyone who offers drugs. It may mean planning a different route home if the

usual route is a trigger to buy, use, or think about using drugs. Sometimes, a

new patient is paired with a “buddy” (a stable program member or graduate)

who will accompany him or her to a self-help meeting and be available to lend

16
support when needed. Before the first session ends, patients are reminded

that a urine sample will be taken at the next visit to keep them accountable for

their actions and to thwart the impulse to have one last fling and use, rather

than destroy, their remaining drug supply. Patients are asked to set aside at

least 2 hours for the initial evaluation because extra time is needed to go over

the first workbook unit, “Tips for Quitting Cocaine” (Washton 1990), with the

newcomer to create a personalized plan for remaining drug-free until the next

contact (usually the next day).

Sometimes it is necessary for the patient to ask a trusted friend or relative for

help on a “search-and-destroy mission” to rid his or her home or car of all

drug supplies and paraphernalia. The first step is purely behavioral and

focuses intensively on breaking the cycle of use, not on overhauling the

patient’s lifestyle, although at some later point, it clearly will need to be

overhauled. This step is routinely bypassed in inpatient treatment and is

often the weakest part of programs that rely solely on environmental control

to establish abstinence. Outpatients should be helped to learn early that

they must assume full responsibility for their own behavior and must take an

active role in their recovery because nothing and no one is going to “cure”

their addiction. The challenge of outpatient treatment is to guide the patient

carefully through the “minefields,” ”boobytraps,” and “steep inclines” of daily

life and teach him or her how to avoid drug triggers, dealers, and users and

how to manage feelings rather than chemically escape from them.

There is no medical need to hospitalize cocaine addicts for the purpose of

managing a “withdrawal syndrome.” Technically speaking, there is no

withdrawal syndrome after abruptly stopping cocaine. That is, the body has

never developed a need for cocaine to maintain homeostasis, and so there

are no withdrawal symptoms that require medication such as those

administered to alleviate abstinence symptoms in alcoholics or heroin addicts.

However, there are often unpleasant rebound symptoms after stopping heavy

cocaine use. The person feels lethargic and generally out of sorts from

depleting the stores of dopamine and other brain neurotransmitters that are

needed to maintain a normal mood state. But most, if not all, of these

symptoms disappear on their own without medication over the course of a few

days. Sleep and regular meals work fine for most patients.

Those patients who do need hospitalization often do well with an abbreviated

stay followed directly by intensive outpatient care. It is rare to find serious

medical complications that have resulted from cocaine abuse, which is

contrary to media sensationalism that plays up the deaths and disasters. It is

usually the patient’s thinking patterns, behavior, motivation, and lifestyle

choices that need intensive and expert attention, not his or her body.

17
ARE COCAINE ADDICTS REALLY DIFFERENT FROM ALCOHOLICS?

Although cocaine addiction and alcoholism have much in common, they differ

in clinically important ways. It is a mistake to view the cocaine addict as just an

alcoholic who happened to get involved with a different drug. It is also a

mistake to stick rigidly to the belief that “a drug is a drug is a drug” as

justification for refusing to treat cocaine addicts any differently from alcoholics

and for refusing to “give in” to the cocaine addict’s “grandiosity“ or need to be

“special.” All patients who seek help deserve to be treated as individuals and

to receive treatment that meets their individual needs. Some of the most

clinically important differences between cocaine addiction and alcoholism are

listed below.

1.

2.

3.

4.

The opposite psychoactive effects of cocaine-a central nervous system

(CNS) stimulant-and of alcohol-a CNS depressant-n the human brain

mean that the types of relapse triggers that stimulate the addict’s desire for

the chemically induced high often will be very different. Cocaine amplifies

sensory experience, whereas alcohol modulates it. Although most cocaine

addicts use (and abuse) alcohol to come down from cocaine, many never

have chosen alcohol for chemically induced highs. That is partly why

cocaine addicts often see no reason to give up alcohol and have a great

deal of difficulty accepting the need for total abstinence.

There is often a strong sexual component to cocaine addiction, especially

in males. Cocaine use frequently is associated with sexual fantasies, with

sexual acting-out behaviors, and, in some cases, with a full-fledged sexual

compulsion-any one of which can become a strong relapse trigger for

cocaine use if not addressed from the outset of treatment (Washton

1989b).

Unlike alcohol, cocaine rarely (if ever) causes noticeable psychomotor

impairment and leaves no telltale odor on the user’s breath. Cocaine

intoxication generally does not cause people to stagger, slur their speech,

or fall down. Therefore, it is more difficult to detect: in addition, alcohol is

far more likely than cocaine to be associated with intoxicated drivers, drunk

driving arrests, driving-while-intoxicated (DWI) charges, and auto crashes

with personal injury.

Cocaine is associated with fewer medical problems and fewer deaths

than alcohol. Contrary to media sensationalism, annual cocaine-related

deaths in the United States are a tiny fraction of those caused by alcohol

or cigarettes, and unlike alcoholics, few cocaine addicts seek or are

referred to treatment because of medical problems alone. The dangers

associated with cocaine stem primarily from its extraordinary addiction

potential and its ability to alter the user’s brain function and behavior.

18
5. Cocaine is illegal; alcohol is not. In society’s view, cocaine addicts

are deviants who have only themselves to blame for their addiction.

They are criminals deserving punishment, not sick people deserving

treatment. This negative, moralistic attitude sometimes spills over into

the treatment setting. Counselors may be particularly intolerant of the

cocaine addict’s manipulativeness, guardedness, deviousness, and

noncompliance. These behaviors lead many counselors to feel ineffective

and frustrated. Destructive counter-transference reactions (strongly

negative, countertherapeutic responses to a patient’s behavior) may

get played out in the name of “limit setting” and in attempts to avoid

“enabling” patients who are noncompliant. This is a major obstacle in

treating cocaine addicts but one that is rarely addressed.

6. Addiction develops much more rapidly with cocaine than alcohol, often

within a few weeks or months, and especially when smoked as freebase

(crack). Thus, the dynamics of cocaine addiction are different from those

of alcoholism, including its impact on the individual and the family.

Cocaine addiction can be likened to a rapid-onset trauma that stuns its

victims, compared with alcoholism, which progressively and insidiously

debilitates the drinker over a much longer period. The cocaine-affected

family is less likely to show the deeply ingrained systemic aberrations and

codependent relationships so commonly seen in alcoholic families.

7. Cocaine addicts often feel better so quickly after stopping cocaine that their

motivation to remain in treatment may evaporate just as quickly.

8. Last, but certainly not least, the power of cocaine conditioning is awesome.

Cocaine cravings are undoubtedly more troublesome in early abstinence

than any analogous phenomenon seen with alcohol or other drugs.

Almost anything and anyone in the cocaine addict’s life can become a

conditioned trigger for cocaine cravings and relapse. Moreover, settings,

circumstances, feelings, and experiences previously associated with

cocaine use often retain their ability to set off powerful cravings and drugseeking behavior long after the cocaine use has stopped. Medications

and nutritional supplements, although widely publicized, are not very

effective in suppressing cocaine cravings, and it appears that the best

strategy is to teach patients specific cognitive and behavioral techniques

to short-circuit cravings and counteract the strong euphoric recall for the

cocaine high (Wallace 1989; Washton 1988, 1989a).

Should cocaine addicts be treated separately from alcoholics and other drug

abusers? Not unless the program has had very poor success in treating them

together. Some programs may have to go through an interim phase of creating

a specialized cocaine treatment track to acquire the experience, confidence,

19
and skills that are needed to effectively treat cocaine addicts and alcoholics

together. Cocaine addicts do not need separate programs or entirely new

treatment approaches, but they do need treatment that addresses their special

needs. Treatment of the cocaine addict is not identical to that of the alcoholic,

especially in the early stages where clinical differences between these patient

subgroups are most pronounced (Washton 1989a). Clinicians must be

knowledgeable about cocaine and the particulars of cocaine recovery. It can

be difficult for a patient to place trust in a clinician who, for example, does not

know the difference between an “eighth,” a “quarter,” and an "ounce” of cocaine

or that crack and freebase are the same drug. Every cocaine addict who

comes for treatment needs assurance that the clinician offering help has a

thorough working knowledge (not a superficial book knowledge) about cocaine

and other drugs. The clinician need not have used or been addicted to

cocaine, but he or she must be able to anticipate and deal with the predictable

problems that cocaine addicts commonly face at each stage of the recovery

process.

MOTIVATING THE UNMOTIVATED

The first treatment goal should not be to convince the patient that he or she is

an addict since accepting the identity of “addict” Is not a prerequisite to getting

clean and sober, which is the first and foremost goal of an outpatient program

(Washton and Stone-Washton 1991). Besides, getting into debates and power

struggles with cocaine addicts over this issue is countertherapeutic and a major

cause of early dropout. Patients who claim to have gotten a little “carried away”

with cocaine, but do not see it as a serious problem, do not necessarily have

intractable denial that needs to be assaulted. This difficulty in seeing the

problem in a realistic light is an early (and predictable) stage in developing the

motivation to change and is not unique to addicts (Prochaska and DiClemente

1986). A power struggle over this issue will surely drive the patient away and

will seem to confirm the self-fulfilling prophecy of the clinician who still believes

that patients have to “hit bottom” before they get serious about recovery (Miller

1985). This is a therapeutic blunder-a failure to “start where the patient is.”

Forming a good working relationship with the patient is the basis for positively

influencing his or her behavior. Giving cocaine addicts permission to resist

and to be ambivalent fosters openness and a willingness to take personal

responsibility for their own actions (Zweben 1989). When clinicians are

extreme in their opposition to alcohol and other drug use, patients become

reluctant to share their drug fantasies and are likely to act out rather than talk

out their secret impulses to get high. However, the clinician who instead joins

with the patient around shared goals and can convey understanding, empathy,

and respect will often be able to engage even a highly resistant patient in the

treatment process and help him or her to begin to honestly explore his or her

20
true attachment to drugs. A patient’s inability or unwillingness to accept that

he or she has a problem may not be evidence of intractable denial; it may just

mean that he or she is in a very early stage of change and that it will take time

and a good bit of respectful coaxing to move that patient forward into the next

stage of change. Understanding and being able to identify the predictable

stages of all human behavioral change will allow clinicians to maintain the

perspective needed to avoid unnecessary frustration and equip themselves

with the understanding they will need to help patients see the need for

changing.

Prochaska and DiClemente (1986) have identified several stages of change

and the types of interventions that work best within each stage when people

attempt to overcome addictions, either on their own or with outside help. In the

“precontemplation” stage the person is actively practicing the problem behavior

but does not perceive it as a problem, although others do. Precontemplators

invest no effort in thinking about or attempting to change and, thus, are not

ordinarily seen in treatment unless forced by such circumstances as an arrest,

DWI, or positive urine test that threatens his or her job. In the “contemplation”

stage, the individual begins to experience ambivalence about the problem

behavior, considers doing something about it, but does not enter treatment

since he or she is still not convinced that the behavior is serious enough to

warrant such action. The contemplator may remain in this stage indefinitely

(“I’ll quit tomorrow”), vacillating back and forth about whether to change

(barring such unforeseen circumstances as those mentioned above), thereby

reflecting the ambivalence and motivational conflict that are so characteristic of

this stage.

In the “determination” or “decision” stage, the balance tips in favor of change

(for whatever reasons, whether internal or external), and the individual “shops

around” in typically human fashion for the easiest, quickest, and most painless

and face-saving way to change. In the “initial action” stage, the individual

makes an active attempt to do something about the problem behavior, either

alone or with outside help. Most treatment programs are geared toward this

stage (i.e., establishing abstinence) and are generally not prepared to deal with

people in earlier or later stages of change. The “maintenance” stage Is the real

challenge in overcoming addictions. For example, it is usually much easier to

stop using cocaine than it is to stay permanently stopped. The challenge

during this stage is to consolidate gains already made, to continue making

positive gains, and to avoid relapse.

The most important goal in the early sessions is to join with the patient around

shared goals and to instill trust and hope by conveying understanding,

empathy, respect, and confidence. Adopting an objective wait-and-see attitude

or joining the resistance may facilitate the therapeutic alliance. The first step in

21
treatment (establishing total abstinence) is often quite a bit ahead of where the

entry-level patient is ready to begin. Part of the inhibition that counselors feel

about working at this stage of treatment with outpatients may stem from what

we call “enabling phobia.” By refusing to work with patients who do not

immediately curtail all drug use and admit to having a lifelong disease,

counselors miss the opportunity to facilitate the patient’s progress through the

initial decisionmaking phases of change, and they miss opportunities to help

patients avoid more severe suffering and damage that will result from continuing

drug use. (What other field of health care encourages its practitioners to tell

patients they can benefit from treatment only after they deteriorate further and

suffer intolerable pain?)

The clinician must be willing and able to start where the client is, recognizing

fully that at the beginning of treatment the program and the patient are not

always focused on the same goal. Frequently, the patient’s hidden agenda is

to eliminate the consequences of cocaine use without eliminating the cocaine

use itself; in addition, many cocaine addicts do not want to stop using alcohol

and/or marijuana. Clinicians must avoid getting locked into power struggles

around these and other thorny issues that arise with resistant patients (Zweben

1989). Rather than insisting on absolute compliance, the clinician can form a

therapeutic alliance with the patient around a proposed trial period of total

abstinence, which is explained as necessary to assess the nature and extent

of the patient’s attachment to psychoactive drugs. Not every cocaine addict

who appears at the door of a drug clinic is ready to enter a full-scale intensive

treatment program. For example, some patients need intensive individual

counseling before they are ready even to consider entering a group or full-scale

program. Others require education and feedback about their drug involvement

before developing sufficient motivation to sustain and make use of more

intensive treatment.

The Washton Institute’s program attempts to address this need by offering an

8-week basic training course (called Substance Abuse Treatment for People

Who Don’t Think They Need It). Patients are asked to remain totally drug- and

alcohol-free throughout the course while they realistically explore the nature of

their attachment to psychoactive drugs. By putting the emphasis on examining

the patient’s attachment to drugs rather than insisting that he or she accept

the identity of “addict,” a therapeutic alliance can be formed around this "timelimited experiment” by giving the counselor a golden opportunity to join rather

than fight the patient’s resistance. Patients attend a basic training class (group)

twice a week and document their abstinence with supervised urine and

breathalyzer tests. Patients who complete this course then may be eligible to

enter the full-scale intensive outpatient program or to receive other supportive

services.

22
Counselors must be careful not to convey low expectations and promote a

self-fulfilling prophecy of treatment failure with patients who are at first poorly

motivated and resistant to accepting your view of their problem. No one has

a crystal ball for predicting treatment outcome, and first impressions can be

deceiving. For example, many patients who are extremely resistant at first

become very involved with the recovery process.

The challenge is to work creatively with (not against) the patient’s resistance to

bring about change (Zweben 1987). Resistance is to be expected: It is one

focus of the therapeutic work, not a distraction. It is essential that the

counselor meet the patient at least halfway to get the treatment going, because

success in this effort rests on cooperation, not coercion.

A useful metaphor to describe the respective roles of the patient and counselor

is that of a hiker and guide setting out together on a mountain trail. The role

of the guide is just that-to guide, not to carry or control, the hiker along the

trail; to keep the hiker moving in the right direction; to alert him or her to

potential dangers; to teach basic survival skills: to motivate and encourage,

especially when the going gets tough; and to respectfully correct mistakes.

However, the hiker will have to take each and every step on the climb and

exert his or her own energy and determination along the way to reach the

desired destination.

BONDING

An outpatient program constantly competes for the patient’s loyalty and

attention with the ever-present lure of cocaine. Because the treatment can

be effective only if the patient shows up, getting new patients to bond quickly

to both their clinician and group is critical. All group members in the authors’

program are supplied with a continuously updated telephone list and are

encouraged to make contact with at least two other members every day.

When patients miss an individual or group session, the clinician calls

immediately after the session, and other group members are urged to call

as well. It is critical that outpatients know that their attendance at all scheduled

sessions is absolutely essential and that when they fail to show up they are

definitely missed.

URINE TESTING

Urine testing is essential in outpatient treatment. It helps to create a safe

environment for the patient, to enhance trust between the clinician and patient,

and to provide an objective measure of treatment progress. The purpose of

urine testing is not to catch patients in lies but to instill greater confidence in

the treatment. Cocaine addicts usually appreciate the value of mandatory

23
urine testing because it helps them counteract their impulses to use and to

hide their use. Not being able to hoodwink the clinician or the program can

keep a patient from devaluing his or her treatment. And, with accurate urine

surveillance, family members and employers can breathe a little easier and be

more supportive of the recovering outpatient when they no longer feel the need

to scrutinize his or her every move for signs of possible drug use.

The following steps should be taken to maximize the clinical value of urine

testing: (1) All samples should be supervised (witnessed) to prevent

falsification. The practical problem of having sufficient staff members to

supervise urine samples can be overcome by, for example, a buddy system

in which patients give urine under the rotating supervision of a same-sex group

member who signs for having monitored that sample. (2) Urine samples should

be taken routinely at least every 3 to 4 days so as not to exceed the sensitivity

limits of standard laboratory testing methods. (3) Samples should be tested

by enzyme immunoassay or radioimmunoassay methods to ensure accuracy,

and all positive results should be confirmed by a second test (Verebey 1987).

(4) The samples should be routinely tested not only for cocaine but also for

amphetamine, opiates, marijuana, benzodiazepines, and barbiturates, (5)

Patients should be tested throughout the entire treatment program and not be

taken off urine testing until solidly in recovery. Even then, occasional testing

can be helpful.

COCAINE AND COMPULSIVE SEXUALITY

As many as 70 percent of cocaine addicts entering the institute’s treatment

program are dually addicted cocaine and sex (Washton 1989b). Cocainerelated compulsive sexuality contributes to chronic relapse, treatment failure,

and perpetuation of high-risk sexual behaviors that may foster the spread of

acquired immunodeficiency syndrome. Undiagnosed and untreated compulsive

sexuality is one of the most common, preventable relapse factors in cocaine

treatment today. The following are key points to consider.

The strong connection between cocaine and compulsive sexuality stems from

the fact that many users experience strong sexual stimulation from cocaine,

perhaps more so than from any other drug. Cocaine produces hypersexuality

characterized by obsessive thoughts, feelings, and fantasies that lead to sexual

acting-out behaviors of every kind. It increases libido and reduces inhibition, a

dangerous combination that often sparks marathon cocaine and sex binges.

These drug effects are considerably more intense when cocaine is smoked (or

injected), rather than snorted, because of the substantially higher dosages that

are delivered to the brain by rapid absorption methods. Since binge use, rather

than daily use, is the norm for most cocaine addicts, many users manage to

avoid or delay the onset of tolerance and the accompanying sexual dysfunction

24
associated with chronic cocaine use. To assume that all cocaine addicts are

sexually dysfunctional is incorrect.

The clinician can assess a patient’s cocaine-related sexual behavior by

asking such specific questions as: Does your cocaine use ever involve

sexual thoughts, fantasies, or behaviors? If so, during what percentage of

your drug use episodes does this happen? Do you engage in any of the

following behaviors while high on cocaine: compulsive masturbation,

encounters with prostitutes, compulsive intercourse, compulsively viewing

peepshows or pornographic movies, switching from heterosexual to

homosexual sex, dressing in clothing of the opposite sex, or sadomasochistic

sex? Unless asked such specific questions as these, most patients will not

spontaneously volunteer information about their compulsive sexuality because

they are usually too ashamed and guilty, fear being labeled as “perverts,”

and/or assume that their sexual behavior is irrelevant to treatment of their

cocaine problem. Compulsive sexuality is more common among cocainedependent males than females and is more common among cocaine freebase

smokers than snorters.

Sexual addiction or compulsivity is defined by the same criteria that are applied

to other addictions: loss of control, compulsion, and continued involvement

despite serious adverse consequences. It is the individual’s pattern of sexual

behavior and the degree to which it interferes with his or her functioning that

define it as compulsive. No single sexual practice, no matter how bizarre,

should be categorized as compulsive merely because it deviates from societal

norms. (Although there is much debate about whether sexual compulsions are

truly addictions, the terms are used here interchangeably.)

Drug-related compulsive sexuality must be treated directly and as a primary

problem that is part of a dual addiction pattern, even when the patient had

no history of compulsive sexuality prior to involvement with cocaine. The

patient’s sexual addiction does not automatically disappear when he or she

stops using cocaine. Sexual feelings and fantasies often trigger powerful

urges and cravings for cocaine. Many patients become trapped in a “reciprocal

relapse” pattern in which compulsive sexual behavior precipitates relapse to

cocaine and vice versa.

Although both addictions must be treated, abstinence from cocaine and all

other psychoactive drugs is the first and foremost goal of early treatment. Until

total drug abstinence is established, it is impossible to address the sexual

addiction. The authors ask the dually addicted patients to completely refrain

from all sexual activity during the first 30 days of treatment. This gives the

clinician an opportunity to teach patients how to differentiate between “normal”

and compulsive/addictive sex, how to identify sexual relapse triggers, and how

25
to respond to them safely. We have generally found that sexual issues are

best handled in same-sex groups with same-sex therapists.

HANDLING “SLIPS”

Clinicians working in outpatient settings must be prepared to deal

therapeutically with patients who are actively using drugs and with those

who return to using one or more times after temporary periods of abstinence.

All such slips are best avoided, but should they occur, they must be

addressed as mistakes and motivational crises rather than tragic failures

or willful noncompliance (Marlatt 1985). Slips can be valuable learning

experiences (although always dangerous and never encouraged), especially

when the patient is helped to figure out why the slip happened and how to

prevent it from happening again. Slips often turn out to be much more

effective than lectures, for example, in convincing resistant cocaine addicts to

stop using alcohol or marijuana.

Many programs adopt inflexible, “get tough” attitudes about patients who slip.

It is common practice to summarily terminate patients who fail to maintain

complete abstinence within the first few days or weeks of outpatient treatment.

The patient who has one or more slips is often labeled an outpatient failure

and told to go into a residential program. Although it is a delicate balancing

act to avoid being an enabler on the one hand, and a hard-liner on the other,

it hardly seems appropriate to terminate the patient for engaging in the very

behavior that brought him or her to treatment without first making a concerted

effort to figure out more precisely why drug use is continuing. Saying that

the patient is “unmotivated” or “noncompliant” is an inadequate explanation.

Studies have repeatedly shown that the longer addicts stay in treatment,

the better they do (Washton 1989c; Cooper et al. 1983). Most dropouts in

outpatient programs occur within the first 60 days. Thus, keeping patients in

treatment through this difficult startup period, despite initial slips and relapses,

can markedly improve the chances of a successful outcome.

How should clinicians respond when a patient says that he or she has used

drugs or a urine test indicates that this is so? How many slips are too many

for a program or group to tolerate? It is essential to point out discrepancies

between a patient’s stated intentions (e.g., “I want to stop using drugs”) and

his or her actual behavior (drug use). A group member who repeatedly slips

and then fails to utilize the group’s or clinician’s advice should be temporarily

suspended from the group and seen individually to work through motivational

problems and establish a period of continuous abstinence (e.g., 30 days)

before earning the privilege to reenter the group. It is counterproductive to

specify in advance exactly how many slips or positive urines will lead to

suspension from the group since this is tantamount to giving group members

26
permission to have one less slip than this specified number. In making such

decisions there are no pat formulas or other substitutes for the clinician’s

good clinical judgment combined with the collective wisdom of the group.

SELF-HELP

Treatment, no matter how effective, is time limited and often leaves a void in

the patient’s life that substantially increases the potential for relapse. The 12-

step programs of CA, NA, and AA have been helpful to many thousands of

addicts throughout the world, and it is generally wise to encourage all patients

to at least try to get involved with one or more of these self-help fellowships.

Despite encouragement, however, many patients reject self-help and either

flatly refuse to attend meetings or fail to attend them for very long. This is

another area in which the clinician must avoid getting into power struggles

and must look instead for ways to creatively work through, rather than attack,

the patient’s resistance. For example, strong rejection of self-help can be used

as an opportunity to explore the patient’s resistance to the recovery process

as a whole (Zweben 1987). Although one’s chances of sustained recovery

are likely to improve with self-help involvement, there is no basis for insisting

that self-help presents the one and only pathway to permanent change. It is

regrettable that some programs either directly or indirectly drive out of

treatment cocaine addicts who refuse self-help.

IS OUTPATIENT TREATMENT EFFECTIVE?

A recent uncontrolled study at this facility compared treatment outcome

following either inpatient or intensive outpatient treatment in 60 drug addicts,

most of whom were employed cocaine or crack addicts. Forty actively

addicted patients came directly into our intensive outpatient program. The

remaining 20 patients entered our outpatient aftercare program, where they

joined graduates of the intensive outpatient program after completing 28 days

or longer of inpatient treatment at various facilities in the New York metropolitan

area and elsewhere. Patients in this study represented 60 consecutive

admissions to our programs who remained in treatment for at least 2 weeks.

All met DSM-III-R criteria (American Psychiatric Association 1987) for severe

psychoactive drug dependence. Eighty-five percent were cocaine addicts and

were about evenly divided between cocaine snorters and crack smokers. The

remaining 15 percent were addicted to opiates or sedative-hypnotics,

Nearly all these patients used alcohol and/or marijuana in combination with

their drug of choice. Ninety percent were employed at jobs ranging from bluecollar worker to office worker to executive. Whether a given patient received

primary inpatient or outpatient treatment was determined in most cases by

insurance coverage and whether he or she happened to contact the outpatient

27
program initially or was in one of the inpatient rehabilitation programs that later

referred the patient to the institute for aftercare. Few patients had deliberately

chosen one type of treatment over the other. Most were following the

recommendations of a family member, employee-assistance counselor, or

treatment professional. Although numerous uncontrolled selection factors

(both clinical and nonclinical) affected whether a given patient received

inpatient or outpatient treatment, the clinical profiles of the two comparison

groups were strikingly similar with regard to drug use, addiction severity,

employment status, previous treatment history, and other relevant patient

characteristics.

The results were as follows: Aftercare completion rates were nearly identical

for inpatients (77 percent) and outpatients (74 percent) as were posttreatment

abstinence rates: 68 percent of the outpatients and 64 percent of the inpatients

were abstinent at 6- to 24-month followups according to urine tests and clinical

interviews. Nearly half (46 percent) of the abstinent patients were continuously

abstinent during the entire treatment and followup period. Thirty-three percent

slipped at least once to their primary drug, and 23 percent slipped at least

once to alcohol or marijuana but not to their primary drug. Premature dropout

was synonymous with relapse: Among relapsed patients, none had completed

treatment, whereas among abstinent patients, 87 percent were treatment

completers. Cocaine smokers showed significantly lower, albeit decent,

abstinence followup rates (58 percent) compared with cocaine snorters (78

percent), but followup rates for both types of users were similar with inpatient

compared with outpatient treatment.

Because of the small subject sample and other limitations in methodology,

results of this study are suggestive, not conclusive. The findings indicate that

(1) employed cocaine and crack addicts can be treated successfully in inpatient

or outpatient programs that are followed by intensive aftercare treatment

emphasizing relapse prevention, and (2) intensive outpatient treatment can

be a cost-effective alternative to inpatient care for many of these patients.

FINAL COMMENT

This chapter describes strategies for treating cocaine and crack addicts as

outpatients. Intensive outpatient treatment, although not for everyone, can be

an effective primary treatment modality for many patients. It is an appealing

alternative to residential care not only for reasons of cost and convenience, but

also because it supports patients while they are involved with the critical tasks

of learning and practicing drug-free coping skills in a real-life setting.

28
REFERENCES

American Psychiatric Association. Diagnostic and Statistical Manual of Mental

Disorders: Third Edition-Revised. Washington, DC: American Psychiatric

Press, 1987.

Cooper, J.; Altman, F.; Brown, B.; and Czechowicz, D., eds. Research on the

Treatment of Narcotic Addiction. National Institute on Drug Abuse Treatment

Research Monograph Series. DHHS Pub. No. (ADM)83-1281. Rockville,

MD: Alcohol, Drug Abuse, and Mental Health Administration, U.S. Public

Health Service, US. Department of Health and Human Services, 1983.

Marlatt, G.A. Relapse prevention: Theoretical rationale and overview of the

model. In: Marlatt, G.A., and Gordon, J.R., eds. Relapse Prevention. New

York: Guilford, 1985. pp. 3-67.

Miller, W.R. Motivation for treatment: A review with special emphasis on

alcoholism. Psychol Bull 98(1):84-107, 1985.

Prochaska, J.O., and DiClemente, CC. Toward a comprehensive model

of change. In: Miller, W.R., and Heather, N., eds. Treating Addictive

Behaviors: Processes of Change. New York: Plenum Press, 1986.

pp. 3-28.

Verebey, K. Cocaine abuse detection by laboratory methods. In: Washton,

A.M., and Gold, M.S., eds. Cocaine: A Clinician’s Handbook. New York:

Guilford. 1987. pp. 214-226.

Wallace, B. Relapse prevention in psychoeducational groups for compulsive

crack cocaine smokers. J Subst Abuse Treat 6:229-239, 1989.

Washton, A.M. Staying Off Cocaine. Avoiding Relapse, Part 1; Treating

Cocaine Addiction Successfully, Part 2. Woodstock, NY: Reelizations Video,

1987.

Washton, A.M. Preventing relapse to cocaine. J Clin Psychiatry 49(Suppl 2):34-

38, 1988.

Washton, A.M. Cocaine Addiction: Treatment, Recovery, and Relapse

Prevention. New York: W.W. Norton, 1989a.

Washton, A.M. Cocaine abuse and compulsive sexuality. Med Aspect Hum

Sexuality 23:32-39, 1989b.

Washton, A.M. Outpatient treatment works, too. U S J Drug Alcohol Depend

13(2):14, 1989c.

Washton, A.M. Cocaine Recovery Workbooks. Center City, MN: Hazelden

Education Materials, 1990.

Washton, A.M., and Stone-Washton, N.S. Preventing relapse in outpatient

cocaine addicts. J Psychoactive Drugs 22(2):135-147, 1990.

Washton, A.M., and Stone-Washton, N.S. Step Zero: Getting to Recovery.

Center City, MN: Hazelden Educational Materials, 1991.

Zweben, J.E. Recovery-oriented psychotherapy: Facilitating the use of 12-step

programs. J Psychoactive Drugs 19(3):243-251, 1987.

Zweben, J.E. Recovery-oriented psychotherapy: Patient resistances and

therapist dilemmas. J Subst Abuse Treat 6:123-132, 1989.

29
AUTHORS

Arnold M. Washton, Ph.D.

Founding Director

Nannette Stone-Washton, M.S.

Assistant Director

The Washton Institute on the Addictions

Four Park Avenue

New York, NY 10016

30
Comorbid Psychiatric Disorders and

Cocaine Abuse

Richard Schottenfeld, Kathleen Carroll, and Bruce Rounsaville

BACKGROUND

An increased prevalence of psychopathology in both treatment-seeking

and community populations of substance abusers has been repeatedly

documented, with affective disorders and personality disorders the most

common diagnoses (Hesselbrock et al. 1985; Khantzian and Treece 1985;

Powell et al. 1982; Rounsaville et al. 1982, 1986, 1987; Schuckit 1985; Ross

et al. 1988). By and large, psychopathology is associated with poor prognosis

(Hesselbrock et al. 1985; Rounsaville et al. 1982, 1986, 1987). With the

exception of depression in women alcoholics, who have been found to respond

better to treatment than their nondepressed counterparts (Schuckit and Winslow

1972; Rounsaville et al. 1987), increased psychiatric severity predicts poor

treatment outcome regardless of treatment modality. However, studies of

treatment also point to the importance of providing specific treatments to addicts

or alcoholics with specific psychiatric disorders to improve treatment outcome

(Kranzler and Liebowitz 1988; Rounsaville et al. 1985; Rounsaville and Kleber

1985; Woody et al. 1985). The addition of professional psychotherapy to

standard methadone maintenance treatment, for example, has been shown to

improve treatment outcome for psychiatrically impaired patients (Rounsaville

and Kleber 1985; Woody et al. 1983; McLellan et al. 1983); the use of

antidepressant medications as an adjunct in treatment for persistently

depressed alcohol- or opioid-dependent patients also has led to improved

outcome (Kranzler and Liebowitz 1988; Rounsaville et al. 1985).

Although high rates of psychopathology have been documented in persons with

alcohol and opiold disorders and although the relationships of psychopathology,

prognosis, and differential effects of treatment are well documented in those

disorders, considerably less attention has been paid to these issues in cocaine

abusers. Specific areas that require further clarification include the following:

1. Is there an increased prevalence of psychiatric disorders among cocaine

abusers compared with non-substance abusers?

31
2. How do rates of psychopathology among cocaine abusers compare with

rates in other substance abusers?

3. Which psychiatric disorders are found most frequently among cocaine

abusers?

4. Does psychopathology differentially affect prognosis or response to

treatment?

Several theoretical issues color expectations about the relationship of

cocaine abuse and psychopathology. Sociological theories on deviance

would suggest that when use of a specific drug is particularly deviant in the

population, users of the drug will be deviant in other respects, and greater

rates of psychopathology will be found in users. Thus, with regard to cocaine,

since its use is more widespread in the general population than is opioid abuse,

one might expect to find less psychopathology in cocaine abusers. In contrast,

given the pharmacologic properties of cocaine, high rates of psychopathology

might be expected among cocaine abusers. Prolonged use of stimulants,

including amphetamine or cocaine, can lead to paranoid states and has been

associated with prolonged anhedonia and affective disturbances (Gawin and

Ellinwood 1988). High rates of psychopathology in cocaine abusers also

would be expected if cocaine is used, as many investigators suggest, to selfmedicate underlying psychiatric disorders. For example, Khantzian and

Khantzian (1984) believe that cocaine is used to (1) combat fatigue, depletion,

depression, boredom, or emptiness; (2) increase assertiveness, self-esteem,

and/or frustration tolerance; or (3) augment a hyperactive lifestyle and an

exaggerated need for self-sufficiency. Rather than indicating any causal

association, high rates of psychopathology in treatment-seeking cocaine

abusers might be a result of Berkson’s bias (ie., cocaine abusers with

comorbid psychopathology are more likely to seek treatment than those

without psychopathology, leading to a spurious increased prevalence of

psychopathology in treatment seekers). However, an increased rate of

psychopathology among cocaine abusers in epidemiologic studies of

community samples would provide strong support for a clinically significant

association,

This chapter first reviews the findings from several studies on comorbidity of

psychiatric disorders in cocaine abusers, then discusses in somewhat greater

detail the findings from the authors’ comorbidity study, and finally links these

findings to treatment implications.

32
STUDIES OF PSYCHOPATHOLOGY AMONG COCAINE ABUSERS

Several studies have investigated the association between cocaine abuse

and psychopathology in both treatment-seeking and community populations

(table 1). Methodological differences, including use of standardized and

nonstandardized diagnostic assessments and employment of both specified

and unspecified diagnostic criteria, limit the comparability of the studies and

help explain some of the differences found among them. In one of the early

studies of psychopathology among treatment-seeking cocaine abusers,

Helfrich and colleagues (1983) reviewed the clinical records and Minnesota

Multiphasic Personality Inventory profiles of 136 treatment-seeking cocaine

abusers: 43 percent experienced major psychological symptoms, Including

suicide attempts or psychotic symptoms. Chitwood and Morningstar (1985)

used a structured interview to study 95 treatment-seeking cocaine users and

a community sample of 75 non-treatment-seeking cocaine users who were

located using a snowball technique. Compared with the community sample,

treatment seekers reported more long-term depression (34 vs. 11 percent), as

well as a higher intensity of use and more adverse consequences associated

with cocaine use (e.g., job loss, separation or divorce, and drug overdose).

These findings suggest that the occurrence of depression and other drugrelated problems leads cocaine users to seek treatment.

Other studies of treatment-seeking cocaine abusers also have documented

high rates of psychopathology, especially affective and anxiety disorders,

childhood attention deficit disorder (ADD), and personality disorders. Gawin

and Kleber (1986) used the Diagnostic Interview Schedule to evaluate 30

treatment-seeking cocaine abusers—33 percent met criteria for depressive

disorders (13 percent, major depression; 20 percent, dysthymia) and 17

percent for cyclothymia; 3 percent had adult residual ADD. In Weiss and

coworkers’ (1986) study of 30 cocaine abusers hospitalized at McLean

Hospital, 53 percent of the sample were reported to suffer from affective

disorders (20 percent, major depression; 17 percent, cyclothymia; 7 percent,

bipolar disorders; 10 percent, atypical depression). Their findings were based

on psychiatric clinical interviews, the symptom checklist, the Beck Depression

Inventory, and the Hamilton Depression Rating Scale. A subsequent study

(Weiss et al. 1988) compared the findings in the first 30 patients with the next

119 patients admitted to the same hospital facility and documented a marked

decline over time in the prevalence of affective disorders (from 53 percent in

1980-82 to 21 percent in 1982-86). Antisocial personality (ASP) disorder,

which had been found in 3.3 percent of the first 30 patients, was found in 19.3

percent of those admitted in 1982-86. A history of childhood ADD was found

in 4.6 percent; overall, 16 percent of patients suffered from cyclothymia or

bipolar disorder. The McLean studies also documented significant differences

in rates of psychopathology in men compared with women cocaine abusers

33
TABLE 1. Studies of psychopathology among treatment-seeking cocaine

abusers

Study Sample Diagnostic

Investigators Size Setting Instrument Flndlngs

Helfrlch et al.

1983

136 Outpatient

Chitwood and 170 Outpatient

Morningstar 1985 (TS and CC)

Gawin and Kleber 30 Outpatient

1986

Weiss et al. 1988 30 Inpatient

Weiss et al. 1988 149 Inpatient

Griffin et al. 1999 129 lnpatient

Nunes et al. 1989 30 Outpatient

Clinical data;

MMPI

Structured

Interview

DIS

Psychiatrlc

interviews;

SCL-90, BDI,

HDRS

Psychiatric

interviews;

SCL-90, BDI,

HDRS

Psychiatric

Interviews;

SCL-90, BDI,

HDRS

43% major psychological

symptoms

Compared with CC, TS

reported more long-term

depresslon (34 vs. 11%),

higher Intensity of use, and

more adverse consequences

(job loss, separatlon or

divorce, overdose)

13% major depression, 20%

dysthymic, 17% cyclothymla,

3% residual ADD

20% major depression, 17%

cyclothymla, 7% bipolar, 10%

atypical depression

53% affective disorders (1980-

82), 21% affective disorders

(1982-86), 3.3-19.3% ASP,

4.6% ADD, 16% cyclothymia

or bipolar

23.5% women and 4.2% men

with major depression, 22%

men with ASP vs. 0% women

with ASP, 18% cyclothymla or

bipolar

SCID, atypical 30% lifetime bipolar spectrum,

depression 33% unlpolar depression, 31%

scale, HDRS anxiety disorders

KEY: MMPIMinnesota Multiphasic Personality Inventory; TS=treatment Seeking;

CC=community controls; DlS=Dlagnostlc Interview Schedule; ADD=attention

deflclt disorders; SCL-90=Symptom Checklist 90; BDI=Beck Depression Inventory;

HDRS=Hamilton Depression Rating Scale; ASP=antlsoclal personality;

SCID=Structured Clinical Interview for DSM-III

34
(Griffin et al. 1989). Women constituted approximately 25 percent of patients

admitted to the hospital for cocaine treatment. Major depression was found

in 23.5 percent of women compared with 4.2 percent of men, whereas ASP

disorder was found in 22 percent of men and no women. Depression also

was found to improve more slowly in female compared with male patients.

Weiss and colleagues (1988) noted that patients with cyclothymia typically

reported cocaine use at a time of hyperthymic rather than depressed mood

and suggested that cocaine is used to augment the high or to prevent the

depressed mood or that the use is a result of impaired judgment associated

with hypomania. Family history data collected as part of the study documented

a greater prevalence of affective disorders in family members of hospitalized

cocaine abusers with affective disorders compared with family members of

patients without affective disorders.

The failure in the McLean studies to use a structured interview and clearly

specified diagnostic criteria may have contributed to the marked change

in prevalence of affective and ASP disorders during the two periods—

the change in prevalence might reflect a drift in the diagnostic interview

or diagnostic criteria rather than a trend in diagnosis. A decline in the

prevalence of affective disorders over the two periods (but not the increase

in ASP disorder), however, also would be consistent with the deviance theory

discussed above. Cocaine abusers hospitalized from 1980-82 began their

cocaine use in the early to mid-1970s when cocaine use was not widely

prevalent in the general population; those hospitalized from 1982-86 likely

began their use in the late 1970s and early 1980s when cocaine use was

much less deviant,

More recently, Nunes and coworkers (1989) reported the results of their

evaluations of 30 consecutive admissions to an outpatient cocaine treatment

program. They used the SCID and an atypical depression scale to determine

psychiatric diagnoses. Fifty percent of the patients were found to have current

affective disorder, and lifetime affective disorders were found in 83 percent.

Thirty percent of patients experienced lifetime bipolar spectrum disorders,

mainly of the depressed subtype, and 33 percent experienced primarily

unipolar depression. Overall, 27 percent experienced atypical depression,

and 80 percent experienced other substance use disorders. Thirty-one

percent of the sample experienced anxiety disorders, including 12 percent

suffering from social phobia. There was a trend suggesting that a family

history of depression was more likely in depressed cocaine abusers than in

nondepressed cocaine abusers. The investigators suggested that cocaine

might be used by patients with social phobia to bolster their self-confidence

and by those with depression to ameliorate their depressive symptoms.

35
Although the findings of an increased prevalence of psychopathology

among treatment-seeking cocaine abusers might result from Berkson’s bias,

epidemiologic studies of non-treatment-seeking adults also document an

increased co-occurrence of psychopathology in cocaine users compared with

nonusers (table 2). Kandel and associates (1985) reported on the results from

a community survey of 1,325 young adults in New York State who participated

in earlier studies while still in high school. Based on a structured interview,

thelr cross-sectional survey revealed that women cocaine users were less

happy and had higher rates of psychiatric hospitalization compared with

women who did not use cocaine. No association was found between

depression or psychiatric hospitalization and cocaine use among males.

Newcomb and colleagues (1987) studied a community sample of 739 young

adults in Los Angeles County, approximately one-third of whom came from

minority groups. They utilized a 7-point scale to assess intensity of cocaine

use and a brief symptom checklist to assess anxiety and depressive

symptoms. In their sample, 34 percent reported cocaine use (37 percent

of the men and 34 percent of the women), and 5 percent reported weekly

cocaine use. Symptoms of anxiety and depression were associated with

cocaine use.

TABLE 2. Epidemiological studies of psychopathology among treatmentseeking cocaine abusers

Study Sample

Investigators Size Setting

Diagnostic

Instrument Findings

Kandel et al.

1985

1,325 Community Structured

sample Interview

Newcomb et al. 739 Community Cocaine use

1987 sample 7-point scale,

SCL-43,

CES-D

Anthony and 20,862 Community DIS

Trinkoff 1969 sample

Women cocaine users are the

least happy and have highest

rates of psychiatric

hospitalization

34% use cocaine (37% men,

34% women); 5% use cocaine

weekly: anxiety and

depression symptoms

associated with cocaine use

Lifetime major depresslon in

25.6% of cocaine abusers vs.

7.6% of those with little

cocaine use; panic disorder in

15.8% of cocaine abusers vs.

1.7% of those with little

cocaine use

KEY: CES-D=Communlty Epidemiology Survey-Depression

36
The best data regarding the co-occurrence of psychiatric and substance abuse

disorders in community as opposed to treatment-seeking samples come from

the epidemiologic catchment area (ECA) study (Anthony and Trinkoff 1989),

which used a structured psychiatric interview (DIS) to assess psychopathology

and substance use disorders in a carefully designed epidemiologic sample of

adults. In the ECA study, the lifetime prevalence of drug abuse or

dependence among males ages 18 to 44 was 12.5 percent. A lifetime history

of major depression was found in 14 percent of men with a history of drug

abuse or dependence compared with 4 percent among those with no history of

drug abuse or depression. Lifetime ASP among those with drug abuse or

dependence was 38 percent compared with 10 percent among those without

substance abuse history. The lifetime prevalence of panic disorder was 3.2

percent among those with drug abuse or dependence compared with 0.9

percent among those with substance abuse history. ECA study data on

cocaine comorbidity document an increased lifetime prevalence of major

depression among heavier users of cocaine. For men ages 18 to 44 who had

never used cocaine or had used cocaine one to five times, the lifetime

prevalence of major depression was 7.8 percent; for those with a history of

more than five times of cocaine use but no history of daily use, lifetime

depression was 11 percent: men with a history of daily use for 2 weeks or

more but who did not meet DSM-III criteria for cocaine abuse had a lifetime

prevalence of 14.8 percent; and men with a history of cocaine abuse had a

lifetime prevalence of major depression of 25.8 percent. Similarly, a lifetime

prevalence of panic disorder was considerably higher in men with a history of

cocaine abuse (15.3 percent) compared with men who had used zero to five

times (1.7 percent), had used more than five times but never daily (2.4

percent), or had used daily for 2 weeks or more but did not meet criteria for

cocaine abuse (2.3 percent). Similar rates were found with regard to patterns

of use of both marijuana and heroin (tables 3 and 4).

TEMPORAL SEQUENCING OF DISORDERS

Most of the studies of psychopathology in cocaine abusers are crosssectional and shed little light on the temporal sequence of cocaine use and

psychopathology. However, McLellan and associates (1979) studied the

longitudinal course of 11 persistent stimulant abusers and documented the

onset of symptoms of paranoid schizophrenia in 5 of the 11 patients. Kandel

and Davies (1988) have reported results, from their longitudinal study of New

York State high school students, indicating that although depression predicted

subsequent cigarette use (57 percent of those with depression in the initial

interview reported subsequent cigarette use vs. 30 percent of those without

depression), very little of the variance among subsequent cocaine users could

be explained by early depression,

37
TABLE 3. ECA data on comorbidity, lifetime prevalence of major

depression (percent)

Drug History Cocaine Marijuana Heroin

Used 0-5 times 7.8 6.7 7.8

Used >5 times but not on a daily basis 11.0 8.0 8.7

Daily use for 2 weeks or more 14.6 13.2 17.4

Abuse/dependence 25.8 15.3 23.0

SOURCE: Anthony and Trinkoff 1989

TABLE 4. ECA data on comorbidity, lifetime prevalence of panic disorder

(percent)

Drug History Cocaine Marijuana Heroin

Used 0-5 times 1.7 1.7 1.7

Used >5 times but not on a daily basis 2.4 1.7 3.9

Daily use for 2 weeks or more 2.3 1.8 16.9

Abuse/dependence 15.3 3.2 9.2

SOURCE: Anthony and Trinkoff 1989

The most important data regarding the temporal sequencing of cocaine use

and psychopathology come from the ECA studies of incidence of psychiatric

disorders (Anthony and Petronis 1989, 1991). Subjects were interviewed

initially and at a 1 -year followup interval to determine the incidence or new

onset of psychiatric disorder. Those who reported cocaine use during the

initial interview were 14 times more likely subsequently to experience a panic

attack than were nonusers; users of cocaine and stimulants were 7.7 times

more likely than nonusers to experience a depression syndrome: and all users

of cocaine were twice as likely as nonusers to develop a depression syndrome.

Somewhat surprisingly, users of cocaine only (those who did not use other

stimulants) did not have a substantially increased risk of the depression

syndrome (estimated relative risk of 1.1). Cocaine users also were more

likely than nonusers to experience a manic episode (estimated relative odds

of 11.8) or a “mania syndrome” (defined as a spell of mania, hypomania, or

elation accompanied by some symptoms, such as racing thoughts, agitation,

or sleep disturbance-estimated relative odds of 5.5).

38
THE NEW HAVEN DIAGNOSTIC STUDY

In the New Haven study conducted by the authors’ group (Rounsaville et al.

1991), a consecutive sample of adults seeking inpatient treatment (n=149) and

outpatient treatment (n=149) were evaluated using the Schedule for Affective

Disorders in Schizophrenia lifetime version to assess research diagnostic

criteria (RDC) for cocaine abuse and other psychiatric disorders, All patients

met criteria for cocaine abuse or dependence. In an effort to distinguish

psychiatric syndromes from transient psychiatric symptomatology associated

with drug use and withdrawal, psychiatric symptoms occurring within 10 days

following the last use of cocaine or other drugs were excluded in the diagnostic

decision tree. Patients with a prior history of heroin dependence were excluded

from the study. Sixty-nine percent of the sample was male; 64 percent was

white. Most of the subjects were from lower social classes (76 percent social

class 4 or 5), and most (72 percent) were single, separated, or divorced. Fortyseven percent of the subjects were intranasal cocaine users, 13 percent were

intravenous users, and 40 percent smoked cocaine. The average age of the

sample was approximately 26 years, and the average age of drug abuse onset

in the sample was 16.6 years. Rates of psychiatric disorders did not differ

significantly between the inpatient and outpatient samples so that the results

have been pooled for the discussion,

Current affective disorders were found in 26.6 percent of the subjects (major

depression in 4.7 percent, cyclothymia or hyperthymia in 19.9 percent, and

hypomania in 2 percent) (see table 5). Current anxiety disorders were found

in 15.7 percent (panic disorder in 0.3 percent, generalized anxiety disorders in

3.7 percent, and phobias in 11.7 percent). Current diagnosis of alcoholism was

found in 28.9 percent. Using RDC, ASP disorder was found in 7.7 percent:

using DSM-III criteria, ASP was found in 32.9 percent. A lifetime history of

affective disorder was found in 61.5 percent (including a lifetime prevalence of

major depression of 30.5 percent: cyclothymia or hyperthymia, 19.9 percent:

mania, 3.7 percent; and hypomania, 7.4 percent). Lifetime prevalence of

anxiety disorders was 22.1 percent (panic disorder, 1.7 percent; generalized

anxiety disorder, 7 percent: and phobia, 13.4 percent). Lifetime history of

RDC alcoholism was 61 .1 percent. The prevalence of ADD in the sample

was 34.9 percent. Lifetime prevalence of schizophrenia or schizoaffective

disorder was 1.3 percent.

Because subjects had been asked to date the onset of symptoms of psychiatric

disorders and use of substances, the study allows evaluation of the temporal

sequencing of disorders. Depressive disorders were found to precede the

onset of drug abuse in approximately one-third of patients and followed the

onset of drug abuse in two-thirds. Anxiety disorders preceded the onset of

drug abuse in 68 percent of the patients: phobias preceded the onset of drug

39
TABLE 5. New Haven cocaine diagnostic study results (percent)

Psychiatric Diagnosis Current Disorder Lifetime Disorder

Major depression

Cyclothymial/hyperthymia

Mania

Hypomania

Panic disorder

Generalized anxiety

Phobia

Schizophrenia

Schizoaffective

Alcoholism

ASP-RDC

ASP-DSM-III

ADD

SOURCE: Rounsaville et al. 1991

4.7 30.5

19.9 19.9

0.0 3.7

2.0 7.4

0.3 1.7

3.7 7.0

11.7 13.4

0.0 0.3

0.3 1.0

28.9 61 .1

7.7 7.7

32.9 32.9

34.9

abuse in 87 percent of cases. Alcoholism preceded the onset of drug abuse

in only 21 percent of patients. Lifetime major depression would have been

diagnosed in 58.7 percent of patients if symptoms occurring within 10 days of

the last use of cocaine or other drugs were included in the diagnosis, compared

with the findings of lifetime major depression in 30.5 percent when symptoms

that did not persist more than 10 days after cessation of use were excluded.

Like opioid abusers in prior studies (Rounsaville et al. 1982), cocaine abusers

experienced increased rates of major depression, minor bipolar disorders,

anxiety disorders, and ASP disorder compared with rates found in the general

population. Major depression, anxiety disorders, and ASP disorder, however,

were somewhat more common in opioid addicts compared with cocaine

abusers. Minor bipolar disorder, alcoholism, and childhood ADD were more

common in cocaine abusers compared with opioid addicts.

Both alcoholism and major depression, which were found in high rates among

cocaine abusers, followed the onset of cocaine abuse in most patients,

suggesting that both disorders may be a consequence of cocaine abuse.

Major depression may result from both the social disruption associated with

cocaine abuse as well as the pharmacologic effects of prolonged abuse. The

high rates of alcoholism may result from patients’ attempts to self-medicate

symptoms of cocaine-induced anxiety or withdrawal and abstinence.

40
in the overall sample no gender differences were found in rates of major

depression, which is in contrast to the findings of Griffin and coworkers (1989)

and to findings about rates of depression in the community among men and

women. However, within subjects recruited from an inpatient setting in the

New Haven study, major depression was significantly more common among

women than among men.

COCAINE ABUSE AND SCHIZOPHRENIA

In almost all studies of psychopathology among treatment-seeking cocaine

abusers, including the authors’ studies, the prevalence of schizophrenia and

schizoaffective disorders is quite low. Rather than indicating a low prevalence

of cocaine abuse in schizophrenia or a protective effect of cocaine use in

preventing schizophrenia, this finding results from the exclusion of patients

with schizophrenia from admission to drug treatment programs. in fact, studies

document a high prevalence of stimulant use, including cocaine abuse, in

patients with schizophrenia. Schizophrenic patients appear to be more prone

to abuse stimulants than other drugs (Mueser et al. 1990; Schneier and Siris

1987). Although the diagnosis of cocaine abuse is often missed in clinical

settings (Ananth et al. 1989) several studies document cocaine abuse in

12 to 15 percent of patients with schizophrenia (Mueser et al. 1990; Negrete

et al. 1968; Siris et al. 1966; Richard et al. 1985).

High rates of cocaine abuse among patients with schizophrenia are believed

to result from several factors. Many patients with schizophrenia self-administer

stimulants to relieve the negative symptoms of schizophrenia (dysphoria,

anergia), postpsychotic depression, or neuroleptic side effects (Dixon et al.

1990; Siris 1990). Cocaine and other substance abuse also may reflect

attempts, albeit unsuccessful, at socialization.

TREATMENT IMPLICATIONS

Tricyclic antidepressants have been demonstrated to be beneficial in facilitating

initial abstinence from cocaine in cocaine abusers regardless of a diagnosis

of major depression (Gawin et al. 1989). Only 10 percent of the patients in

Gawin and coworkers’ study had major affective disorders, and the presence

or absence of these disorders did not differentially affect efficacy.

Although the initial response to tricyclic antidepressants does not appear

to depend on underlying psychopathology, clinically there may be some

differences In how long tricyclic medications are beneficial for cocaine

abusers depending on underlying psychopathology. For those without major

depression, there is little rationale to continue tricyclic antidepressants beyond

6 to 10 weeks. Tricyclic antidepressants may even exacerbate cocaine use

41
in some patients, possibly because side effects, such as jitteriness and

stimulation, may serve as conditioned cues leading to relapse (Weiss 1966).

For cocaine abusers with major depression, however, it may be beneficial to

continue tricyclic antidepressant use beyond the initial 6- to 10-week period

to prevent recurrence of symptoms of depression. Otherwise, recurrent

depression may lead to patients returning to cocaine use in an attempt to

ameliorate their depressive symptoms.

Cyclothymic disorders, including mania, hypomania, cyclothymia, and

hyperthymia, have been found in high rates among cocaine abusers,

suggesting the possibility of utilizing specific pharmacologic interventions for

these patients. Cocaine is thought to be used when patients are “high” to

amplify the high and avoid the crash or depression; use also is thought to

result from impulsivity and poor judgment associated with hypomania (Weiss

et al. 1988). Results of studies of lithium treatment, which is effective for

many cyclothymic disorders, have been conflicting. Gawin and Kleber (1984)

reported that four out of five patients with cyclothymic diagnoses, treated

with lithium in an open pilot study, stopped cocaine use abruptly after

administration of lithium carbonate. However, Nunes and coworkers (1990)

reported lithium responsiveness in one-third of cyclothymic patients treated

with lithium (with response defined as 3 weeks of cocaine abstinence), but

only 1 of 10 patients treated in the open pilot trial remained on lithium for

any prolonged period. The possibility that there is a differential treatment

response to lithium for those with mania or hypomania preceding drug

abuse (27 percent of the patients) needs to be evaluated.

Cyclothymia also may reflect the affective lability characteristic of severe

underlying personality disorders or atypical depression (rejection sensitivity).

Although atypical depression appears to be common in cocaine abusers

(27 percent as reported by Nunes and coworkers [1989]), treatment of

these patients with a monoamine oxidase inhibitor (MAOI) is probably

contraindicated, given the possibility of relapse to cocaine abuse and the

toxic interaction of cocaine and MAOIs. Carbamazepine, which has been

found to be effective in bipolar disorder and is currently under study for the

treatment of cocaine abuse, also needs to be evaluated for cocaine abusers

with cyclical mood disorders.

The high prevalence of childhood ADD among patients with cocaine abuse

(35 percent in the authors’ study, and adult residual ADD found in 7 percent

of Weiss and coworkers’ sample [1986]) suggests that cocaine abusers with

residual ADD may be using cocaine to self-medicate symptoms. Case reports

suggest that both pemoline magnesium and methylphenidate may lead to

cocaine abstinence and symptom reduction in these patients (Khantzian et al.

1984; Weiss et al. 1983). However, methyiphenidate has not been shown to

42
be effective in unselected patients and may even exacerbate cocaine

abuse by acting as a conditioned cue (Gawin et al. 1985). Further research

needs to be conducted to determine whether treatment response to either

methylphenidate or pemoline magnesium is related to a diagnostic subtype

of cocaine abusers.

Cocaine-abusing patients with schizophrenia may benefit from several

pharmacologic interventions, such as (1) neuroleptic dose reduction or

change of neuroleptic (if cocaine is used to counter neuroleptic side effects),

(2) neuroleptic dose increase or change of neuroleptic (to ameliorate

exacerbation of psychotic symptoms associated with cocaine abuse),

(3) adjunctive anticholinergic agents or amantadine (to counter neuroieptic

side effects and thus reduce the need to use cocaine to counter these

effects), or (4) tricyciic antidepressants (if cocaine is used to counter

anhedonia, anergia, or postpsychotic depression). Siris and associates

(1988) have found imipramine in conjunction with a neuroleptic effective

in treating postpsychotic depression in schizophrenic patients with a history

of substance abuse. The newly approved antipsychotic ciozapine, which has

a low incidence of neuroieptic side effects and seems particularly beneficial

in countering the negative symptoms of schizophrenia, may be particularly

beneficial for cocaine-abusing schizophrenic patients. Since cocaine may

be used by schizophrenic patients as a result of peer pressure in an attempt

at “normal” socialization, these patients also may benefit from participation

in drug-free social activities, clubs, and groups.

In addition to the search for better pharmacologic agents to treat patients with

comorbid psychiatric diagnoses and cocaine abuse, a variety of psychosocial

interventions also must be developed and tested. Patients with affective

instability, rejection sensitivity, and borderline or ASP disorder may benefit

from participation in, for example, Cocaine Anonymous or other self-help

groups, in which consistent support for abstinence and 24-hour assistance

from sponsors and other members may be available. Intensive, daily

treatment programs also may provide the necessary level and consistency

of support for these patients. As documented by McLellan and coworkers

(1983) for opiate addicts with significant psychiatric symptomatology,

utilization of experienced psychotherapists, rather than drug counselors,

also may be beneficial for cocaine abusers with severe psychopathology.

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46
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AUTHORS

Richard Schottenfeld, M.D.

Associate Professor of Psychiatry

Kathleen Carroll, Ph.D.

Assistant Professor of Psychiatry (Psychology)

Bruce Rounsaville, M.D.

Associate Professor of Psychiatry

Department of Psychiatry

Yale University School of Medicine

CMHC

34 Park Street

New Haven, CT 06519

47
Clinical and Research Perspectives on

Cocaine Abuse: The

Pharmacotherapy of Cocaine Abuse

Thomas R. Kosten

INTRODUCTION

The development of medications to treat cocaine abuse has become a major

research initiative of the National Institute on Drug Abuse (NIDA). A variety

of medications already have been used to attain cocaine abstinence and to

decrease relapse back to cocaine abuse (Kosten 1989). These medications

generally have been selected based on two rationales, one clinical, the other

neurochemical (Kosten 1989). First, because the clinical syndrome that

evolves after discontinuation of cocaine binges resembles a depressive

disorder, antidepressant medications may have clinical utility in alleviating

this syndrome and facilitating abstinence from cocaine (Gawin and Kleber

1986). The second, neurochemical rationale follows from cocaine’s effect

on dopaminergic reinforcement mechanisms in the brain. Because of this

dopamine connection, pharmacological agents with dopaminergic activity

have been considered prime candidates for treatment of cocaine dependence.

These agents might have a range of action, including either substitution

or blocking agents for cocaine or agents that restore cocaine-induced

neurochemical changes back to normal. These rationales are not

necessarily mutually exclusive, and an antidepressant agent that reduces

the clinical phenomena observed during cocaine discontinuation also might

have significant dopaminergic activity that would be consistent with a

neurochemicai rationale for the treatment of cocaine dependence. Other

medications also have been proposed to treat cocaine dependence based

on some of the other actions of cocaine, such as sensitization or its effect

on nondopaminergic neurotransmitters (Kosten 1990). Examples of these

agents include carbamazepine, an agent to reverse sensitization from cocaine,

and gepirone, a serotonergic agonist that has antidepressant activity. Finally,

agents to reduce cocaine toxicity, such as calcium channel blockers, have

been examined as pharmacotherapies for cocaine dependence (Muntaner

et al. 1988).

46
DESIPRAMINE

Although a variety of agents have been examined in uncontrolled pilot

studies, randomized, placebo-controlled studies are critical in this field

because a significant placebo response may occur in cocain abusers

(satel and Kosten 1991). Comparatively few agents have been subjected

to randomized placebo-controlled studies. The tricyclic antidepressant

desipramine is the first medication to recieve substantial support for its efficacy

(Gawin et al. 1989a). In a double-blind comparison of desipramine to lithium

and placebo in 72 cocaine-abusing patients, it was found that 60 percent of

the desipramine patients were abstinent for 3 to 4 continuous weeks during

the first 6 weeks of treatment. In comparison, the placebo group had only

20 percent of patients abstinent and lithium only 25 percent. This was a

statistically significant demonstration of desipramine's efficacy as an agent

to initiate abstinence from cocaine (Gawin et al. 1989a). In this study there

was a substantial reduction in cocaine use from a mean of 3.5 g per week down

to 0.5 g per week within the first week of treatment. A statistically significant

difference between the desipramine and placebo treatments at week 2 was

sustained for the rest of the treatment period.

Cocaine craving also was reduced significantly with desipramine compared

with placebo, although this craving reduction on desipramine did not become

significantly different from the placebo reduction until week 4 or 5 in the trial.

This finding was different than the original pilot studies, which suggested

that cocaine craving initially was reduced by desipramine, followed by a

reduction in cocaine use. Instead, it appears that a significant reduction in

cocaine craving lags behind the reduction in cocaine use by about 3 weeks.

Thus, the mechanism of desipramine’s action in reducing cocaine abuse did

not appear to be a simple anticraving agent, which subsequently led to a

decrease in cocaine use.

The clinical efficacy of desipramine also has been examined in other cocainabusing populations, including cocaine abusers who are on methadone

maintenance. In a recently completed study, Kosten and colleagues (in

press[a]) compared desipramine at 150 mg a day to amantadine at 300

mg a day and to placebo in the treatment of cocaine-abusing methadone

patients, In this double-blind, randomized clinical trial, patients entered at

a stable methadone dose (average 45 mg daily), and cocaine abuse was

monitored using twice-weekly urines. Other outcome measures included

self-reported use of cocain and assessments of cocaine craving as well as

blood levels of amantadine and desipramine. Treatment retention in this

methadone population was excellent, with more than 80 percent of the

patients completing the full 12-week trial.

49
In this cocaine study (Kosten et al., in press[a]), cocaine craving was minimally

changed by desipramine compared with placebo or amantadine. The greatest

reduction in craving was found with amantadine, which dropped to 25 percent

below baseline, whereas with desipramine, craving never dropped more than

15 percent belove baseline. At week 5 desipramine craving actually went 25

percent above baseline, suggesting that desipramine had no efficacy as an

anticraving agent in this population. Despite this lack of efficacy for cocaine

craving, cocaine use substantially declined within the first week of treatment

with desipramine, with a 50-percent reduction in dollars spent on cocaine.

A comparable reduction in cocaine use was found with amantadine, whereas

the placebo group showed an increase in cocaine use to 140 percent above

baseline through week 5. Subsequent use of cocaine by the placebo group

then declined after week 5; by week 9, use was equivalent to that for the

desipramine group. During weeks 10 and 11 the desipramine group showed

a further decline in use, which was not shown by the placebo group. At all

time points after the baseline, cocaine use by the amantadine group was less

than use by the placebo group. The percentage of patients who were cocaine

abstinent for at least 2 weeks was significantly greater in the amantadine group

than in either the desipramine or placebo group. This increased abstinence

with amantadine was found whether considering all patients who entered the

study or considering only those patients who completed the 12-week treatment

program. Kosten and colleagues found that, by either excluding those patients

with antisocial personality disorder or focusing only on those patients with

depressive disorders, deslpramine had some efficacy in reducing cocaine use,

but it still did not produce a significant reduction in cocaine craving (Ziedonis

and Kosten 1991). In summary, amantadine appeared to show good treatment

response in this population of cocaine-abusing methadone patients, whereas

desipramine failed to show a significant anticraving effect and showed a

significant reduction in cocaine usage only in selected patient subgroups,

as Arndt and colleagues (1990) also found.

These findings of either no change or a significant delay in reduction in cocaine

craving with desipramine suggested that its potential mechanism of action in

reducing cocaine use be examined more carefully. This examination was done

in a laboratory study involving the administration of intravenous (IV) cocaine to

subjects who were stabilized on desipramine for at least 10 days (Kosten et al.,

in press[b]). In these studies, eight challenges with IV cocaine were given,

four of the challenges while on placebo desipramine, four while on active

desipramine. The IV cocaine dosages ranged from 0 to 0.5 mg/kg at a fixed

desipramine dosageof 150 mg daily. In these studies, the subjective effects

and physiological responses to the cocaine challenges were examined.

50
Physiologically, it was found that the heart rate was approximately 10 beats per

minute higher while maintained on desipramine than while on placebo, but this

baseline change in heart rate was not associated with a substantial increase in

response to acute cocaine administration. Instead, there was an attenuation

in the change of heart rate with increasing cocaine doses on desipramine

compared with placebo. On placebo desipramine, the heart rate change rose

12 percent from baseline at the 0.125-mg/kg dose and rose 60 percent from

baseline at the 0.5-mg/kg dose. In contrast, when treated with desipramine,

heart rate rose 8 percent over baseline at the 0.125-mg/kg dose and only

21 percent over baseline at the 0.5-mg/kg dose. Thus, a fairly steep doseresponse curve was found for placebo desipramine, whereas for active

desipramine the dose response curve was quite flat, with a slope that was

four times steeper in the placebo compared with the desipramine condition.

It was thought that this substantial attenuation in physiological response

also might be reflected in a reduced subjective response to cocaine while

in the desipramine condition. Whereas neither high, rush, nor euphoria was

attenuated during the desipramine treatment condition for any of the cocaine

dosages, another measure of subjective response to cocaine—desire or craving

for cocaine—as altered by desipramine, which was stimulated by the acute

cocaine administration. Previous work by Jaffe and colleagues (1989) had

shown that cocaine markedly stimulated the desire or craving for more cocaine.

The study found that this craving for cocaine was higher at the baseline in the

no-desipramine than in the desipramine condition and that the craving returned

to baseline significantly more rapidly during the desipramine condition. Within

45 minutes, craving was back to baseline levels during the desipramine

condition and completely fell to zero within 90 minutes. In contrast, during the

no-desipramine condition, it took 90 minutes for craving to return to baseline

and more than 240 minutes for it to fall to near zero levels. Thus, desipramine

appeared to reduce the duration of desire for cocaine and perhaps reduce the

priming effect of a single dosage of cocaine, which may lead to relapse.

Similar findings have been described by Fischman and coworkers (1990) in

examining acute cocaine responses in desipramine-stabilized patients. In

addition, they found a reduction in euphoria and high in the desipramine

condition, but their design suffered from a lack of placebo control for the

desipramine condition. Further work should examine this issue clearly and

also look at the possible interaction between the attenuated physiological

responses and the reduced subjective effects of acute cocaine dosing. Clearly,

this conceptualization of craving is different from asking patients about level

of craving over the previous 24 hours, and this more general assessment of

craving used during clinical trials may not be related to the acute craving that

occurs soon after using cocaine (Gawin et al. 1989a; Kosten et al., in press[a ]).

51
BUPRENORPHINE

Other agents also have been examined in the treatment of cocaine abuse.

Most prominently, recent work with buprenorphine has demonstrated the utility

of this agent in the cocaine-abusing opioid addict (Kosten et al. 1989a, 1989b).

Because this population has not responded particularly well to desipramine

(Kosten et al., in press[a]; Arndt et al. 1990), it Is important to find agents for

this high-risk population that is spreading acquired immunodeficiency syndrome

by IV cocaine abuse (Kosten et al. 1987). In a 1-month trial comparing 41

patients on buprenorphine with 60 patients on methadone, it was found that

the rate of illicit cocaine in urines for the methadone sample was more than

25 percent, whereas the rate of illicit cocaine urines in the buprenorphine

sample was less than 3 percent. This almost tenfold difference was statistically

significant and strongly suggested the clinical utility of this approach (Kosten

et at. 1989a). Patients who were abusing cocaine were switched onto

buprenorphine; in a crossover of 12 patients from methadone, 5 who were

shown to be abusing cocaine in up to 70 percent of their urine samples

stopped their cocaine abuse; 1 patient reduced his cocaine use by

50 percent. The other six patients did not show any cocaine use either on

methadone or when switched over to buprenorphine (Kosten et al. 1989b).

Double-blind, randomized clinical trials are under way examining the efficacy

of buprenorphine vs. methadone for opioid as well as cocaine abuse. Although

a recent study examining pharmacological efficacy of buprenorphine found no

difference between methadone and buprenorphine in the rate of cocainepositive urines during a 6-month outpatient trial (Johnson et al. 1990), some

methodological issues need to be considered in its interpretation. Because of

poor treatment retention and a lack of concurrent psychosocial interventions

accompanying the use of methadone or buprenorphine, this issue of efficacy for

cocaine abuse remains to be examined in a more intensive intervention setting.

OTHER AGENTS

Other agents that have been examined in pilot studies include mazindol,

sertraline, flupenthixol, calcium channel blockers, and antiseizure medications

such as carbamazepine. Pilot work with mazindol in eight cocaine-abusing

methadone patients demonstrated a substantial reduction in craving and use

of cocaine within 1 week, which was sustained for a month (Berger et al.1989).

However, a subsequent crossover study by Diakogiannis and colleagues (1991)

failed to demonstrate a significant difference from placebo, although this study

was limited by potential carryover effects, a short duration of treatment (1

week), and a special population of methadone-maintained cocaine abusers.

52
Pilot work with sertraline, a serotonin uptake inhibitor, has appeared quite

promising, with a reduction in cocaine use equivalent to that found in

desipramine studies (Gawin et al. 1989a). Interestingly, the cocaine-craving

assessments were higher than those found in placebo treatments during the

first 4 weeks of treatment with sertraline, whereas cocaine use had essentially

stopped. Thus, sertraline appeared to be stimulating reported craving, yet

at the same time reducing cocaine usage. This association raises further

interesting questions about assessments of craving as well as the relationship

between cocain craving and cessation of cocaine use.

Another interesting agent has been the recent work with flupenthixol by Gawin

and colleagues (19896). This injectable, long-acting dopamine antagonist was

found to significantly improve retention in treatment as well as to decrease

cocaine craving and use among crack abusers in the Bahamas. Because of its

long-acting formulation, it can be given as infrequently as every 2 weeks. This

may be a significant clinical advance as well as an important basic finding,

because it is a dopamine antagonist that has shown efficacy. Animal studies

have suggested that dopamine antagonists should be effective treatment

agents, but to date none have been useful in human cocaine addicts, Thus,

this antagonist provides an important link between animal and human

pharmacology.

Finally, agents to reduce cocaine toxicity have been examined, including

the calcium channel blocker nifedipine. In studies by Muntaner and colleagues

(1988), it has been found that nifedipine reduces the acute effects of cocaine

and attenuates cocaine-induced high and euphoria. It also may reduce cardiac

toxicity from cocaine and be particularly useful in those patients who develop

cardiac complications from cocaine usage. Other work with antiseizure

medications, particularly carbamazepine, by Halikas and colleagues (1989)

and Kuhn and colleagues (1990) has suggested that these agents may

be useful in reducing cocaine craving and use. Although a double-blind,

randomized clinical trial is not yet available on the efficacy of these agents,

a variety of animal studies have suggested that these agents may be useful

in reducing the sensitization produced by cocaine. Controlled trials of

carbamazepine are clearly indicated.

CONCLUSIONS

Overall, a variety of agents have been developed for the treatment of cocaine

dependence, and although few of them have been tested for efficacy in

randomized clinical trials, they hold much promise for future treatments of

cocaine-dependent patients. An important consideration in the future

development of pharmacotherapies for cocaine dependence involves the

53
matching of patients to appropriate pharmacological treatments based on

stages of recovery as well as predisposing and vulnerability factors such as

psychopathology (e.g., major depressive disorder and possibly antisocial

personality disorder).

REFERENCES

Arndt, I.; Dorozynsky, L.; Woody, G.; Mclellan, A.T.; and O’Brien, C.P.

Desipramine treatment of cocaine abuse in methadone maintenance

patients. In: Harris, L.S., ed. Problems of Drug Dependence 1989:

Proceedings of the 51st Annual Scientific meeting, The Committee on

Problems of Drug Dependence, Inc. National Institute on Drug Abuse

Research Monograph 95. DHHS Pub. No. (ADM)90-1663. Washington, DC:

Supt. of Docs., U.S. Govt. Print. Off., 1990. pp. 322-325.

Berger, P.; Gawin, F.H.; and Kosten, T.R. Treatment of cocaine abuse with

mazindol. Lancet 1:263, 1989.

Diakogiannis, I.A.; Steinberg, M.; and Kosten, T.R. Mazindol treatment of

cocaine abuse. A double-blind investigation. In: Harris, L., ed. Problems of

Drug Dependence 1990: Proceeding of the 52nd Annual Scientific Meeting,

The Committee on Problems of Drug Dependence, Inc. National Institute on

Drug Abuse Research Monograph 105. DHHS Pub. No. (ADM)91-1753.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1991. p. 514.

Fischman, M.W.; Foltin, R.W.; Nestadt, G.; and Pearlson, G.D. Effects of

desipramine maintenance on cocaine self-administration by humans.

J Pharmacol Exp Ther 253:760-770, 1990.

Gawin, F.H.; Allen, D.; and Humblestone, B. Outpatient treatment of “crack”

cocaine smoking with flupenthixol decanoate. Arch Gen Psychiatry 46:322-

325,1989b.

Gawin, F.H., and Kleber, H.D. Abstinence symptomatology and psychiatric

diagnosis in cocaine abusers: Clinical observations. Arch Gen Psychiatry

43:107-113, 1986.

Gawin, F.H.; Kleber, H.D.; Byck, R.; Rounsaville, B.J.; Kosten, T.R.; Jatlow, P.I.;

and Morgan, C. Desipramine facilitation of initial cocaine abstinence. Arch

Gen Psychiatry 46:117-121, 1989a.

Halikas, J.; Kemp, K.; Kuhn, K.; Carlson, G.; and Crea, F. Carbamazepine for

cocaine addiction? Lancet 1:623-624, 1989.

Jaffe, J.H.; Cascella, N.G.; Kumor, K.M.; and Sherer, M.A. Cocaine-induced

cocaine craving. Psychopharmacology 97:59-64, 1989.

Johnson, R.E.; Fudala, P.J.; Collins, C.C.; and Jaffe, J.H. Outpatient

maintenance/detoxification comparison of methadone and buprenorphine.

In: Harris, L.S., ed. Problems of Drug Dependence 1989: Proceedings of

the 51st Annual Scientific Meeting, The Committee on Problems of Drug

Dependence, Inc. National Institute on Drug Abuse Research Monograph

95. DHHS Pub. No. (ADM)90-1663. Washington, DC: Supt. of Docs, U.S.

Govt. Print. Off., 1990. p. 384.

54
Kosten, T.R. Pharmacotherapeutic interventions for cocaine abuse: Matching

patients to treatments. J Nerv Ment Dis 177:379-389, 1989.

Kosten, T.R. Neurobiology of abused drugs: Opioids and stimulants. J Nerv Ment

Dis 178:217-227, 1990.

Kosten, T.R.; Gawin, F.H.; Silverman, D.G.; Fleming, J.; Compton, M.; Jatlow,

R.; and Byck, R. Intravenous challenges during desipramine maintenance.

Neuropsychopharmacology, in press(b).

Kosten, T.R.; Kleber, H.D.; and Morgan, C. Treatment of cocaine abuse with

buprenorphine. Biol Psychiatry 26:637-639, 1989a.

Kosten, T.R.; Kleber, H.D.; and Morgan, C.H. Role of opioid antagonists in

treating intravenous cocaine abuse. Life Sci 44:887-892, 1989b.

Kosten, T.R.; Morgan, C.J.; and Schottenfeld, R. Amantadine and desipramine

for cocaine abusing methadone patients. Arch Gen Psychiatry, in press(a).

Kosten, T.R.; Rounsaville, B.J.; and Kleber, H.D. A 2.5 year follow-up of

cocaine use among treated opioid addicts: Have our treatments helped?

Arch Gen Psychiatry 44:281-284, 1987.

Kuhn, K.L.; Halikas, J.A.; and Kemp, K.D. Carbamazepine treatment of cocaine

dependence in methadone maintenance patients with dual opiate-cocaine

addiction. In: Harris, L.S., ed. Problems of Drug Dependence 1989:

Proceedings of the 51st Annual Scientific Meeting, The Committee on

Problems of Drug Dependence, Inc. National Institute on Drug Abuse

Research Monograph 95. DHHS Pub. No. (ADM)90-1663. Washington, DC:

Supt. of Docs., US. Govt. Print. Off., 1990. pp. 316-317.

Muntaner, C.; Kumor, K.; Nagoshi, C.; and Jaffe, J. Effects of nifedipine (a

Ca++ modulator) pre-treatment on cardiovascular and subjective responses

to intravenous cocaine administration in humans. In: Harris, L.S., ed.

Problems of Drug Dependence 1088: Proceedings of the 50th Annual

Scientific Meeting, The Committee on Problems of Drug Dependence, Inc.

National Institute on Drug Abuse Research Monograph 90. DHHS Pub. No.

(ADM)89-1605. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off.,

1988. p. 388.

Satel, S.L., and Kosten, T.R. Designing drug efficacy trials in the treatment of

cocaine abuse. J Nerv Ment Dis 179:89-96, 1991.

Ziedonis, D.M., and Kosten, T.R. Depression as a prognostic factor for

pharmacological treatment of cocaine dependence. Psychopharmacol

Bull 27:337-343, 1991.

ACKNOWLEDGMENT

The work described in this chapter was supported by NIDA grants DA-04060,

DA-04505, DA-05626, DA-061 90, and DA-0112.

55
AUTHOR

Thomas R. Kosten, M.D.

Associate Professor of Psychiatry

Substance Abuse Treatment Unit

Department of Psychiatry

Yale University School of Medicine

27 Sylvan Avenue

New Haven, CT 06519

56
Medications Development at the

National Institute on Drug Abuse:

Focus on Cocaine

David N. Johnson and Frank J. Vocci*

HISTORY

Congress passed the Anti-Drug Abuse Act of 1988 as a legislative

response to the current drug epidemic. Cocaine and crack use was an

important consideration in the development and passage of this legislation,

Cocaine has been reported to be the third most commonly abused drug,

after alcohol and marijuana (Kosten et al. 1987). Epidemiological surveys

indicated that, in 1988, 11 percent of the U.S. household population had

used cocaine one or more times in their lives, 4 percent in the past year,

and 2 percent in the past month (Alcohol, Drug Abuse, and Mental Health

Administration 1990a). These figures are probably an underestimate of

the problem because they represent a sample of only households and do

not include other populations, such as those in prisons and street people,

who are known to be heavy users of illicit substances. Furthermore, these

surveys are self-reporting and thus have the potential to be skewed by

respondents’ lack of truthfulness.

In recent years, smoking cocaine has become more prevalent, Crack

emerged in 1983 in the Bahamas as a cheaper, high-quality substitute

for “freebasing,” which required elaborate equipment and flammable

solvents. Crack was easily produced by mixing cocaine with baking

soda and water. It was easier to handle and use and produced a more

rapid and intense euphoric effect. Approximately 31 percent of cocaine

users in the 1988 National Household Survey on Drug Abuse indicated

they had smoked crack within the past year. Although the ratio of male

to female users of intravenous or intranasal cocaine administration has

*The opinions expressed in this chapter are those of the authors

and do not necessarily reflect the opinions or policies of NIDA.

57
remained relatively constant at 2:1, the introduction of crack has resulted

in a more acceptable form of drug-taking for women, and the ratio of men

to women abusers has narrowed closer to 1.5:1 (Alcohol, Drug Abuse,

and Mental Health Administration 1990b).

The 1988 legislation authorized up to $2.7 billion for all Federal

activities in the “war on drugs.” The National Institute on Drug Abuse

(NIDA) received almost $300 million for use in data collection, treatment

evaluation, demonstration projects, and, for the first time, the development

of new and improved medications to fight drug abuse.

Of the $2.7 billion, $10 million was allocated for medications development.

In subsequent years, the budget for medications development has

increased as programs have been initiated and studies funded.

MEDICATIONS DEVELOPMENT

The new legislation involved the establishment of a new division within

NIDA. In 1989, the Medications Development Division (MDD) was outlined,

although it did not become official until 1990 (Alcohol, Drug Abuse, and

Mental Health Administration 1990c). Its goals include the following:

1.

2.

3.

4.

Conducting necessary studies to identify, develop, and obtain Food

and Drug Administration (FDA) marketing approval for new medications

for the treatment of drug addiction and other brain and behavioral

disorders

Developing and administering a national program of basic clinical

pharmaceutical research designed to develop innovative biological

and pharmacological treatment approaches for addictive disorders

Establishing a close working relationship with pharmaceutical and

chemical companies in the United States and abroad and with medication

development programs that may be found in other agencies in the United

States or abroad

Developing a specific medication to treat cocaine overdose

MDD is currently one of six divisions within NIDA. It is composed of the

following branches: Chemistry/Pharmaceutics, Pharmacology/Toxicology,

Statistics, Regulatory Affairs, and Clinical Trials.

Working with pharmaceutical companies, academia, and other

Government agencies, MDD plans to identify and develop up to eight

new chemical entities per year. At a recent American Chemical Society

58
meeting on drug abuse, Dr. Duncan Taylor (senior research fellow at

Bristol-Myers Squibb) stated that MDD is “the Manhattan Project for

chemists in the war on drugs” (Waldrop 1989). Taylor’s company

currently is cosponsoring with NIDA the clinical trials of a new drug

that may be of use in the treatment of cocaine abuse.

The development of these compounds can be a long and costly procedure.

The Pharmaceutical Manufacturers Association has estimated that the

average time and cost for a new chemical entity to be developed, from

synthesis to marketing, is 7 to 11 years and $120 million (NIDA launches

$20 million . . . 1988-1989). MDD has received some assurance from

FDA that cocaine dependence treatments will receive expedited review.

Furthermore, the treatments may be eligible for Subpart E classification

(reserved for diseases that produce mortality or serious irreversible

morbidity).

From a scientific and regulatory standpoint, there are three possible

indications that would be useful in the treatment of dependence:

(1) initiation and facilitation of abstinence, (2) treatment of cocainespecific withdrawal symptoms (e.g., anhedonia), and (3) prevention

of relapse to drug-seeking behavior.

There is currently no approved pharmacologic adjunct to the management

of cocaine dependence. In outpatient clinical trials, the dropout rate is high.

It has been estimated that relapse rates as high as 50 percent within 1 to 2

weeks occur in addicts (Gawin and Kleber 1988; Weddington et al. 1991).

Thus, initiation or facilitation of abstinence can likely be demonstrated in

6- to 8-week trials when the right medicine is found.

There are three possible types of medications that would be of value

in facilitating abstinence. The first type of medication would be limited

agonist therapy (e.g., cocaine chewing gum) that may help the addict

stay off cocaine. Another example of limited agonist activity would be

a delayed-release sympathomimetic anorectic. (It is not clear whether

substitution therapy, albeit limited, will have a salutary effect on this

disorder. Moreover, the duration of therapy for this phase of treatment

is unknown.)

The second type of potential treatment would be a medication that

reverses or ameliorates biochemical alterations in the central nervous

system and, as a consequence, reduces or eliminates cocaine intake.

The “dopamine-deficit” hypothesis of Dackis and Gold (1985) and its

proposed reversal by bromocriptine is an example of a potential therapy

by increasing dopaminergic tone.

59
The third type of potential agent that might be of value in the facilitation

of abstinence would be a cocaine antagonist. Such a treatment could

be a true pharmacologic antagonist or could indirectly block the reinforcing

actions of cocaine. The hypothesis is that an antagonist would facilitate

extinction of drug-seeking behavior by reducing or eliminating the reinforcing/

subjective effects of cocaine. Compliance problems may be anticipated with

such a medication. A depot intramuscular dosage form may have to

be developed for this purpose.

The usual manifestations of physiological withdrawal (hypertension,

tachycardia, diaphoresis, piloerection, cramps, and seizures) seen in

opiate or barbiturate addicts are not present in cocaine abusers. However,

Gawin and Kleber (1988) have reported that cocaine abstinence results in

the gradual onset of a significant protracted dysphoric syndrome, including

decreased activation, amotivation, depression, and intense boredom with

limited pleasure from the environment (anhedonia). Cognitive deficits also

have been reported (Fischman 1984). Preceding these dysphoric events

is a euthymic period that lasts from 1 to 5 days. In inpatient settings, drug

craving decreases in a monotonic fashion during this euthymic period

(Weddington et al. 1991). The early withdrawal syndrome noted following

cessation of cocaine is not life threatening, nor does it appear to require

pharmacologic intervention for symptom management.

There are several types of agents that might be developed for the

treatment or reversal of symptoms associated with cocaine withdrawal.

Agents for the treatment of cocaine-associated anhedonia, cognitive

deficits, and possibly cocaine-related depression are examples of the

types of agents that may be developed.

Agents for the prevention of relapse to drug-seeking behavior fall into

two general categories. The first type of medication is an antagonist

that could block the effects of cocaine. The second type is an agent

that affects the response to conditioned stimuli associated with cocaine

abuse.

Although there are no prototypic agents that block the response to

conditioned stimuli, laboratory techniques are available that present

conditioned stimuli associated with cocaine abuse. It is possible to

measure the increase in desire (craving) for cocaine associated with

these conditioned stimuli and test which drugs may reduce or eliminate it.

Finally, agents that will manage patients in acute cocaine overdose

situations need to be developed. For the most part, these probably

would be cocaine antagonists, like naloxone, which is used for opiate

intoxication.

60
NEUROBIOLOGICAL RATIONALE

Dopamino and Cocaine

Like other abused stimulant drugs, cocaine has multiple effects on

endogenous neurotransmitter systems. The accepted explanation of

cocaine-induced euphoria is related to the compound’s profound inhibition

of dopamine reuptake systems, This increases the concentration of

dopamine in the brain, particularly within the pleasure centers and

reward pathways (Bozarth and Wise 1986). If these pathways are

antagonized with dopamine blockers (neuroleptics) or if they are

chemically destroyed (6-hydroxy-dopamine) or surgically ablated, the

behavioral effects of cocaine in such procedures as self-administration

are eliminated (Wise 1984). Ritz and colleagues (1987) identified a

cocaine-binding site in the brain that has been associated with the

compound’s reinforcing properties. This binding site appears to be on

the dopamine transporter or dopaminergic nerve terminals, Woolverton

and colleagues have reported a decrease in D, binding sites in rats

(Kleven et al. 1990) and in monkeys (Farfel et al. 1990) after chronic

cocaine administration.

Serotonin and Cocaine

In addition to blockade of dopamine reuptake, cocaine is thought to

produce an increase in serotonergic tone in the synaptic cleft by inhibiting

reuptake (Hall et al. 1990). It has been reported that cocaine is actually

more efficacious as an inhibitor of serotonin uptake compared with

dopamine uptake (Lakoski and Cunningham 1988). Furthermore,

serotonergic fibers emanating from the raphe magnus have been

shown to inhibit the release of dopamine (White et al. 1987). It is not

known whether the effect of cocaine on the serotonin system enhances

or modulates its effect on the dopamine system. Agents that modulate

the serotonin system may be tested for alteration of cocaine’s effect.

Opiates and Cocaine

Recent evidence has suggested that there are comodulatory

interactions between endogenous opioid and dopaminergic systems

in brain, DiChiara and lmperato (1988) reported that μ-agonists

(morphine, methadone) stimulate dopamine transmission in the

mesolimbic system, whereas -agonists reduce it by the same extent.

Furthermore, morphine suppressed cocaine self-administration in

squirrel monkeys (Kosten et al. 1987) whereas buprenorphine—a

μ-partial agonist—also suppressed cocaine self-administration in

rhesus monkeys at doses similar to those that suppressed opioid61
maintained responding (Mello et al. 1990). These data suggest a link

between the opioid system and the other systems responsible for the

reinforcing effect of cocaine in nonhuman primates. However, recent

data from the University of Michigan (Winger and Woods 1992) failed

to replicate Mello’s data, as much higher doses of buprenorphine were

required to suppress cocaine self-administration than were required to

suppress alfentanil self-administration.

The extrapolation of these animal data to the clinical setting requires

caution, especially because it is well-known that addicts coadminister

opiate agonists with cocaine. In one recent study, Johnson and coworkers

(1991) reported that heroin addicts given 6 mg of buprenorphine or 60 mg

of methadone daily for up to 18 weeks did not reduce their cocaine intake.

Nonetheless, the link between the opiate and the dopaminergic systems

needs to be explored.

TREATMENT RATIONALE

Reversal of Cocaine Deficits

Binding studies of long-term cocaine administration to animals have

shown increased -adrenergic, -adrenergic, and dopaminergic receptor

sensitivities. In addicts, this increased dopaminergic receptor sensitivity

has been hypothesized to explain the abstinence-induced dysphoria and

craving (Kleber and Gawin 1984). Since chronic tricyclic antidepressant

treatment has been shown to down-regulate ß-adrenergic and dopaminergic

receptor sensitivities (as a compensatory response to presynaptic uptake

blockade), it has been suggested that antidepressant agents, such as

desipramine, could reverse the neuroreceptor adaptations to cocaine

abuse and facilitate a neuronal homeostasis in addicts (Hall et al. 1990).

Blockade of Cocaine-Related Effects

Seizures associated with cocaine use, or overuse, have been reported.

Because the addict uses more and more cocaine to satisfy his or her habit,

it is possible that this stimulant can result in the “kindling” phenomenon of

seizure production. Animal studies have shown that cocaine administered

in subconvulsive doses over a period of time will result in the production of

convulsions (Post et al. 1976). Carbamazepine, an antiepileptic agent, has

been used with some success to prevent the effects of prolonged cocaine

exposure (Post et al. 1987) and also as a treatment for craving (Halakis et

al. 1989).

62
Abstinence Therapy

Drugs currently under investigation for the first phase of cocaine

withdrawal (abstinence initiation) include antidepressants (imipramine,

desipramine, sertraline, and fluoxetine), an antiepileptic (carbamazepine),

and an anorectic (mazindol). These compounds are believed to treat

some of the symptoms of the withdrawal. Other drugs that have shown

efficacy in blocking the reinforcing properties of cocaine include the calcium

channel blockers (nimodipine, nifedipine) and lithium, a compound useful

in the treatment of manic-depressive illness. However, dopamine receptor

blockers, such as haloperidol, perphenazine, pimozide, and sulpiride,

have been reported to increase the rate of self-administration in animals

(Woolverton and Kleven 1988), an effect that may be consistent with the

antagonist properties of the dopamine blockers.

Maintenance Treatment

For maintenance therapy, dopamine agonists have been prescribed,

including amantadine, bromocryptine, methylphenidate, and L-dopa.

These compounds have been alleged to reduce craving (Gawin 1988).

Relapse Prevention

There are no known cocaine antagonists (Gawin and Kleber 1988).

These compounds would be useful in preventing relapse. Psychotherapy

has been shown to be of limited value (Gawin and Kleber 1988).

Overdose Therapy

As stated above, there are no compounds that are known to antagonize

the toxic effects of cocaine. Overdose therapy is currently limited to

supportive treatment, including blockers to attenuate the cardiovascular

effects and anxiolytics to support the psychological well-being of a patient

(Millman1988).

TREATMENT DRUGS

Many treatment compounds are in the early preclinical stages of

investigation, and others are currently in clinical trials. The preclinical

development of candidate compounds is centered on modifying cues

and behaviors associated with addiction, which generally involve selfadministration and drug discrimination studies in rodents and nonhuman

primates. The propensity of the compound to produce physical

dependence or to maintain the physical dependence of other abusable

substances is determined. In addition, drug interaction studies are

63
carried out because most cocaine addicts are polydrug users and the

interactions between a potential therapeutic agent and cocaine are

considered necessary data to support the safety of a potential

medication to the addicted population.

In MDD, compounds that are effective in antagonizing the effects of

cocaine and that have an acceptable toxicity profile will be submitted

for clinical testing, once the Investigational New Drug application has

been approved by FDA. Phase I clinical trials are concerned with the

safety of the compound in human volunteers after single or multiple

doses. Following are some of the compounds that have been studied

by NIDA or by outside investigators.

Compounds Under Study

Desipramlne. Anhedonia is a common symptom in affective disorders.

it also is seen in a large percentage of addicts during the withdrawal

phase. The first clinical study using desipramine in cocaine addicts

was reported by Tennant and Rawson (1983). These investigators

found that 60 to 85 percent of the subjects remained free of cocaine

or other abusable substances while on the drug. Subsequent reports

(Giannini et al. 1986; Giannini and Billet 1987; O’Brien et al. 1988;

Gawin et al. 1989a) indicated an effectiveness in treating the

depression, although craving scores remained elevated.

Bromocrlptlne. Bromocriptine, a dopamimetic agent that appears to

facilitate binding of dopamine to postsynaptic receptors, has been the

subject of countless preclinical and clinical studies. Hubner and Koob

(1990) reported that the drug attenuated cocaine self-administration in

monkeys, whereas Campbell and colleagues (1989) found that the drug

suppressed cocaine-induced behavioral arousal in rats. Several studies

in humans have indicated that bromocriptine is effective in suppressing

the symptoms of withdrawal in cocaine addicts (Dackis et al. 1987;

Giannini et al. 1987, 1989; Tennant and Sagherian 1987; Teller and

Devenyi 1988; Kumor et al. 1989). Kumor and colleagues (1989) also

indicated that the drug decreased cocaine’s hypertensive effect in

patients but did not alleviate the “rush” seen with cocaine administration.

Dackis and colleagues (1987) suggested that bromocriptine also was

effective in suppressing cocaine-induced craving in addicts.

Bromocriptine also has been tested in a Phase II clinical trial in cocaine

addicts (D. Gorelick, personal communication, June 1989). The results

have not been analyzed yet. Thus, the potential efficacy of bromocriptine

remains to be determined.

64
Amantadine. Amantadine, another dopamine agonist, was studied in

preclinical and clinical tests. Sannerud and Griffiths (1988) reported

that the drug attenuated self-administration of cocaine in baboons.

Furthermore, experienced baboons would not self-administer

amantadine. In studies with humans, Gawin and colleagues (1989b)

found that amantadine was less effective than placebo in suppressing

withdrawal in addicts, whereas Tennant and Sagherian (1987) and

Morgan and coworkers (1988) found that it was effective in

suppressing withdrawal symptoms and craving.

Dopa. Although dopa has been suggested as being efficacious in treating

cocaine addiction, there are few studies that have shown efficacy. Rosen

and colleagues (1986) reported that 100 mg of L-dopa in combination with

10 mg of carbidopa (BID or TID) was effective in ameliorating the signs of

withdrawal in human cocaine addicts.

Apomorphlne. Apomorphine, a direct-acting dopamine agonist, did not

alter cocaine-induced locomotor activity in mice, although it did suppress

amphetamine-induced hyperactivity (Riffee et al. 1988). There have not

been any reported studies of apomorphine in cocaine addicts, perhaps

because of the compound’s well-known emetic potential.

Nimodipine. Pani and coworkers (1990) found that nimodipine decreased

cocaine-induced dopamine release and increased motor stimulation in rats.

Trouve and colleagues (1990) found that nimodipine decreased cocaineinduced hypertensive effects in rats.

Lithium. Pretreatment with lithium has been shown to block many of

the behavioral and biochemical effects of cocaine (Kleber and Gawin

1988). Case study reports have indicated a diminution of cocaineinduced euphoria in human volunteers and a reduced cocaine intake

in addicts (Mandell and Knapp 1976; Resnick et al. 1977; Gawin and

Kleber 1984). However, in a more recent study, Gawin and coworkers

(1989a) did not find any significant amelioration of cocaine abstinence

with lithium carbonate.

SUMMARY

NIDA’s MDD is faced with the formidable task of identifying, characterizing,

and developing new chemical entities to combat substance abuse. The

primary challenge is to find one or more medications that will be useful in

treating cocaine addiction, withdrawal, and abstinence. In addition, a

treatment for cocaine overdose is in progress. Methodological approaches

include testing compounds that alter endogenous neurotransmitters and

compounds that suppress conditioned cues and stimuli. Compounds that

65
appear efficacious in these tasks and that have a satisfactory safety

profile will be studied in humans.

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AUTHORS

David N. Johnson, Ph.D.

Pharmacologist

Frank J. Vocci, Ph.D.

Deputy Director

Medications Development Division

National Institute on Drug Abuse

Parklawn Building, Room 11A-55

5600 Fishers Lane

Rockville, MD 20857

70
Developing Treatments That Address

Classical Conditioning1

Charles P. O’Brien, Anna Rose Childress,

A. Thomas McLellan, and Ronald Ehrman

INTRODUCTION

Drugs that produce prompt, pleasant feelings in the user tend to be taken

excessively. In addition to producing reliable and rapid changes in affect

(feelings), drugs of abuse produce changes in numerous organ systems such

as cardiovascular, digestive, and endocrine systems. Such pharmacological

effects may not be perceptible to the drug user, or these effects (e.g.,

tachycardia) may simply contribute to an overall feeling of excitement.

These changes occur repeatedly within the context of a drug-seeking and

drug-using environment. Thus, there are environmental cues that are

consistently present before the user experiences the effects of the drug.

In addition to the appearance of the drug, the people, sights, sounds, odors,

and situations that often are associated with drug use can become predictors

of the onset of drug effects. The user need not consciously be aware of

these cues for an association to occur. With repetition, the cues may provoke

a chain of behaviors leading to drug administration. The same stimuli may

also begin to produce automatic changes in various organ systems in

advance of the drug being received. These predrug effects in drug users

can be demonstrated in a laboratory situation by giving experienced users a

placebo when drug is expected. The observed nonpharmacological changes

have been considered to be a form of learning and have been the focus of

study for many years (Wikler 1948).

The learning factors involved in drug dependence have been examined from

both respondent and operant conditioning perspectives. Environmental cues

that have been associated with drug use in the past can evoke physiological

changes (autonomic responses) that the experienced user interprets as drug

craving or withdrawal symptoms. These symptoms may, in turn, motivate

voluntary drug-seeking (operant) behaviors. If the drug seeker succeeds in

finding the drug, the chain of behaviors is again reinforced by the pleasant

drug-induced feelings (brain effects) and by the drug-induced

pharmacological effects on various other organ systems.

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CYCLES OFREMISSION AND RELAPSE

Typical treatment of addiction requires a period of detoxification or gradual

removal from the addicting drug by the administration of decreasing doses of the

drug or of a replacement drug from a similar category. Detoxification is followed

by rehabilitative measures usually involving group or individual counseling or

psychotherapy. After leaving the hospital or rehabilitation center, the treated,

drug-free former addict may report occasional unexpected episodes of a sudden

compulsion or drive to obtain the drug. In these instances the relapse may

appear paradoxical. For example, a male patient has completed a rehabilitation

program: he has returned to his job: he is reunited with his family; he can

present an apparently genuine and logical argument that he never intends

to touch the drug again, And then, as one patient said, “I bumped into

a guy that I used to do coke with and my heart started pounding and I started

shaking. Then I went on automatic pilot.” Although it is possible that some

of these patients are making up stories to evade responsibility for the relapse,

they appear sincere, and there is a consistency to their reports. These relapse

anecdotes suggest that there are involuntary factors involved and that learning

produced by repetitive drug use may play a role in the mechanisms of relapse.

From the perspective of the clinician, cessation of drug use (detoxification) is

just the beginning of treatment. Even a 28-day rehabilitation program has no

impact unless there is some program to deal with the proneness to relapse

when the former addict returns to his or her usual environment. As is the

case with chronic medical illnesses such as arthritis, addictive behavior has

a proclivity to return repeatedly, even after apparently successful short-term

treatment. Even without treatment there are interruptions in regular drug taking.

During the years of active drug use, there are often periods when the addict

temporarily stops taking drugs. This may be by choice in an attempt to stop or

reduce drug use or by force, such as when he or she is arrested. Detoxification

may be accomplished with medical assistance or by abrupt stopping of the

drug of abuse. However, detoxification, even when accompanied by brief

treatment, rarely has a lasting effect. True success is measured by the function

of patients over the weeks, months, and years after an initial detoxification,

The typical addict may continue drug use for years before seriously trying

to break the habit by entering a treatment program. Although the length of

time before requesting treatment varies, the effects of daily compulsive drug

use produce long-term changes in a person. These changes mean that the

reactions of the drug user are different from the way they were before beginning

drug use. Thus, it is not surprising that the reasons for relapse after treatment

may be different from the reasons that caused the patient to begin using drugs

(O’Brien et al. 1986). Both psychosocial and biological factors probably

contribute to the phenomenon of relapse. A critical part of treatment is analyzing

those factors that increase the likelihood of relapse after a period of abstinence.

72
Followup studies have examined the factors that have been associated with

relapse. For drug dependence disorders in general, multiple factors have

been found to be important in influencing long-term outcome. The presence

of a psychiatric disorder in addition to addiction significantly worsens prognosis

(McLellan et al. 1983), and clinical evidence suggests that social and economic

conditions and drug availability in the community play a role. Withdrawal

symptoms that persist for months (Martin and Jasinski 1969) may also

increase the risk of relapse. The combination of animal and human

laboratory evidence plus clinical reports (Wikler 1948; O’Brien 1975)

suggest that learning factors also play a role in relapse.

STUDIES OF CONDITIONING PHENOMENA

One of the first scientists to study relapse among addicts was Abraham

Wikler (1948). Wikler (1948, 1973a) noted the similarity of certain relapse

phenomena to Pavlovian conditioned responses (CRs). Wikler observed

withdrawal-like signs in opioid addicts who were participating in group therapy

sessions in the U.S. Public Health Service Hospital in Lexington, KY. These

patients had been completely drug-free for at least several months and

therefore should not have had any signs of opioid withdrawal. But when

they started talking about drugs in group therapy, Wikler observed yawning,

sniffling, and tearing of the eyes—signs of an opioid abstinence syndrome.

He was aware of studies from Pavlov’s lab in the 1920s (Pavlov 1927) showing

that the effects of morphine could be conditioned, and he postulated that

conditioning had occurred in his patients.

Wikler labeled this phenomenon “conditioned withdrawal,” speculating that

environmental stimuli had acquired the ability through classical conditioning

to elicit many of the signs and symptoms of pharmacological withdrawal. He

further hypothesized that cues formerly associated with drug effects or drug

withdrawal symptoms might play an important role in triggering relapse to drug

use in the abstinent opioid abuser, Wikler also pointed out that the adaptation

to drugs could be conditioned, a phenomenon later explored in a series of

elegant studies by Siegel and colleagues on conditioning of drug tolerance

(Siegel 1975, 1978; Siegel et al. 1978, 1981). Wikler developed a rat model

for studying morphine withdrawal, and in subsequent experiments he

demonstrated that withdrawal signs could be conditioned in rats (Wikler

and Pescor 1967; Wikler 1968; Wikler et al. 1971). Goldberg and Schuster

(1970) Davis and Smith (1974), Siegel (1975, 1978), Siegel and colleagues

(1978, 1981), and others (Le et al. 1979; Poulos and Hinson 1982) confirmed

that many drugs from different pharmacological classes can produce CRs.

Conditioned opioid withdrawal responses have also been experimentally

produced in human subjects (O’Brien 1975; O’Brien et al. 1975, 1977). For

a detailed review of CRs reported in animals and in humans, see Grabowski

and O’Brien (1980).

73
CATEGORIES OF CONDITIONED RESPONSES

Studies in human subjects have demonstrated that CRs can be drug-like or

drug-opposite depending on the circumstances (O’Brien et al. 1986, 1988).

The authors and colleagues at the Addiction Treatment Research Center have

attempted to classify these responses according to the proposed mechanism

of their origin and the conditions under which they can be demonstrated.

Drug-opposite CRs

- Conditioned withdrawal

- Conditioned tolerance

Drug-like CRs

- Conditioned euphoria (“needle-freak” phenomenon)

- Placebo effects of drugs (under certain circumstances)

Drug-Opposite Condltloned Responses

Repetitive use of the same drug can produce CRs that are opposite to

the effects produced by the pharmacological action of the drug. For example,

opioid injections produce elevations in skin temperature in human subjects,

but stimuli that have repeatedly preceded opioid injections will reliably produce

reductions in skin temperature when presented to experienced opioid users.

This reduction in skin temperature begins before the person receives the

drug. Thus, it cannot be a pharmacological effect, and it is presumed to

be a CR. There are many other examples of drug-opposite CRs that can

be demonstrated by polygraphic measurement of physiological changes,

by ratings of effects that subjects perceive (subjective effects), or by observer

ratings of subject behavior. The drug-opposite responses can mimic the drug

withdrawal syndrome. If these responses occur just before a dose of the drug

is received, they subtract from the drug effect, resulting in an attenuation of

drug effects. The attenuation of drug effects produced by CRs can be classed

as a form of “tolerance” and may form a partial explanation for the diminished

drug effects commonly seen with repeated administration under similar

circumstances of the same dose of a drug (Siegel et al. 1978).

One of the reasons given by opioid users for continuing opioid use is

the avoidance of withdrawal symptoms. But viewing addiction as being

motivated solely by avoidance of withdrawal symptoms is clearly incomplete.

Furthermore, the appearance of conditioned withdrawal symptoms in former

drug users does not fully explain the high rate of relapse in former users.

Although the phenomenon of conditioned withdrawal was the first type of

conditioning considered by Wikler and is still closely associated with his name,

Wikler (1973a) also emphasized the importance of reward mechanisms in the

maintenance of drug-taking behavior. In opioid addicts, however, physical

74
dependence and withdrawal symptoms are very common, especially in those

applying for treatment. The presumed mechanism for the development of

conditioned withdrawal is shown in figure 1. Because in most opioid addicts

some withdrawal symptoms will occur several times per day, there may be

thousands of pairings of environmental stimuli and withdrawal symptoms

during the life of a patient before he or she seeks treatment. In the laboratory,

O’Brien and colleagues (1975,1977) have shown that after as few as seven

pairings between mild methadone withdrawal symptoms (unconditioned

response, UR) and a neutral stimulus (conditioned stimulus, CS), such as

a peppermint odor, humans begin to show signs of withdrawal (CR) when

exposed to the odor alone. These CRs have been found to be long-lasting

in an animal model (Eikelboom and Stewart 1982), and they have been found

to occur when the subject is reexposed to the CS long after detoxification

from drugs. Therefore, this mechanism could explain the stories repotted

by Wikler (Wikler and Pescor 1967; Wikler 1968) and others (O’Brien 1975)

concerning onset of withdrawal symptoms when a drug-free patient returns

to an environment in which withdrawal symptoms had occurred in the past.

This mechanism would also explain the reactions of drug-free former addicts

when shown, while in the laboratory, visual and auditory cues previously

associated with past drug use (O’Brien 1975; Teasdale 1973; Ternes et

al. 1980; Sideroff and Jarvik 1980).

Conditioned tolerance is a term applied to another mechanism by which drugopposite responses might be produced by conditioning. Siegel and others, in

a series of experiments utilizing morphine, alcohol, and insulin (Siegel 1975,

1978; Siegel et al. 1978, 1981; Le et al. 1979; Poulos and Hinson 1982)

presented evidence that drug tolerance could be considered, at least in part,

to be a classically conditioned phenomenon. As shown in figure 2, the drug

Unconditioned Stimulus

Opioid is metabolized and

disappears

Receptors are evacuated

Unconditioned Response

Rebound activity, such as

adrenergic or cholinergic

(e.g., tearing, rhinorrhea,

tachycardia, nausea,

diarrhea), drug-opposite

effects

Conditioned Stimulus Conditioned Response

Drug-procuring or drug-using Mild version of above

environment: sights, sounds, symptoms, drug-opposite

smells, situations, fantasies effects

FIGURE 1. Conditioned withdrawal (dependent subject)

75
disturbs homeostatic equilibrium resulting in a reflex response against the drug

as the organism attempts to regain equilibrium. This reflex response (UR)

counteracts the effects of the drug. The environmental cues (sights, smells,

situations) repeatedly associated with drug procurement or injection provide

a signal (CS) that, after repetition, can trigger homeostatic responses that are

opposite to the effects of the drug (tolerance) in advance of the drug’s being

received. The conditioning of tolerance was termed “counter-adaptation” by

Wikler (1973b). Siegel and colleagues’ studies (cited above) demonstrate that

the learned aspects of tolerance follow the pattern of classically conditioned

responses.

Ehrman and colleagues (1992a) have demonstrated apparent conditioned

tolerance in a group of detoxified opioid addicts who were studied on four

separate occasions under double-blind conditions. The subjects received

either unsignaled infusions of a moderate dose of opioid (4 mg

hydromorphone) or a self-injection of the same dose. On the two other

occasions, the subjects received an unsignaled infusion of saline or a

self-injection of saline. When the opioid was given without warning by

an infusion (unsignaled), the subjects showed a significantly greater

physiological response to the drug than when the same dose was “expected”

(self-injected). The authors’ interpretation is that the unsignaled nature of

the infusion of opioid prevented any warning that would have triggered the

onset of drug-opposite or conditioned tolerance responses. On the occasions

when the opioid was expected, the conditioned drug-opposite responses

reduced the observed drug effect. This interpretation was supported by the

saline self-injection occasion, which showed greater drug-opposite responses

presumably because there was no opioid in the injection to oppose the CRs.

Conditioning clearly does not explain the entire phenomenon of tolerance,

but the magnitude of the portion produced by conditioning may be significant,

Siegel and colleagues (1982) showed that situation-specific tolerance can

Unconditioned Stimulus Unconditioned Response

Drug injection, drug effects Homeostatic response

counter to drug effect

Conditioned Stimulus Conditioned Response

Sights, sounds, smells that Homeostatic responses

signal that drug is about counter to drug effects

to appear that in the absence of

drug can be perceived

as withdrawal

FIGURE 2. Conditioned tolerance (dependent or nondependent subject)

76
protect against the deadly effects of an opioid overdose. When rats

experienced with morphine received a high dose of the drug in an environment

different from the conditions under which they had learned to expect morphine,

rapid overdose signs ensued and death occurred in some animals. In contrast,

another group of rats with the same experience of morphine exposure showed

significantly less drug effect and no deaths when given the same high dose

of morphine in the environment where morphine was expected.

Conditioned drug-opposing (tolerance) responses can occur in opioid users

who have used only intermittently and thus have never been physically

dependent on opioids. This is because even intermittent users generally

develop tolerance. Learned tolerance responses can develop according to

the mechanism described in figure 2. The learned tolerance responses will

be evoked by drug-related stimuli, and they will be opposite to the effects of

the drug, thus resembling opioid withdrawal responses. Similarly, a user

such as a physician or pharmacist who has had enough opioids consistently

available to avoid repeated episodes of withdrawal could still show conditioned

withdrawal-like responses even though true pharmacological withdrawal

had never occurred. In this situation, the learned tolerance would be based

on a CR that is drug-opposite and physiologically similar to a withdrawal

response. If the former addict encounters stimuli that were previously

associated with drug use (CS), the CR would produce symptoms that may

be perceived as withdrawal-like. Typical drug users who have had repeated

episodes of withdrawal in a specific environment will thus have two

mechanisms for producing conditioned withdrawal-like symptoms: the

first by the “conditioned withdrawal” paradigm described in figure 1 and the

second by the “conditioned tolerance” mechanism described in figure 2.

Drug-Like Conditioned Responses

Drug-like CRs can also be produced by pairing distinct stimuli with drug

administration. After repeated pairing, the stimuli by themselves can produce

drug-like effects (Grabowski and O’Brien 1980; Lynch et al. 1973). Pavlov’s

original report (1927) of morphine conditioning described a CR that resembled

the unconditioned effects of morphine. Similar findings of drug-like conditioning

have been reported by others in dogs (Lynch et al. 1973; Collins and Tatum

1925; Rush et al. 1970) and in rats (Goldberg and Schuster 1970; Miksic et al.

1975; Numan et al. 1975). Drug-like conditioned effects have also been

described in human studies (O’Brien 1975). Such a conditioning mechanism

may form a partial explanation for what are known as the “placebo effects” of

drugs. A variety of subjective and physiological responses have been reported

when research subjects or patients are given an inert substance when they are

expecting an active drug. The conditioning explanation presumes that drug-like

or placebo effects have been conditioned by past exposure to drugs under

similar circumstances. The authors’ research over the years has provided

77
clues as to which conditioning paradigms are most likely to produce either druglike CRs or drug-opposite responses. Confusion occurs in trying to understand

these drug-conditioned phenomena because both drug-like and drug-opposite

effects can be learned. Both animal and human data suggest that stimulants

such as amphetamine and cocaine are more likely to produce drug-like CRs,

whereas opioids in human subjects produce more prominent drug-opposite

responses, particularly in response to stimuli associated with preinjection

rituals. However, drug-like effects in opioid addicts in the laboratory have

been demonstrated after self-injection (O’Brien 1975; O’Brien et al. 1980;

Meyer and Mirin 1979). Thus, it is possible to observe opioid-opposite and

opioid-like effects sequentially in the same opioid addict subject while he or

she prepares and injects placebo material in the laboratory.

Drug-like effects are found clinically in patients known as “needle freaks”

(Levine 1974). Typically, these are individuals who may formerly have been

physically dependent on opioids but are currently using drugs intermittently or

using low-potency opioid supplies. These individuals report euphoria from the

act of self-injection, and they have also been observed to show physiological

signs such as pupillary constriction after injecting saline (O’Brien 1975). A

similar finding was reported by Meyer and Mirin (1979). Some needle freaks

have been detected among applicants applying for methadone treatment.

Federal regulations limit the use of methadone maintenance (except in certain

special cases) to individuals who are already physically dependent on opioids

at the time of application for treatment. If there are no signs of withdrawal in

an applicant for methadone, the opioid antagonist naloxone may be given as

a diagnostic test for the presence of dependence (Blachly 1973). Even a very

small dose of naloxone will precipitate withdrawal symptoms in a person

physically dependent on opioids. Occasionally, the authors and colleagues

have observed the naloxone injection to produce mild euphoria instead of

withdrawal in applicants for methadone who claim to be addicts and who show

the scars of chronic drug injections. Subsequently, we observed sedation and

reports of euphoria when these subjects self-injected saline in the laboratory.

Thus, the euphoria observed after naloxone was not a pharmacological effect

of naloxone, but likely a CR to the injection procedure that served as a CS

(O’Brien 1975).

There have been few direct observations using physiological and psychological

monitoring of human addicts in the act of self-injecting addicting drugs. Our

group reported a series of such studies (O’Brien 1975; O’Brien et al. 1974;

Levine 1974) that described self-injections in detoxified opioid addicts being

treated with the opioid antagonists cyclazocine or naltrexone. Several

experimental protocols were used that involved maintaining patients on opioid

antagonists that block the pharmacological effects of opioids. In one series of

experiments, the patients were randomly assigned to self-injections with either

saline or opioid; in others, the patients were tested with both saline and opioid

78
on different occasions. These experiments began with prenaltrexone trials in

which the subject’s responses to unblocked opioid was compared with saline

under double-blind conditions. Subsequently, we conducted “extinction trials”

in which the subject repeatedly self-injected opioid or saline while being

maintained on the opioid antagonist for up to 6 months. The findings were

that saline self-injections were usually reported as pleasurable and identified

as a low dose of opioid. This reaction to saline was assumed to be a druglike CR (placebo effect). The effect was greatest when the subjects injected

themselves under naturalistic conditions resembling the patient’s “shooting

gallery” with the patient expecting to get “high.” The drug-like effect was

diminished but still present when the patient was placed alone in a more

artificial setting, such as a recording chamber, with various electrodes and

strain gauges attached.

We found that drug-like effects in most patients did not persist with repeated

trials as did the drug-opposite effects described above. After several

unreinforced trials consisting of either saline injections or blocked opioid

injections in patients pretreated with an antagonist, the drug-like effects

disappeared. The drug-opposite effects persisted in these patients, however.

Meyer and Mirin (1979) used a different design and also observed conditioned

opioid-like autonomic effects in human subjects. Their subjects were all

recently detoxified inpatients who were given either naltrexone or naltrexone

placebo under double-blind conditions. The subjects were then permitted to

self-inject known amounts of heroin that they had earned by performing a

simple operant task. The subjects who received naltrexone placebo, in effect,

had the opportunity to inject heroin unimpeded by naltrexone, and they injected

it nearly the maximum number of times permitted by the protocol. However,

the 22 subjects who received naltrexone had the rewarding effects of heroin

blocked by this antagonist. Eleven of these subjects stopped injecting heroin

after fewer than 5 trials, but the other 11 subjects took an average of 16 doses

of heroin despite the presence of naltrexone. These 11 subjects were found

to be different from those who stopped quickly in that they showed distinct

autonomic changes during and after the injection procedure. These

physiological responses resembled opioid effects and continued even after

the first three blocked injections. Meyer and Mirin (1979) interpreted these

autonomic changes (pupil, heart rate, and blood pressure) as conditioned

opioid-like effects, and they found that these autonomic changes had

disappeared (extinguished) by the time the subjects decided to stop injecting.

Unlike the outpatient studies described above, the Meyer and Mirin protocol

did not require the subjects to continue to inject unless they wished to do so.

Patients did not continue injecting past the point at which their response to

the procedure changed from positive to neutral, and this probably explains

why unpleasant or withdrawal-like symptoms were not reported.

79
Therefore, the evidence for conditioned opioid-like effects in humans is based

on clinical anecdotes and on the laboratory studies involving self-injection

described above. These CRs are elicited by the complex CS of preinjection

rituals and the act of self-injection. In most subjects the opioid-like CR is

extinguished quickly, and then withdrawal-like CRs are elicited by the

same CSs that previously produced opioid-like effects.

SPECIFICITY

A question that arises concerns the specificity of responses to drug-related

stimuli. Are these responses present in non-drug users? Ternes and

colleagues (1980) compared the reactions of opioid addicts to those of

nonaddicts viewing the same stimuli. It was found that nonaddicts showed

signs of arousal when viewing scenes of drug-taking behavior, but they

showed rapid habituation compared with opioid addicts in the study who

persisted in their arousal and withdrawal-like responses. Another study of

specificity has just been completed among cocaine addicts. Ehrman and

colleagues (19926) compared the responses of cocaine addicts and normals

to neutral stimuli, cocaine stimuli, and opioid stimuli. The normals showed

nonsignificant reactions to all sets of stimuli. The cocaine addicts showed

significant responses only to the cocaine-related stimuli and not to the

opioid-related stimuli.

Additional studies of the responses demonstrated by abstinent drug addicts

have shown that they interact with negative mood states. Recent work from

our laboratory has demonstrated that depression, anxiety, and anger increase

the responses in opioid addicts to opioid-related stimuli. After making these

observations, Childress and colleagues (in press) designed an experiment

in which negative mood states were elicited in addict volunteers using a

hypnotic procedure. In this study, negative mood states increased the

response to drug cues, and euphoric states reduced the response.

CLINICAL RELEVANCE

One way of assessing clinical importance is to determine whether

modification of CRs can influence the course of addiction. Using a variety

of patient populations, we have attempted to extinguish or reduce presumed

CRs in patient volunteers and compare their clinical course with that of

control patients who do not receive extinction therapy. We first studied

the CRs associated with chronic opioid use, speculating that some of these

responses (particularly conditioned craving and withdrawal) could lead to

drug use in the abstinent patient (O’Brien 1975; O’Brien et al. 1986; Childress

et al. 1984, 1986a; McLellan et al. 1986). The responses targeted in our

extinction program included subjective responses such as “craving,” feelings

of “high,” and feelings of drug withdrawal. We also have studied the effects of

80
the extinction program on autonomic responses such as changes in pulse,

blood pressure, skin resistance, and skin temperature. The procedure for

modifying these responses was based on a process of systematic, gradual

exposure to drug-associated cues without the possibility of reinforcement

(actually receiving a drug). The general approach in this series of studies

has been first to select cues that reliably elicit subjective and physiological

responses in the target population and then to attempt to reduce these

responses through repeated, nonreinforced exposure (extinction).

We found that conditioned opioid-like responses extinguished rapidly in most

patients, but responses that were opposite to the effects of opioids (withdrawallike physiological responses and subjective craving) were very resistant to

extinction (O’Brien et al. 1974, 1980; Childress et al. 1986b). We first studied

detoxified and long-term drug-free patients, some of whom were therapeutic

community graduates, We also studied methadone patients in a large-scale

treatment-outcome study employing extinction trials (Childress et al. 1984,

1986a). Drug-related stimuli were found to be reliable elicitors of conditioned

opioid-related responses, particularly conditioned craving and conditioned

withdrawal, even in a methadone population. With 20 or more extinction

sessions, conditioned craving was significantly reduced, but conditioned

withdrawal signs and symptoms were still present in response to opioidrelated cues.

RESPONSES TOCOCAINE-RELATED STIMULI

Over the past several years, most of the patients applying for treatment in our

program have been cocaine dependent or were cocaine abusers. Cocaine is

cheap and widely available in Philadelphia. Most of our current research,

therefore, is focused on cocaine dependence (O’Brien et al. 1992). Cocaine

use generally is episodic. Whether the user has stopped taking cocaine

because of toxicity, incarceration, or admission to hospital for detoxification,

there is a strong tendency to resume taking cocaine after a short abstinent

period. When detoxified former cocaine users are confronted with stimuli

previously associated with cocaine use, they report cocaine craving despite

their expressed and apparently genuine intention to refrain from returning to

drug use. Some report intense urges to use cocaine along with arousal and

palpitations when they encounter stimuli as diverse as seeing a friend with

whom they had used cocaine or seeing any powdery substance such as sugar

or talcum powder. Some users interpret these responses as beginning to feel

a cocaine high when they get close to the drug, but before it even enters their

body. Detoxified formerly cocaine-dependent patients also experience similar

responses when they encounter drug-buying locations, a pharmaceutical odor,

or almost anything that has been repeatedly associated with getting and using

cocaine. These stimuli appear to act as a trigger for arousal and cocaine

81
craving. After years of using cocaine, there are usually numerous stimuli

within the patient’s normal environment that have strong links to cocaine.

There are numerous studies in animals showing the conditioning of

responses to cocaine and other stimulants (Post et al. 1987). In human

cocaine-using subjects, we have conducted laboratory studies of reactivity

to cocaine-related cues (O’Brien et al. 1990; Childress et al. 1987). We found

significant effects of cocaine-related stimuli compared with control stimuli on

autonomic measures such as skin temperature and skin resistance and on

subjective measures such as feelings of craving, withdrawal, or being high.

A subgroup of patients who had spent a period of 26 days in rehabilitation

treatment in a hospital environment after detoxification from cocaine was also

studied. All these patients expressed the strong intention of remaining

abstinent after leaving the hospital. The patients were shown cocaine and

neutral stimuli on separate days in a balanced order while being monitored

in a laboratory setting. The results were similar to those in patients recently

detoxified; there was strong reaction to the cocaine cues, and many of the

rehabilitated patients reported surprise at the severity of their responses.

The additional 28 days of treatment had no apparent effect on the reactivity

to cocaine-related cues.

It is of interest that not all patients in treatment for cocaine dependence

showed reactivity to cocaine-related cues. At least one-third of these patients

were adamant “nonresponders,” insisting that the cocaine-related stimuli

triggered no craving, arousal, or other responses. For these patients,

physiological arousal (as reflected in either decreased skin temperature or

a fall in galvanic skin response) was sometimes present, even though the

patients denied experiencing any subjective reaction. The subjective and

physiological data were analyzed for the total sample, including those

who reported no effects from the stimuli used. The average temperature

reduction in response to cocaine-related stimuli for the entire unselected

group (including nonresponders) was approximately 2.5 °C. Among those

classed as responders, however, dramatic reductions of 5 to 8 °C (in

response to cocaine-related stimuli) were not uncommon.

CLASSIFICATION OF THE COCAINE-RELATED RESPONSES

Reactions to opioid-related stimuli among opioid abusers could be classified

as drug-like or drug-opposite. This is because opioids affect several systems

in specific ways. Opioid-like effects observed in our studies are rush,

euphoria, pupillary constriction, slowing of the heart, lowered blood pressure,

warming of the skin, and increased skin resistance. Withdrawal effects are

the opposite of the preceding list plus yawning, tearing, sniffing, and nausea.

Classification is much less clear among cocaine users, The physiological

effects seen in abstinent former users when exposed to cocaine-related

82
stimuli are decreased skin temperature, increased heart rate, and increases in

skin conductance. These are the signs of both stimulant drug effects and

nonspecific arousal. Some patients report high-like effects; others simply

report craving or even “crash” feelings. Animal studies show clear conditioning

of cocaine-induced hyperactivity, a drug-like response. A most intriguing study

of the CR for cocaine comes from direct brain studies using the microdialysis

technique in the region of the nucleus accumbens in rats (Kalivas and Duffy

1990). Increased dopamine was recorded in this region after each dose of

intraperitoneal cocaine. The dopamine responses increased with successive

cocaine doses (sensitization). After repeated exposure to cocaine injections,

the animals were given a saline (placebo) injection under similar conditions

on a different day. The response in the nucleus accumbens was a small but

significant augmentation of dopamine, presumably conditioned by the prior

experiences with cocaine. This work will have to be replicated, but it raises

the possibility that the formerly cocaine-using patients experience a similar

augmentation of limbic dopamine when they are exposed to cocaine-related

stimuli. The peripheral measures of arousal would be consistent with this

interpretation. The central dopamine increase could provide a priming effect

in former users and precipitate a relapse to cocaine use.

COCAINE TREATMENT STUDY

Traditional treatment approaches have intuitively recognized the power of drugassociated stimuli, Therefore, abstinent patients are warned to avoid people,

places, and things associated with prior cocaine use. In reality, complete

avoidance is very difficult, even in a well-motivated patient. Patients need

additional tools for coping with and reducing drug craving. Our research

treatment strategy consists of systematically exposing patients to stimuli that

they are likely to see when they leave the treatment program (O’Brien et al.

1990). Patients are given repeated exposure to cocaine “reminders” while

they are in a safe environment in an attempt to reduce the craving and arousal

often triggered by these stimuli. This strategy complements an avoidance

approach, and it is a potentially useful adjunct to traditional abstinence-oriented

treatment programs. This treatment approach is based on the view that

cocaine reminders are classically conditioned stimuli that acquire their

“reminder power” through repeated pairings with cocaine’s pharmacologic

effects over the natural course of a patient’s drug use. By repeatedly exposing

the patient to cocaine reminders without cocaine, it should be possible to

reduce or extinguish the power of such cues to trigger the CRs (e.g.,

arousal, craving) that could lead to drug use and relapse to addiction.

To prevent relapse, all categories of relapse-producing factors should be

addressed, including pharmacological, social, occupational, medical, legal,

and family issues. If conditioning factors play a role in relapse, the influence

of conditioning probably varies with the individual patient depending on the

83
relative importance of other relapse-producing factors, Thus, the extinction

procedure has been integrated within the context of a treatment program that

addresses a wide range of issues thought to be important to the recovering

addict. Initial exposure to drug-related stimuli should be conducted in a

protected therapeutic setting to minimize the possibility of drug use in

association with the strong craving/arousal triggered by the cocaine

reminders. The stimuli should be tied closely to the patient’s cocaine

history, particularly to his or her preferred mode of cocaine administration

(intranasal, Intravenous, or smoked).

Our early studies among cocaine subjects also taught us that the CRs

produced by cocaine could be highly varied and complex. When smoked

or injected, cocaine results in a rapid onset of euphoria and pleasurable

sensations, often followed, only a few minutes later, by dysphoria,

nervousness, and extreme drug craving. These biphasic effects are further

complicated by the appearance of toxic symptoms (e.g., suspiciousness,

paranoia) after high doses, long binges, or even a long history of less

frequent use. Finally, after termination of use, patients may complain of

crash feelings that may include depression, irritability, and fatigue. Any of

these affective and physiologic effects of cocaine could become conditioned

to the many environmental stimuli consistently associated with cocaine use.

We recently completed a randomized trial of cocaine-dependent patients

assigned to extinction or to a control group. This was an 8-week outpatient

study. The results of this randomized clinical trial of passive cue exposure

or extinction are reported in detail elsewhere (Childress et al., submitted for

publication). Briefly, the patients randomly assigned to extinction showed

better retention in outpatient treatment and a higher proportion of clean urines

than the control group. Both of these differences were significant at the

5-percent level. These results were encouraging because the extinction

sessions were well accepted by the patients, and the technique can be

applied by nonprofessional drug counselors. However, despite the improved

results, full extinction of the responses was not accomplished, and relapses

continued to occur, although they were less common in the extinction group.

These results suggested that an active procedure should be tried to enhance

the results of passive extinction.

ACTIVE PROCEDURES TO COMBAT CRAVING

Clearly, detoxified cocaine abusers can experience conditioned craving and

arousal to cocaine reminder stimuli. These responses can be both intense

and persistent, meaning that the abstinent cocaine abuser may be vulnerable

long after detoxification is complete. Although the program of extinction

described here is effective in reducing craving to cocaine-related stimuli

presented in the context of the laboratory or clinic, patients can still

84
report craving in the natural environment. Two approaches to improve

generalization from the lab to the street are currently being evaluated. One

approach is an attempt to increase the generalization of extinction by the use of

even more realistic stimuli (e.g., the sight of real cocaine) and stimulus contexts

(e.g., in vivo repeated exposures). Previously, we have been reluctant to

employ in vivo exposures near “copping” corners or shooting galleries because

of possible risk to both patients and clinical staff. Somewhat less dangerous

stimuli could involve the patient’s own home or the use of neighborhood videos

taped from a moving car. A second approach involves the use of several other

techniques in countering or reducing conditioned craving and arousal, such as

training of alternative behaviors (e.g., competing responses, thought blocklng,

relaxation response) as a useful adjunct to more conventional treatments for

cocaine abuse (e.g., counseling, therapy, and relapse prevention techniques).

We are currently conducting a randomized clinical trial of active techniques

to combat craving. The experimental treatment involves evoking responses

to cocaine-related cues in the clinic and coaching the patient in the use of a

behavioral technique to combat the response. The pilot work suggests that

this technique will be more successful than a passive cue exposure technique.

The patient learns a set of active coping devices and has the opportunity to

practice them in the clinic with the help of a therapist. This increases the

patient’s confidence that he or she can resist the responses that occur when

confronted with cocaine cues in the patient’s natural environment. In addition,

the new extinction procedures include (1) more individualized cocaine

reminders to benefit patients who do not respond strongly to the standard

test stimuli and (2) more extinction sessions, in an attempt to more completely

extinguish the persistent physiological arousal that occurs in response to

cocaine cues.

USE OF RESPONSE TO COCAINE-RELATED CUES AS A MEDICATION

SCREENING DEVICE

A potential application of the response to drug-related cues is the screening of

new medications to aid in the maintenance of abstinence. For cocaine

dependence, it is unlikely that any single treatment approach will be effective.

The University of Pennsylvania group has been trying to find more effective

medications for cocaine dependence and devise a way to combine the effects

of various treatments such as medications and behavior therapy. Our group

has just completed a preliminary study of the effects of a putative medication for

cocaine dependence on the magnitude of the reaction to cocaine-related cues.

The purpose was to determine whether potential medications could be tested

for their effects on craving and arousal evoked by the drug-related cues in the

laboratory. Medications that seemed to reduce the reaction to cocaine-related

cues might then be tested in a controlled clinical trial to determine their overall

clinical efficacy.

85
Patients volunteering for a trial of amantadine therapy were tested for their

reactivity to cocaine cues before receiving either amantadine or placebo

(Robbins et al. 1992). They were tested again after 7 to 10 days of

stabilization on the medication (either amantadine or placebo). The two

groups of patients had similar reactions to the cocaine cues on the first

occasion, but after stabilization on the medication, the patients assigned

to amantadine had significantly greater reactions to the cues than did the

patients assigned to placebo. This effect may relate to the prodopamine

activity of amantadine. The clinical significance of this finding is not clear

at this time. In our efforts to develop predictors of successful medication for

cocaine dependence, we will have to test many potential medications and

correlate the findings in the test model with clinical outcome. Thus far, the

clinical outcome studies with amantadine are equivocal, but we are in the

process of comparing the results of cue reactivity with the clinical outcome.

SUMMARY

Repetitive use of psychoactive drugs produces a variety of learned behaviors.

These can be classified in the laboratory according to an operant/classical

paradigm, but in vivo the two types of learning overlap. The classical

CRs produced by drugs are complex and bidirectional. There has been

progress in classifying and predicting the types of CRs, but little is known

of mechanisms. New techniques for understanding brain function, such as

microdialysis probes in animals and advanced imaging techniques (positron

emission tomography and single photon emission computerized tomography)

in human subjects, may be utilized in conditioning paradigms to “open the

black box.”

Because the existence of CRs in drug users is now well established, clinical

studies have been instituted to determine whether modification of CRs can

influence clinical outcome. A recently completed study in cocaine addicts has

produced evidence that outcome can be improved by a passive extinction

technique over an 8-week outpatient treatment program.

NOTE

1. This chapter was presented in part at the 26th annual meeting of the

Association for Research on Nervous and Mental Disease, 1990 (see

also O’Brien and colleagues [1990]) and at other National Institute on

Drug Abuse technical reviews.

86
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ACKNOWLEDGMENT

This work was supported by U.S. Public Health Service grants DA-000586

and DA-5186 and by the US. Department of Veterans Affairs,

AUTHORS

Charles P. O’Brien, M.D., Ph.D.

Professor and Vice Chairman

Department of Psychiatry

Addiction Research Center

University of Pennsylvania

Chief of Psychiatry

90
Anna Rose Childress, Ph.D.

Clinical Associate Professor

Department of Psychology in Psychiatry

Addiction Research Center

University of Pennsylvania

Clinical Psychologist

A. Thomas McLellan, Ph.D.

Adjunct Professor

Department of Psychiatry

Addiction Research Center

University of Pennsylvania

Psychologist

Ronald Ehrman, Ph.D.

Clinical Assistant Professor

Department of Psychology in Psychiatry

Addiction Research Center

University of Pennsylvania

Scientist

Veterans Administration Medical Center

Philadelphia, PA 19104

91
Neurobehavioral Treatment for

Cocaine Dependency: A Preliminary

Evaluation

Richard A. Rawson, Jeanne L. Obert, Michael J. McCann,

and Walter Ling

INTRODUCTION

The emergence of the cocaine epidemic in the 1980s placed unforeseen

demands on the addiction treatment system. Reports from data collected

by the 800-Cocaine Hotline, which began in 1983, provided a clear indication

that many people were seeking information about problems resulting from

cocaine abuse (Gold 1984). Other indications of drug abuse trends

documented that during the first half of the 1980s the United States was

profoundly affected by a major increase in high-dose cocaine use (Kozel

and Adams 1985). During 1984 in Los Angeles, the development and

widespread use of smokeable cocaine (known first as freebase” and later

as “rock” or “crack”) intensified concern over the spread of cocaine use.

These developments, plus the deaths of several sports figures and

celebrities, with subsequent media coverage, alerted the American public

to the dangers of cocaine use.

In response to this media attention and because of the psychological and

medical problems created by chronic high-dose cocaine abuse, a demand

for cocaine dependency treatment services rapidly emerged. Clinical

researchers in the addictions field began to address the cocaine epidemic by

developing a variety of treatment strategies that used several pharmacologic

approaches to ameliorate the cocaine withdrawal syndrome. To date, no

medication has received widespread acceptance as an effective treatment

for cocaine dependency (Johnson and Vocci, this volume).

Numerous nonpharmacologic strategies for treating cocaine users have

been suggested by clinical researchers. Crowley and associates (1987)

have utilized contingency contracting procedures with cocaine abusers

as a behavioral method of controlling cocaine use. Siegel (1984) has

suggested slow, long-distance running as a valuable tool in aiding the

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cocaine dependency recovery process. Smith (1984) has recommended

the incorporation of peer-group therapy strategies and involvement in selfhelp programs as being of value in treating cocaine abusers. Resnick and

Resnick (1984) have reported the merits of exercise and deep muscle

massage as methods to help cocaine abusers cope with poorly tolerated

emotional states. A research group at Lexington Hospital in New York City

under Michael Smith has reported that acupuncture appears to provide

significant benefits in relieving cocaine craving (Chicago Sun Times 1989).

Washton has developed a structured outpatient treatment approach

combining behavioral techniques, cognitive strategies, educational

information, family involvement, self-help groups, and urine testing (Washton

1986, 1987). Washton has reported that this combination of procedures

appears to provide patients with a set of tools that allows them to stop

cocaine use and initiate positive lifestyle changes that promote continued

abstinence. His initial reports on treatment outcome are encouraging: Of

127 patients who entered treatment, 65 percent completed the 6- to 12-month

program, and 75 percent were drug-free at 1- to 2-year followup (Washton

et al. 1988). In addition, he reports that there was a significant positive

relationship between length of time in treatment and drug-free outcome.

THE NEUROBEHAVIORAL MODEL

The Matrix Center was established in 1983 in southern California to develop

a viable model of outpatient treatment for cocaine abusers, Known as the

neurobehavioral model, it utilizes information and strategies derived from

clinical research on addiction in an intensive treatment experience. The

treatment materials have evolved from applying concepts described in

theoretical and applied research to the needs of cocaine abusers attempting

to stop cocaine use. The materials used in treatment are original, but the

ideas that generated these materials were developed in many of the addiction

research centers in the United States,

The work of several research groups has been particularly important in.

the development of this treatment approach. The Yale University research

group, directed by Herbert Kleber, has been extremely helpful in providing

an understanding of the biochemistry of cocaine addiction and in identifying

key issues concerning the biological readjustment experienced in cocaine

recovery (Kleber and Gawin 1984). The work of researchers at the

Philadelphia Veterans’ Affairs Medical Center (O’Brien et al. 1990),

particularly that of Charles O’Brien, Thomas McLellan, and George Woody,

and at Johns Hopkins (Stitzer et al. 1985), including George Bigelow and

Maxine Stitzer’s work, has been of tremendous help in developing cognitive/

behavioral strategies and focusing on the need to evaluate clinical efforts

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empirically. The structure of the treatment model has been influenced by

Washton’s (1989) work. The cognitive/behavioral orientation to the problem

of relapse reflects the approach developed by Marlatt and Gordon (1985)

and Gorski and Miller (1982). The family portion of the program has been

influenced by the thinking of Salvador Minuchin (1974) and Duncan Stanton

(Stanton et al. 1982). The value of effectively educating clients about

addiction has been incorporated from the work of David Smith, Donald

Wesson, and their associates (Smith 1984; Wesson and Smith 1985).

The neurobehavioral approach to cocaine dependency has been constructed

to address the types of dysfunction that exist when cocaine abusers enter

treatment. No presumptions are made about underlying psychopathology.

The needs of the clients have been determined by a behavioral analysis of

the types of problems encountered by cocaine abusers as they proceed

through a period of cocaine abstinence. More than 1,000 cocaine abusers

have been treated with the methodology. The experience of these clients

has been the source of the data for the model.

STAGES OF RECOVERY

To construct a treatment model that addresses the needs of cocaine abusers

in a systematic way, it has been necessary to separate the problem areas

into distinct categories: behavioral, cognitive, emotional, and relationship.

The treatment focuses on particular issues in each of these areas that

emerge during the stages of recovery experienced by clients during the

first year. Characteristic periods for the stages of recovery are as follows:

0 to 15 days postcocaine-withdrawal

16 to 45 days postcocaine-honeymoon

46 to 120 days postcocaine-the wall

121 to 180 days postcocaine-adjustment

181+ days postcocaine-resolution

Typical issues and patterns of problems occur across the course of the

stages of recovery from cocaine dependency. They are categorized within

the stages as follows:

Withdrawal Stage

During withdrawal, clients are disoriented, depressed, and fatigued and feel

very much out of control. They do not understand what is happening to them

and require explicit direction during this period.

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Behavioral Emotional

Increased need for sleep Depression

Behavioral inconsistency Anxiety

Impulsive, erratic behavior Self-doubt

Anergia Shame

Cognltlve

Difficulty concentrating

Cocaine cravings

Short-term memory disruption

Relationship

Hostility

Confusion

Maladaptive coping responses

Fear

Honeymoon Stage

During the honeymoon stage, cravings are reduced, mood improves, energy

increases, and confidence and optimism return. Frequently, it feels to the

client that the problem is over. Activity is often scattered, inefficient, and

frenetic, Return to alcohol use and discontinuation of recovery activities

may occur because the client sees no obvious need for continued caution.

Behavioral

High energy

Poorly directed behavior

Excessive work

Alcohol use

Emotional

Optimism

Overconfidence

Feelings of being cured

Cognitive

Inability to prioritize

Abbreviated attention span

Inability to recognize relapse

potential

Relationship

Denial of addiction disorder

Desire for things to return to

“normal”

Conflict between family and

treatment

The Wall

This period is viewed as the major hurdle in the cocaine recovery process.

Relapse vulnerability increases as clients experience low energy, anhedonia,

difficulty concentrating, irritability, loss of sex drive, and insomnia. Clients

often perceive that these conditions will persist indefinitely.

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Behavioral

Sluggishness, anergia

Sexual disinterest/dysfunction

Insomnia

Discontinuation of treatment,

recreational, and/or occupational

behaviors

Resumption of alcohol/marijuana

use

Emotional

Depression

Anxiety

Fatigue

Boredom

Anhedonia

Irritability

Cognitive

Cognitive rehearsal of relapse

Euphoric recall of cocaine use

Increased frequency of cocaine

thoughts and cravings

Misattribution of emotional

reactions

Difficulty concentrating

Relationship

Mutual blaming

Irritability

Devaluation of progress

Threatened separation/

expulsion from home

Adjustment Stage

There is often a great feeling of accomplishment at having completed the wall

stage. This can result in a sense that finally everything should go “back to

normal.” Clients who successfully deal with this stage begin to “adjust” to the

continuation of lifestyle and relationship changes that began in previous

stages as the new definition of “normal.”

Behavioral Emotional

Return to alcohol use Reduced depression

Return to high-risk situations Reduced anxiety

Decrease in abstinence-promoting Reduced irritability

behaviors Continued boredom

Return to “normal life” Loneliness

Cognitive

Reduced frequency of cocaine

thoughts and cravings

Questioning of addiction

Relationship

Emergence of long-term

relationship problems

Resistance to assistance with

relationship problems

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Resolution Stage

Completion of the intensive 6-month program signals a shift from learning

new skills to monitoring for relapse signs, maintaining a balanced lifestyle,

and developing new areas of interest in the resolution stage. For some

clients, individual psychotherapy or relationship issues emerge that may

indicate a need for additional attention.

Behavioral Emotional

Emergence of other excessive Emergence of psychodynamic

behavior patterns (e.g., gambling, material

sex, work, eating, alcohol use) Boredom with abstinence

Cognitive

Questioning the need for long-term

monitoring and support

Relationship

Conflict between recovery

principles and relationship

needs

PROGRAM FORMAT

When the neurobehavioral approach is used, the goal of treatment is to

provide a framework within which cocaine abusers (1) cease drug use,

(2) remain in a treatment process for 12 months, (3) learn about issues critical

to addiction and relapse, (4) receive direction and support from a trained

therapist, (5) receive education for family members affected by the addiction

and recovery, (6) become familiar with the support of self-help programs,

and (7) receive monitoring by urine testing. The components of the program

are constructed to eliminate drug use and maximize acquisition of relevant

information while retaining the greatest number of clients in treatment. On

admission, clients enter Phase I of the program. The schedule of program

activities is delineated in table 1.

Individual Sessions

An unusual aspect of the neurobehavioral model is an intense focus on the

use of individual sessions, with a professional therapist serving as the primary

treatment agent. Group dynamics are secondary to the individual, one-to-one

connection between client and therapist. Therapists are master’s degree

counselors who have received an additional 120 hours of specialized training

at the Matrix Center before they are assigned caseloads. Their approach

to working with clients requires that they use a combination of skills and that

they function simultaneously as teacher and coach. The work of Richard and

Elaine Resnick (1984) has made critical contributions to the development

of this treatment philosophy. The therapist fosters a positive, healthy

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TABLE 1. Matrix Center program schedule

Phase I (Months 1-6)

Client Schedule Family/Spouse Schedule

Month 1

Monday - Educational group

Thursday - AA meeting

Friday - Stabilization group

Weekly - three Individual sessions

Weekly - one urine test

Monthly - two conjoint sessions

Months 2-3

Monday - Educational group

Wednesday - Relapse prevention

group

Thursday - AA meeting

Weekly - two individual sessions

Weekly - one urine test

Monthly - one conjoint session

Months 4-6

Wednesday - Relapse prevention

group

Thursday - AA meeting

Weekly - two individual sessions

Weekly - one urine test

Monthly - one conjoint session

Month 1

Monday - Educational group

Wednesday - Family group

Monthly - two conjoint sessions

Months 2-3

Monday - Educational group

Wednesday - Family group

Monthly - one conjoint session

Months 4-6

Monthly - one conjoint session

- Group/individual

sessions as needed

Phase II (Months 7-12)

All clients attend a weekly group for an additional 6 months.

Individual/couples therapy and urine testing are also available.

KEY: AA=Alcoholics Anonymous

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relationship with the client and uses that relationship to reinforce positive

behavior change. The interaction Is realistic and direct but not confrontational

or parental. Therapists are trained to view the treatment process as an

exercise that will promote self-esteem, dignity, and self-worth. A positive

relationship between client and therapist is a critical element for client

retention.

The content of the 45-minute individual sessions is structured to include

specific information and a set of exercises. There are 52 individual sessions

scheduled in the first 6 months of intensive involvement. The sequence of

sessions is structured to present Information in an order that corresponds

with the timetable of issues usually experienced by the clients in the recovery

process, although there is flexibility for attending to individual client issues.

The individual sessions are not open-ended counseling sessions or indepth

psychotherapy sessions. Frequently, part of each session deals with the

session topic and part allows the client to discuss other current problems.

A sample of the session topics include rating withdrawal symptoms, teaching

thought-stopping procedures, presenting time-scheduling techniques, dealing

with drug-using friends, monitoring personal behavior change, reviewing

nutrition and exercise habits, dealing with the wall, examining control issues,

exploring emotional responses to recovery, learning introspection techniques,

and integrating skills learned in treatment into lifestyle changes.

Educatlonal Group

The 12-week educational group is presented to clients and their families

in a classroom setting. The educational component includes such

program topics as the biology of addiction-describing such concepts

as neurotransmitters, brain structure and function, drug tolerance, and

the relationship between exercise and endorphin; conditioning and

addiction—including such concepts as conditioned cues, extinction,

and conditioned abstinence; medical effects of stimulants on the heart,

lungs, reproductive system, and brain; and addiction and the family—

describing how relationships are affected during addiction and recovery.

Eight other topics are covered for a total of 12 lectures.

Stabilization Group

On Friday nights during for the first 4 weeks of treatment, clients participate

in the stabilization group. The four topics covered in this group contain the

key elements to staying sober through the following weekend: scheduling

time, dealing with triggers, alcohol and secondary drug use, and activities to

fill leisure time. This group is typically a small one that is very directed. It

99
provides a nonthreatening introduction to group situations for people who are

unfamiliar with or uncomfortable in groups.

Relapse Preventlon Group

The relapse prevention group is a central component of the neurobehavioral

treatment package, and it has a specific purpose and a specific format.

There are certain things this group is not: It is not an encounter or sensitivity

group, an assertiveness-training or growth group, a self-help or 12-step

program, or a stress-reduction or open-ended “whatever is on your mind

group. The group provides a setting in which information about relapse

and relapse prevention can be shared. Signs of impending relapse can

be identified by staff and clients. Clients heading toward relapse can be

redirected, whereas those who are on a sound course of recovery can be

encouraged. The group setting allows for mutual client assistance within

the guiding constraints of the group leaders. Topics include dealing with

fatigue, addict behavior, truthfulness, relapse justification, sex and recovery,

balance, holidays and relapse, cocaine dreams, and reestablishing trust.

Family Group

The family group covers a 12-week series of topics designed to assist family

members in coping with the stimulant user in recovery. As with the relapse

prevention groups, these are not traditional therapy groups. They are run

by a professional therapist and a coleader, a client who has completed the

family group. Each group is structured with a didactic presentation of an

addiction-related topic followed by discussion. The goal of the group is to

refocus family members on their own issues and give them a forum for

asking questions and expressing concerns and fears. Topics include

effective communication, codependency, healthy intimacy, family rules,

limitations of living with an addict, and relapse and relationships.

Conjolnt Sessions

During the first 6 months of the program, a minimum of seven conjoint

sessions are scheduled that are facilitated by the client’s individual therapist.

These typically are conducted with the patient and spouse/significant other.

However, they can also be used for a child, employer, or friend. There are

specific issues that are discussed at each stage of the recovery. The material

is structured to encourage communication between the client and family

member about positive areas of change, to identify problem areas, and to

devise strategies for dealing with problems. These sessions are helpful in

defusing problem situations without initiating an intensive couples counseling

process.

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Urine Tests

Urine samples are collected randomly on a weekly basis. Full toxicology

screens are used for approximately 10 percent of a client’s tests; the other

tests are for drug of choice only. This allows for regular urine testing without

the excessive cost of full screens. Positive urine tests are used as points

of discussion in individual therapy sessions. They provide an indication that

some aspect of the treatment plan is inadequate or incomplete. Urine tests

are not used for punitive or legal monitoring purposes.

Alcoholics Anonymous Meeting

Each of the Matrix offices has an AA meeting on the premises one night

per week. These meetings are standard AA meetings, run according to

AA’s traditions. Clients are strongly encouraged to participate in these

meetings as part of their recovery plan. Approximately 60 percent of the

clients attend the AA meetings at Matrix and/or other outside meetings.

Zweben’s work (1986) has been of great assistance in describing the

key issues that must be considered to effectively integrate the cognitive/

behavioral, professional therapy aspects of recovery with the more

emotional/spiritual orientation of the self-help programs,

Relapse Analysis

An important aspect of relapse prevention training is how to handle a

relapse if one occurs. Within the neurobehavioral model, the manner in

which a relapse is handled is standardized by the use of a structured

exercise. The exercise aids the client in viewing relapse as part of a

process rather than as an isolated event and allows the therapist to

understand the issues and events that occurred preceding the relapse,

which may provide clues for the prevention of future relapses, The goals

of the relapse analysis are to: (1) prevent similar relapses from happening

without the client being aware of how or why they occur, (2) encourage

the client to focus on the larger picture of the context in which the relapse

occurred as opposed to the isolated event, (3) reframe the self-deprecation

that often follows a relapse into an acceptance of the addiction, (4) remove

the fear and mystique from a relapse episode and give the client a workable

plan for staying drug-free, and (5) acknowledge the feelings the client is

experiencing and help him or her understand that the behaviors can be

controlled even though the feelings cannot.

Phase II

The Phase II component of the program covers months 7 to 12. The only

structured activity recommended for all clients is a weekly Phase II group.

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These groups address somewhat different issues for men and women.

For many men, the Issues tend to focus on career adjustments, self-image

changes, and lifestyle modifications. For many women, the issues tend

to center on relationships, sexual abuse, and self-esteem. In addition to

these groups, individual therapy sessions and couples therapy sessions

can be included during the second phase for clients who desire to remain

in ongoing therapy.

PROGRAM EFFECTIVENESS

The neurobehavioral program has been constructed in a way that facilitates

evaluation and replication. The structured manuals used by the therapists

promote the delivery of a treatment experience that is consistent across

all clients. These manuals have been formalized through a grant from the

National Institute on Drug Abuse (NIDA) (Rawson et al. 1989). A second

phase of this NIDA project is a controlled clinical evaluation of the treatment

model.

One pilot study (Rawson et al. 1986) was conducted to gain a preliminary

assessment of the treatment program. In spring 1985, an independent

research associate was hired by Matrix to follow up three groups of cocaine

abusers at 8 months after their initial evaluation. The subjects in these

groups were cocaine abusers who had entered Matrix for an evaluation

session and had self-selected one of three treatment options: (1) no formal

treatment (voluntary involvement in AA, Cocaine Anonymous, or Narcotics

Anonymous); (2) 28-day hospital-based, AA-based inpatient treatment; or

(3) outpatient treatment for 6 months with the materials developed at Matrix.

In each group, 30 subjects were followed for 8 months after the evaluation

session, and a structured interview was conducted with each subject.

The pilot data were promising and clinically valuable. The subjects who

had attended outpatient treatment reported lower rates of cocaine use

than did those in the hospital-based and the no-treatment groups. There

appeared to be a positive relationship between alcohol consumption and

relapse to cocaine use. The relationship appears to be an important

clinical issue in the achievement of cocaine abstinence. The outpatient

subjects reported satisfaction with the treatment experience that was

significantly greater than subjects who had hospital-based treatment or

who had not entered treatment. Although the conclusions drawn from this

pilot study were limited because of the quasi-experimental design of the

study, there was the strong suggestion from participants that the materials

and clinical strategies produced a useful experience that helped them

achieve cocaine abstinence.

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MATRIX OPEN TRIAL 1986-89

The neurobehavioral model has been implemented in a standardized

manner since 1985 by the Matrix Center. In two of the four Matrix Center

offices, Beverly Hills and Rancho Cucamonga, a large-scale open trial

has been conducted to provide a foundation for future systematic studies

of the model. In this open trial, 486 of the subjects interviewed volunteered

to participate in the model (Beverly Hills, n=314; Rancho Cucamonga,

n=172). In the Beverly Hills office, the source of funding for the treatment

was patient fees or private insurance for 85 percent of the participants

($4,500 per 1 P-month treatment episode). An additional 15 percent

were treated pro bono. In the Rancho Cucamonga office, 20 percent

of the subjects paid fees or used private insurance; 80 percent received

treatment subsidized by the San Bernardino County Health Department.

All subjects who received subsidized treatment paid for treatment on a

sliding scale with the minimum fee of $10 per week. Subjects were not

terminated for failure to pay. The catchment area served by the Beverly

Hills office included the affluent areas of Beverly Hills and Westwood and

the middle-class areas of San Fernando Valley. The Rancho Cucamonga

off ice drew subjects from the lower income areas of Pomona, Ontario,

and Fontana as well as blue-collar areas of San Bernardino and Riverside

counties. The geographical and treatment funding differences in the two

sites resulted in samples with some clear differences. Table 2 presents

some aspects of the subject characteristics.

As table 2 illustrates, the Beverly Hills sample was somewhat older,

had more education, and had a higher annual income. The sex ratios

and marital status of both groups were approximately equal. In both

sites a majority of subjects were Caucasian/Anglo, although the Rancho

Cucamonga office had a somewhat higher percentage of blacks and

Hispanics.

Table 3 illustrates the drug and alcohol histories of the sample. The

samples were similar on all measures except route of administration.

In the Beverly Hills sample, 51 percent used cocaine lntranasally as

the primary route of administration. In Rancho Cucamonga, crack was

smoked by 65 percent of the subjects. Both groups of subjects had

substantial histories with cocaine and other drugs, and about two-thirds

of both groups used alcohol three or more times per week.

The picture that emerges from tables 2 and 3 is that the subjects in this

open trial were 20 to 40 years old and had used cocaine about 7 years;

almost half had experimented with other dependency-producing drugs.

Two-thirds admitted significant amounts of alcohol use on admission.

103
TABLE 2. Subject characteristics in the Matrix 1986-89 open trial

Characteristic

Beverly Hills Rancho Cucamonga

(n=314) (n=172)

Total

(n=486)

Mean age in years 30.8 27.6 29.6

Males 72% 77% 74%

Females 28% 23% 26%

Mean years

of education

14.2 12.6 13.5

Mean annual

legal income

$27,900 $16,700 $23,930

Marital status

Single

Married

Divorced

Other

56%

30%

6%

8%

50%

35%

10%

5%

54%

32%

7%

7%

Ethnicity

Caucasian/Anglo

Black

Hispanic

Other

83%

12%

4%

1%

63%

20%

16%

1%

76%

15%

8%

1%

The majority were male and Caucasian/Anglo. In Beverly Hills, the

subjects had higher incomes and more education, and a larger proportion

used cocaine intranasally. In Rancho Cucamonga, the sample had both

lower incomes and less education, and almost two-thirds used crack.

The mean length of participation in the treatment program was 18.2

weeks. In Beverly Hills, subjects averaged more than 5 months in

treatment, whereas those in Rancho Cucamonga averaged more than

3 months. One of the causes of the discrepancy between the two samples

is that in Rancho Cucamonga, 20 percent of the subjects dropped out

during the first 2 weeks. In Beverly Hills, this early dropout rate was

8 percent. Conversely, in Beverly Hills, almost one-half (48 percent) finished

the intensive 6-month phase of the program, whereas only 22 percent of

the subjects in Rancho Cucamonga completed this phase of treatment.

104
TABLE 3. Drug and alcohol history of subjects in Matrix 1986-89 open trial

Beverly Hills Rancho Cucamonga Total

History Factor (n=314) (n=172) (n=486)

Mean duration of

cocaine use

Mean amount of

cocaine used in the 30

days before admission

Primary route of administration

lntranasal

Smoked

Intravenous

Percent with significant

other drug history

(excluding marijuana)

Percent with significant

alcohol use on admission

(three or more times per week)

7.9 years 6.1 years 7.2 years

18.0 g 20.5 g 18.6 g

51% 26% 43%

43% 65% 51%

6% 9% 6%

48 41 46

72 68 71

Of those subjects who completed the 6-month phase, similar proportions

in both sites completed the treatment program with no cocaine use

detected by urinalysis or self-report (Beverly Hills, 44 percent; Rancho

Cucamonga, 40 percent).

Weekly urine samples were taken on a random basis as part of the

treatment program. Samples were screened for cocaine and amphetamine.

In those cases where a subject self-reported cocaine use, a urine test

was deferred, and a positive result was recorded. Occasionally, samples

were overlooked for the week. Therefore, in table 4, the number of

samples per subject does not equal the number of weeks in treatment.

The results illustrated in table 4 indicate cocaine use was roughly

equivalent in both groups. Overall, nearly 9 of 10 (88 percent) of the

samples taken were negative for stimulants.

To document the involvement of subjects in the treatment program, table 5

lists the amount of involvement in three categories of program participation.

As illustrated in the table, subjects attended about 80 percent of the

105
TABLE 4. Program completion/urinalysis data from subjects in Matrix

1986-89 open trial

Factors Measured

Beverly Hills Rancho Cucamonga Total

(n=314) (n=172) (n=486)

Mean number of

weeks in treatment

21 .0 13.2 18.2

Number of subjects who

completed 6-month

Phase I

151

(48%)

38

(22%)

189

(39%)

Number of subjects with

no drug use

during treatment

66

(44%)

15

(40%:)

81

(43%)

Percent who failed to

complete first 2 weeks

of treatment

8 20

(n=28) (n=35)

13

(n=63)

Number of negative

urinalysis results

15.8 10.2 13.6

Number of positive

urinalysis results

2.1 1.4 1.8

Percent of negative

urinalysis results

88 88 88

scheduled individual therapy sessions while in treatment. In contrast,

the attendance at group sessions was less reliable. Subjects attended just

more than one-half (54 percent) of the stabilization, educational, and relapse

prevention groups. The poorest attendance in any of the formal program

components was in the family group, where participation was only about onequarter of the scheduled sessions (24 percent). Interestingly, the attendance

in the family component appeared slightly better at the Rancho Cucamonga

site (32 percent vs. 22 percent).

These data support the clinical impression that the primary attraction of

this treatment model is the individual session. Although many subjects

reported enthusiasm and interest in the group components of the

program, their attendance suggests that they preferred the individual

106
TABLE 5. Program compliance data for subjects in Matrix 1986-89

open trial

Data Measured

Beverly Hills Rancho Cucamonga Total

(n=314) (n=172) (n=486)

Mean number of

weeks in treatment

21 .0 13.2 18.2

Percent of scheduled

individual sessions

attended

82 78 81

Percent of scheduled

group sessions attended

53 55 54

Percent of family

activities attended

22 32 24

sessions. However, it should be noted that individual sessions were

rescheduled frequently at the convenience of the subjects. Group

sessions were held at fixed times and could not be shifted to meet

individual subject schedules. Therefore, part of the reason for the better

attendance can be explained by the greater flexibility of scheduling of

individual sessions.

The clinical impression of the authors is that subjects whose family

members participate in treatment have better treatment retention rates

than those with no family participation. This impression is particularly

strong in the Rancho Cucamonga off ice, where more low-income subjects

were treated. The involvement of family members appeared particularly

critical for promoting retention in treatment at this site,

As noted in the introduction of this chapter, the neurobehavioral model

hypothesizes the existence of certain stages of cocaine recovery. The

evidence for these stages has been based solely on clinical impression.

In the studies under way, several standardized tests and scales are being

used to investigate the existence of these stages. In addition, a collaborative

research project with the Department of Nuclear Medicine, University of

California, Los Angeles, is allowing for position emission tomography scan

analysis of subjects at different times following cocaine use (Baxter et al.

1988). It is hoped that some biological evidence will be discovered that

will help determine the nature of these presumably biologically based stages.

107
Figure 1 depicts the dropout rates of subjects in the open trial across the

first 25 weeks of the program. As noted in this figure, of the subjects who

terminated before 26 weeks, more than 20 percent did so in the first 2 weeks.

This high dropout rate corresponds with the withdrawal stage noted in the

model. For the next 4 weeks, the rate of dropouts is only about 7 percent per

2-week block; this lowered rate of dropouts corresponds to the honeymoon

stage described earlier. Although there is considerable fluctuation in the

dropout rate over the next 10 weeks (weeks 7 to 16) overall, the dropout

rate is 10.2 percent. This somewhat elevated dropout rate corresponds to

the wall stage. Finally, during the last 10 weeks of the 6-month block, weeks

17 to 25, the dropout rate falls to only about 3.1 percent per 2-week block.

Although these figures have not been compared statistically, the pattern of

the dropout rate does correspond to the pattern of stages observed clinically.

Limitations of the Open Clinical Trial

The data presented in this section are not intended to validate scientifically

the efficacy of the neurobehavioral treatment model. They are intended to

provide some perspective on one body of work conducted with a relatively

large group of cocaine users. Because of the peculiarities of the sample,

the generalizability of the findings is limited. At the present time there are

no followup data available to address the extremely important question of

how these subjects fared after completion of formal treatment involvement.

However, it is hoped that data presented in this open trial can provide some

perspective on issues of importance in the treatment of cocaine dependence.

Some of the working hypotheses generated by the experience of this open

trial that are being tested in controlled research are presented below.

1.

2.

3.

4.

5.

6.

Positive followup status is positively correlated with increased time in

treatment.

Attendance at treatment activities is negatively correlated with drug use

in treatment.

Amount of family involvement in treatment activities is positively

correlated with client involvement in treatment activities.

Amount of AA participation is positively correlated with positive followup

status and negatively correlated with drug use in treatment.

Amount of alcohol use is positively correlated with cocaine use during

treatment and at followup.

Medication may increase participation in treatment activities and retention

in treatment.

108
FlGURE 1. Rate of program dropouts
7. Positive followup will be positively correlated with lifestyle behavior

change during treatment.

FUTURE DIRECTIONS

The keys to further development of a treatment method such as the

neurobehavioral model described here are replicability and controlled

evaluation. To refine the treatment method in a way that increases its

effectiveness or broadens its applicability to other treatment populations, it

is first necessary to be able to replicate the approach systematically. To

promote the replication of the method, a detailed 350-page manual has been

developed in conjunction with NIDA (Rawson et al. 1989) that contains all the

treatment handouts, educational sheets, and written exercises organized into

the different treatment components. In addition, each treatment component

is accompanied by a therapist’s guidebook that orients the therapist or group

leader to the manner in which the materials are to be used and the desired

effect of discussing the topic material.

To evaluate this treatment model systematically, a controlled clinical

evaluation of the model is under way. In this study, 100 cocaine abuser

volunteers are being assigned randomly either to the neurobehavioral

treatment program or to a comparison condition consisting of referral to

available community resources. A variety of psychological data, treatment

compliance data, behavior change data, and alcohol and other drug use data

is being collected on all subjects during the treatment period and at a series

of followup interviews. Results of this study should demonstrate whether

participation in the neurobehavioral program activities produces a measurable

impact on cocaine use during treatment and at followup.

In a study being headed by Felipe Castro, Ph.D., through San Diego State

University, the neurobehavioral model is being evaluated as part of an

inpatient-outpatient study. in this project, data from 120 stimulant users

who participate in the neurobehavioral model program will be compared with

that from a group of stimulant abusers who participate in a 28-day inpatient

program and with a group who received no formal treatment. As the design

of this study does not involve random assignment of subjects to groups,

there will not be a controlled comparison of the efficacy of the treatment

approaches. The primary focus of this study is to determine whether a

patient profile can be constructed that will identify those subjects who

would be most appropriate for either of the treatment approaches. In

addition, use of the Addiction Severity Index (McLellan 1985) and the

Lifestyle Survey (Castro 1993) should provide some valuable data on

the relationship between drug use and prosocial behavior change.

110
Another potentially useful application of this neurobehavioral approach is the

delineation of an explicit framework within which to test new pharmacologic,

medical, or psychological strategies. Many of the pharmacologic strategies

for cocaine dependency treatment have been evaluated separately from any

well-defined ancillary treatment methodology. This is unfortunate because the

chaotic circumstances that most cocaine addicts are in at the time of treatment

initiation make it extremely difficult to assess accurately the value of a specific

therapeutic intervention. For example, a medication that might reduce cocaine

craving will not provide assistance with the social disorganization, family

disruption, financial stress, and other emotional obstacles with which the

cocaine abuser is faced in the first few days of abstinence. It is possible that

a useful pharmacologic approach may be dismissed as not useful because

its effects are overwhelmed by nonpharmacologic issues. Similarly, some

strategies may be useful at later stages in the recovery process. To evaluate

these effects, it may be necessary to work with cocaine abusers for weeks or

months into recovery. The neurobehavioral model may provide a standardized

methodology within which these additional strategies can be assessed. An

evaluation of desipramine for cocaine and methamphetamine dependence is

under way using the neurobehavioral method as the treatment structure.

Particular attention will be given to assessing the value of either of these

medications during the withdrawal and wall phases of stimulant recovery.

Further evaluations of the neurobehavioral model will attempt to systematically

explore the benefits of acupuncture and exercise at different stages in the

recovery process. In addition, several other studies are in preparation to

evaluate the model with cocaine-abusing methadone maintenance patients,

pregnant crack-smoking women, and stimulant-abusing schizophrenics.

Studies under way are listed below.

Inpatient/Outpatient Patient Matching Study, Rancho Cucamonga Office,

Felipe Castro, Ph.D., Principal Investigator, Richard Rawson, Ph.D., CoPrincipal Investigator

Neurobehavioral Model Evaluation With Random Assignment, Glendale

Office, Richard Rawson, Ph.D., Principal Investigator.

Desipramine Double-Blind Evaluation: Research Demonstration Project,

Beverly Hills and Woodland Hills Offices, Richard Rawson, Ph.D.,

Principal Investigator, Walter Ling, M.D., Co-Principal Investigator.

Gepirone for Cocaine Abuse, Beverly Hills Office, Walter Ling, M.D.,

Principal Investigator.

111
SUMMARY

The treatment of cocaine dependency in the 1980s has required the use of a

broad range of strategies. Although there are some promising approaches

for treating certain aspects of the cocaine withdrawal syndrome, there is no

empirical evidence that provides a clear direction to the future development

of a comprehensive treatment approach. The neurobehavioral model is an

initial attempt to structure information, support, and encouragement across

a series of stages that are experienced by cocaine abusers as they progress

through the first 6 months of their recovery. This model attempts to sequence

strategies in a way that will correspond to an expected timetable of problem

emergence during recovery from cocaine dependency. Individual sessions

with trained therapists are used extensively to move clients through the

recovery process. Relapse prevention techniques have been used extensively

within a relapse prevention group format and in a standardized relapse

analysis procedure. This model has been standardized into a manual that

allows for replication and evaluation. Current research efforts are under way

to assess the usefulness of this model as an independent treatment approach

and as a framework for evaluating other potentially useful cocaine dependency

treatment strategies.

REFERENCES

Baxter, L.R.; Schwartz, J.M.; Phelps, M.E.; Mazziotta, J.C.; Barrio, J.; Rawson,

R.A.; Engel, J.; Guze, B.H.; Selin, C.; and Sumida, R. Localization of

neurochemical effects of cocaine and other stimulants in the human brain.

J Clin Psychiatry 49(2)[Suppl]:23-26, 1988.

Castro, F.G. The Lifestyle Survey. Tempe, AZ: Hispanic Research Center,

Arizona State University, 1993.

Chicago Sun Times. “Acupuncture Aids Addicts, Clinic Says.” Chicago Sun

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Crowley, T.J.; Krill-Smith, S.; Atkinson, C.; and Selgestad, B. A treatment for

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M.S., eds. Cocaine: A Clinician’s Handbook. New York: Guilford, 1987. pp.

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Gold, M.S. 800-Cocaine. New York: Bantam Books, 1984.

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Clin N Am 7:1713-728, 1984.

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1985. pp. 31-50.

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Washton, A.M. Cocaine Addiction: Treatment, Recovery, and Relapse

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abusers. In: Harris, L.S., ed. Problems of Drug Dependence, 1985:

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DC: Supt. of Docs., U.S. Govt. Print. Off., 1986. pp. 381-384.

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N.J., and Adams, E.H., eds. Cocaine Use in America: Epidemiologic and

Clinical Perspectives. National Institute on Drug Abuse Research

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262, 1986.

ACKNOWLEDGMENT

The work described in this chapter is supported in part by NIDA grants DA06185-1, DA-05778, and DA-05661 to Matrix Center, Friends Medical

Science Research Center, and San Diego State University.

AUTHORS

Richard A. Rawson, Ph.D.

Assistant Research Psychologist

Department of Psychiatry

University of California, Los Angeles

Los Angeles, CA 90209

Executive Director

Matrix Institute

Suite 409

6447 Wilshire Boulevard

Beverly Hills, CA 90211

Jeanne L. Obert, M.A.

Director of Clinical Services

Michael J. McCann, M.A.

Director of Research

Matrix Institute

Suite 409

8447 Wilshire Boulevard

Beverly Hills, CA 90211

114
Walter Ling, M.D.

Medical Director

Matrix Institute

Suite 409

8447 Wilshire Boulevard

Beverly Hills, CA 90211

Associate Professor

Department of Psychiatry

University of California, Los Angeles

Los Angeles, CA 90209

115
Psychotherapeutic Treatment of

Cocaine Abuse: Models for Its

Evaluation Alone and In Combination

With Pharmacotherapy

Kathleen M. Carroll

INTRODUCTION

Lines of research on psychotherapeutic and pharmacotherapeutic

treatments for cocaine abuse have largely developed separately, with

more rapid proliferation of randomized clinical trials of pharmacologic than

psychotherapeutic treatments in recent years. Although most clinical trials

evaluating pharmacologic agents have included some psychotherapeutic

component, psychotherapy has assumed an essentially supportive role

in these studies, limited to fostering treatment retention and enhancing

compliance with medication. The contribution of psychotherapy per se

has not been a focus of studies evaluating pharmacologic treatments

for cocaine abuse.

What evidence exists for the efficacy of psychotherapy as treatment for

cocaine abuse? What is an appropriate model of psychotherapy research

in cocaine abuse? Should psychotherapy be conceived as an independent

treatment to be used alone or in combination with other treatments, as the

“backbone” of a treatment program to which adjunctive treatments may be

added, or as an adjunct to other forms of treatment such as drug counseling

or pharmacotherapy? This chapter has two parts: (1) a detailed review of

the only randomized clinical trial to date that had adequate historical controls

contrasting different psychotherapies for cocaine abuse to evaluate the

relative efficacy of psychotherapy and pharmacotherapy and (2) an

explication of possible models for conceptualizing and evaluating the

contributions of psychotherapy and pharmacotherapy, alone and in

combination, to the treatment of cocaine abuse.

116
PSYCHOTHERAPEUTIC TREATMENTS: EMPIRIC EVIDENCE

Although few psychotherapeutic treatments have been evaluated in clinical

trials, the large number of articles describing various psychotherapeutic

approaches as treatment for cocaine abuse suggests the intuitive appeal

of these approaches. Approaches described thus far can be broadly

categorized as those that are either primarily interpersonal or

psychodynamically oriented (Rounsaville et al. 1985; Schiffer 1988)

or treatments that are primarily behavioral or cognitive-behavioral in

orientation (Anker and Crowley 1982; Carroll et al. 1991a; O’Brien et al.

1988). Several articles have described psychotherapeutic approaches

delivered as a component of multimodal treatment programs (Rawson

et al. 1990; Washton 1986); most authors have emphasized the value

of self-help groups such as Cocaine Anonymous (Millman 1988). Reports

that have included outcome data consistently point to difficulties met in

treating cocaine abusers with a primarily psychotherapeutic approach,

including high rates of treatment dropout (Anker and Crowley 1982)

mixed compliance with treatment, and high rates of relapse after initial

periods of abstinence (Rawson et al. 1986).

Randomized Clinical Trials

Only one randomized clinical trial evaluating purely psychotherapeutic

approaches for cocaine abuse has been completed to date. This

study (Carroll et al. 1991b) sought to assess the feasibility of purely

psychotherapeutic treatments for cocaine abuse and to contrast two

widely different forms of psychotherapy. Forty-two ambulatory cocaine

abusers were randomly assigned either to relapse prevention (RP), a

cognitive-behavioral approach adapted for cocaine abusers (Carroll et al.

1991a), or to interpersonal psychotherapy (IPT), a short-term psychodynamic

approach (Rounsaville et al. 1985). Dropout was high in both conditions,

but rates of attrition were significantly higher for IPT, with 62 percent of

subjects in IPT vs. 33 percent of those in RP failing to complete a 12-week

course of treatment.

Significant differences by treatment type were not seen on most measures

of outcome but did emerge when subjects were stratified by pretreatment

severity of cocaine abuse: Among the severe users, those treated with

RP were significantly more likely to become abstinent than high-severity

subjects treated with IPT (54 vs. 9 percent). Subjects with lower levels of

severity tended to improve despite type of treatment received. A similar

pattern was seen when subjects were stratified by pretreatment severity

of psychological symptoms: For subjects higher in psychopathology,

those in the RP group were much more likely to become abstinent than

those treated with IPT (58 vs. 14 percent). In parallel to Woody and

117
colleagues’ (1983) findings for psychotherapy outcome with methadonemaintained opiate addicts, the author and coworkers found that cocaine

abusers with concurrent depressive disorders tended to improve regardless

of treatment received. Cocaine abusers with antisocial personality (ASP)

disorder were significantly more likely than those without ASP disorder to

drop out of treatment and tended not to improve in treatment.

This study suggests that (1) at least some cocaine abusers can be

treated successfully with a purely psychotherapeutic approach and

(2) overall response to treatment as well as response to specific forms

of psychotherapy may be mediated by patient characteristics. Limitations

of the purely psychotherapeutlc approaches evaluated here were also

revealed: Attrition was substantial in both treatment conditions and most

marked early in treatment (80 percent of all subjects who dropped out

of treatment did so by week 6). Moreover, although subjects in both

conditions demonstrated significant improvement over baseline levels

on most measures of outcome, more than half the subjects (23 of 42)

failed to become stably abstinent during treatment.

PSYCHOTHERAPY ALONE COMPARED WITH PSYCHOTHERAPY AND

PHRMACO THERAPY COMBINED

Are the limitations of psychotherapy suggested by this study unique to

a primarily psychotherapeutic approach? Given that pharmacotherapies

are generally perceived as faster acting and more potent than psychotherapy

(Karasu 1982), improved treatment retention or initiation of abstinence in

cocaine abusers receiving pharmacologic intervention might be expected.

In particular, abusers’ expectations for medication effects might foster

greater retention during the Initial weeks of treatment, when rates of

attrition are highest.

Because data from direct comparisons of psychotherapy with

pharmacotherapy are not yet available, outcomes from this study of

psychotherapeutic treatments (Carroll et al. 1991b) may be compared

with results from a controlled clinical trial of pharmacotherapies for

cocaine abuse also performed at Yale. In that study (Gawin et al. 1989)

72 ambulatory cocaine abusers were randomly assigned to desipramine

(DMI), lithium (Li), or placebo (PLA), each delivered in combination with

IPT. Subjects treated in the pharmacotherapy trial can be regarded as

historical controls for the psychotherapy study because the following

conditions were met (Pocock 1976): (1) Subjects in both studies were

recruited and treated in the same clinic: (2) IPT was delivered by the

same therapists in both studies: (3) the two samples were almost identical

on pretreatment measures of demographic and psychiatric variables as well

as baseline intensity of cocaine use: (4) identical subject eligibility criteria

118
were used in both studies, with the exception that subjects in the

psychotherapy study did not require medical clearance for pharmacotherapy;

and (5) subjects in both studies were evaluated using identical assessment

Instruments and procedures. Although the two studies were conducted as

distinct investigations and the likelihood of self-selection may limit the

strength of conclusions based on a comparison of the two studies, this

comparison is useful in demonstrating current conceptions of psychotherapy

and pharmacotherapy as treatment for cocaine abuse.

Data contrasting rates of treatment retention and initiation of abstinence

from both studies are presented in table 1. The Gawin and colleagues’

pharmacotherapy study (1989) evaluated outcome through 6 weeks of

treatment, whereas the psychotherapy study evaluated outcome through

12 weeks. Because psychotherapy is generally assumed to require more

time to exert its effects (Elkin et al. 1988a), retention and abstinence data

are presented for both periods.

Several speculations emerge from this comparison regarding the roles

and actions of psychotherapy and pharmacotherapy in the treatment of

cocaine abuse for (1) treatment retention and (2) initiation of abstinence.

Considering treatment retention first, the 6-week retention rate for IPT

TABLE 1. Comparison of pharmacotherapy and psychotherapy studies

Pharmacotherapy+Psychotherapy

(Gawin et al. 1989) Psychotherapy Alone

IPT+DMI Li LIPT IPT+PLA IPT

(n=24) (n=24) (n=24) (n=21) (n=21)

Percent remaining 75.0 45.6 41.7 71.4 52.4

at 6 weeks

Percent abstinent 58.3 25.0 16.7 33.3 28.6

at 6 weeks

Percent abstinent — — — 57.1 33.3

at 12 weeks

KEY : IPT=interpersonal psychotherapy; DMI=desipramine; Li=lithium;

PLA=placebo; RP=relapse prevention

SOURCE: Reprinted from Carroll et al. 1991b by courtesy of Marcel Dekker

Inc. (New York).

119
alone in the psychotherapy study (52 percent) was slightly higher than that

for the IPT+PLA combination in the pharmacotherapy study (42 percent).

One interpretation of this finding is that the addition of expectations for

medication effects in the IPT+PLA combination did little to improve treatment

retention over IPT alone. Instead, expectations for medication effects may

have resulted in slightly greater attrition when expected benefits of the

medication were not forthcoming. Also of note is the rate of retention

through 6 weeks for RP alone in the psychotherapy study (71 percent),

which is comparable to that for the IPT+DMI combination (75 percent).

This suggests that nonpharmacologic interventions may have considerable

power for keeping cocaine users in treatment, even in the absence of

pharmacotherapy. Although retention for the IPT+DMI combination was

markedly higher than that for IPT+PLA, the role of active pharmacotherapy

in fostering treatment retention is not clear, because a pharmacotherapy

alone condition was not included in the pharmacotherapy study.

A comparison of abstinence rates in the two studies shows support for

the expectation that the pharmacotherapy-psychotherapy combinations

would exert effects more rapidly than psychotherapy alone. At 6 weeks,

the abstinence rate for subjects receiving the IPT+DMI combination was

58 percent: abstinence rates for the two psychotherapy-alone conditions

were lower and comparable to each other (33 percent for RP and 29 percent

for IPT). For RP, an additional 6 weeks were required to match the

abstinence rate for the pharmacotherapy-psychotherapy combination

(the abstinence rate for RP increased to 57 percent at 12 weeks).

This suggests that RP, a skills-training approach, requires additional

opportunities for coping skills to be practiced and implemented.

The lower rate of abstinence at 6 weeks for the IPT+PLA combination

(17 percent) in the pharmacotherapy study in contrast to that of IPT

alone (29 percent) in the psychotherapy study is also of interest. Several

factors may account for this discrepancy. First, self-selection may have

resulted in more psychotherapy-responsive subjects in the psychotherapy

study, which may have resulted in better outcome for IPT. Second, for the

IPT+PLA group in the pharmacotherapy study, a negative-placebo effect

(Klerman 1963) may have undercut the efficacy of IPT; that is, patients’

expectations for medication effects may have resulted in their making

less effort through other means to reduce their cocaine use. A third

possibility exists that is of particular interest: Although IPT in both studies

was delivered by the same therapists, differences in conceptions of the

role of psychotherapy in the two studies, and hence the context in which

the psychotherapy was delivered, may have differentially affected the

efficacy of IPT. In the pharmacotherapy study, medications were the

change agents of primary interest, and great emphasis was placed on

protecting the integrity of the pharmacologic components of the treatment.

120
Psychotherapy was conceived as the “ground” against which the impact of

the pharmacologic agents could be assessed and was not evaluated as

a primary change agent; hence, delivery of the psychotherapy was not

systematically monitored or evaluated. This also may have conveyed

to subjects expectations that psychotherapy was a less important or less

effective component of treatment. Conversely, in the psychotherapy

study, the psychotherapies were conceived as powerful change agents,

efforts were made to ensure that subjects received an adequate “dose”

of psychotherapy, and therapies were administered optimally. Hence, the

improved outcome for the IPT-alone condition in the psychotherapy study

over the IPT+PLA combination in the pharmacotherapy study may reflect

delivery of a more potent form of IPT.

To summarize, data from the above comparison suggest that (1)

nonpharmacologic treatments may have an important role in fostering

treatment retention: (2) pharmacotherapy may be a more rapidly acting

form of treatment than psychotherapy for cocaine abusers: and (3) the

often-cited limitations of psychotherapy as treatment for cocaine abuse

(e.g., high attrition, moderate rates of treatment success) are only partly

addressed by combining psychotherapy with desipramine as a

pharmacotherapeutic approach.

MODELS FOR THE EVALUATION OF PSYCHOTHERAPY AND

PHARMACOTHERAPY

The comparison of this pair of studies also provides two illustrative models

for psychotherapy as treatment for cocaine abuse: (1) as a necessary but

largely nonspecific support to pharmacotherapy (Gawin et al. 1989) and

(2) as an effective, and in some cases sufficient, treatment in and of itself

(Carroll et al. 1991b). The first model suggests that psychotherapy has

limited usefulness beyond fostering compliance with pharmacotherapy

and implies uniformity of effects from psychotherapy. Data from this

comparison suggest that this model of psychotherapy may, in part, have

resulted in underestimation of the potential effectiveness of psychotherapy.

The second model assumes a broader role for psychotherapy and suggests

improved outcome may result from preservation of treatment integrity.

Furthermore, it assumes that different forms of treatment may offer

unique and specific contributions to outcome.

Which model of psychotherapy is likely to result in more fruitful treatment

research with cocaine abuse? Before considering research questions

that would follow from adopting different models of psychotherapy as

treatment for cocaine abuse, it may be instructive to review models of

psychotherapy research from other psychiatric disorders as potential

guides for psychotherapy research with cocaine abusers.

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Opiate Dependence

Successful treatments for opiate dependence have generally involved

some combination of psychotherapy and pharmacotherapy, most

convincingly demonstrated by the disappointing results typically achieved

when either modality is used alone. Purely pharmacologic approaches

have generally yielded poor retention and limited outcomes, but marked

improvements have been noted when a psychotherapeutic component

is added to pharmacologic interventions such as medication-assisted

detoxification (Rawson et al. 1983), narcotic antagonist programs (Resnick

et al. 1981), and methadone maintenance (Woody et al. 1983). Conversely,

although it is almost impossible to engage opiate addicts in treatment with a

purely psychotherapeutic approach (Rounsaville and Kleber 1985) delivery

of psychotherapy within methadone maintenance programs has enabled

investigators to rigorously contrast different psychotherapeutic approaches

and identify those addicts who benefit most from professional psychotherapy

over standard drug counseling during methadone maintenance (Woody et al.

1983; Rounsaville et al. 1983). Therefore, all trials demonstrating efficacy of

psychotherapy for opiate addicts have generally involved psychotherapypharmacotherapy combinations, and pharmacotherapy may be a necessary

condition for successful psychotherapeutic intervention with opiate addicts.

Can this model be applied to the treatment of cocaine abuse?

Development of a pharmacologic equivalent of methadone for the

treatment of cocaine abuse is not imminent. Available pharmacologic

agents for the treatment of cocaine abuse do not approach the effectiveness

of methadone for keeping addicts in treatment and reducing illicit substance

use. Furthermore, results from our studies and others (Rawson et al. 1986)

suggest pharmacologic intervention is not essential for all cocaine abusers.

Hence, the current model for psychotherapy research among opiate addicts,

in which psychotherapy is evaluated as an adjunct to the modal form of

treatment (methadone maintenance), has limited usefulness as a model

for psychotherapy research with cocaine abusers.

Depression

A more useful model for evaluating psychotherapy, alone and in

combination with pharmacotherapy, may come from research on the

treatment of depression. In this area, there is a large body of empirical

evidence on the efficacy of different psychotherapies, pharmacotherapies,

and combinations thereof (Conte et al. 1986; Elkin et al. 1989). Well-designed

studies have addressed differentiated questions regarding specificity of the

different forms of treatment and subtypes of depressives for which different

treatments may be most effective (DiMascio et al. 1979; lmber et al. 1990)

and conceptual and methodological issues involved in comparing and

122
combining psychotherapy and pharmacotherapies have been addressed

in detail (Elkin et al. 1988a, 1988b; Hollon and Beck 1978).

Current models for research on the treatment of depression may serve

as useful guides for psychotherapy research with cocaine abusers, given

several parallels in the two disorders and their treatment. In the treatment

of depression, as in the treatment of cocaine abuse, response to available

pharmacologic and psychotherapeutic treatments is incomplete (Karasu

1990a; Morris and Beck 1976); relapse after remission of symptoms is

frequent (Angst 1973); patient groups are heterogeneous and may include

subtypes with differential response to treatment (Karasu 1982); and each

form of treatment (psychotherapy and pharmacotherapy) may address

distinct symptom areas (Klerman 1975). This body of research has led to

current models of treatment that allow for different etiologies of depression,

variability in clinical manifestations of depression, heterogeneity in patient

groups, and variation in response to available treatments. This model also

holds that each form of treatment is powerful and potentially unique.

As Karasu (1990b, p. 276) has noted:

. . . no single therapy is uniformly successful for

all the concomitants of the depressive disorder. For

instance, biological variables may override psychological

ones, or the reverse. In addition to determining whether

treatment should consist of drugs combined with

psychotherapy or of psychotherapy alone, examination

of the (different) psychotherapies lends itself to a more

discriminatory use of each . . . . . Psychotherapy may be

used not only by default, that is, to increase compliance

with medication or as an alternative for patients who

cannot or will not respond to pharmacotherapy, but

in itself as an independent intervention,

One could easily substitute “cocaine abuse” for “depression” in the

quotation above as a potential guide for evaluating psychotherapy and

pharmacotherapy for cocaine abuse. Because it is unlikely that any single

treatment or form of treatment will be adequate for all cocaine abusers,

research should address differentiated questions regarding the roles and

specific contributions of a variety of treatment approaches: What are the

indications for psychotherapy and/or pharmacotherapy for cocaine abuse?

Are different psychotherapies differentially effective with different types of

cocaine abusers or in combination with different pharmacologic agents?

Although treatment research in depression may offer useful models for

evaluating psychotherapy and pharmacotherapy, there are important

differences between depression and cocaine abuse as well as among

123
available therapies that limit the extent to which models from treatment

research for depression can be applied to cocaine abuse. Chief among

these differences is that available pharmacologic agents cannot be

considered “standard” treatments for cocaine abuse as are antidepressants

in the treatment of depression. The promise of tricyclic antidepressants for

cocaine abuse (Gawin et al. 1989) has not yet been widely replicated. In

particular, the efficacy of tricyclic antidepressants as treatment for cocaine

abuse may vary by the treatment modality in which they are administered

(Kosten, this volume). Nevertheless, as new therapies for cocaine abuse

are evaluated, it is possible to draw from research on psychotherapy and

pharmacotherapy in the treatment of depression to conceptualize various

roles for psychotherapy as treatment for cocaine abuse.

ROLES FOR PSYCHOTHERAPY AS TREATMENT FOR COCAINE ABUSE

As Sole Treatment

Initial reports suggest psychotherapy alone may be adequate treatment

for some subgroups of cocaine abusers (Carroll et al. 1991b; Rawson et

al. 1986). This leads to two general types of research questions regarding

psychotherapy as sole treatment for cocaine abusers: First, which subgroups

of cocaine abusers will respond to purely psychotherapeutic treatments?

This line of research could include success profiling, in which characteristics

of subjects responding well vs. poorly to specific psychotherapies are

identified retrospectively. For example, psychotherapy “responders”

might include cocaine abusers with lower levels of severity, those who

can sustain periods of several weeks of abstinence between episodes

of cocaine use, or those who are prone to relapse in identified high-risk

situations. An example of this type of research from the depression

literature is Rush and colleagues’ (1982) finding that depressives with

cognitive distortions respond better to cognitive therapies for depression.

This line of research would also lead to direct comparisons between

psychotherapy and other forms of treatment, particularly pharmacotherapy.

In the treatment of depression, many investigations directly contrasting

psychotherapy and pharmacotherapy have appeared. These have

focused largely on (1) contrasting the efficacy of psychotherapy with

that of pharmacotherapy as a reference condition (Elkin et al. 1985)

and (2) attempting to discern the mode of action and specificity of each

form of treatment (Imber et al. 1990). In the treatment of cocaine abuse,

direct contrasts of psychotherapy with pharmacotherapy might address

similar questions. For example, with respect to time course, the effects of

drugs may be apparent earlier in treatment than those of psychotherapy,

where effects may require more time to become manifest but endure longer

124
than the efforts of pharmacotherapy. Such a finding would have important

implications for treatment: If the effects of pharmacotherapy were found to

be transient, pharmacotherapy would be an appropriate intervention if it were

used to foster initial abstinence, stabilize the patient, and increase availability

for psychotherapy, but might be inappropriate if pharmacotherapy alone were

expected to bring about lasting improvement.

Direct contrasts between psychotherapy and pharmacotherapy also would

allow detection of specific effects associated with each form of treatment.

For example, pharmacotherapy may differentially reduce craving related to

alterations in postsynaptic receptor sensitivity (Gawin et al. 1989), whereas

some forms of psychotherapy might better address craving that resulted

from classical conditioning of particular cocaine cues. Similarly, whereas

pharmacotherapy may help abusers achieve initial periods of abstinence,

psychotherapies may better address their motivation to alter substance use,

resolve issues related to drug availability, and improve their coping skills.

This type of research also could provide guidance regarding indications for

psychotherapy or pharmacotherapy for different types of cocaine abusers.

A second general type of question that could be addressed in research

evaluating psychotherapy as sole treatment for cocaine abuse has to do

with the efficacy of different types of psychotherapy. In the treatment of

depression, there have been many studies contrasting different forms of

psychotherapy; in general, this body of work has supported the effectiveness

of active psychotherapies over controls but has not demonstrated the

superiority of one form of psychotherapy over another (Luborsky et al.

1975; Smith and Glass 1977). In the treatment of cocaine use, evaluation

of IPT and RP revealed no main effects for treatment but suggested more

severe cocaine users as well as those with higher levels of psychiatric

severity had better response to RP than to IPT. Widely used models of

treatment, in particular those derived from the 12-step model, have not

been contrasted with other forms of treatment to discern which subgroups

of cocaine abusers may respond to different forms of psychotherapeutic

intervention.

As Support to Pharmacotherapy

In this model, psychotherapy is seen as providing a minimal supportive structure

against which the efficacy of drugs can be evaluated. A psychotherapeutic

component is included largely to “warm up the drug,” fostering patients’ retention

in treatment and compliance with pharmacotherapy (Docherty et al. 1977; Elkin

et al. 1988a). Few researchers would consider feasible a design in which

pharmacotherapy was administered without any supportive or relationship

elements (Elkin et al. 1988b; Karasu 1982, 1990b).

125
As noted above, psychotherapy as support to pharmacotherapy has

been the dominant model in those investigations that have evaluated

pharmacotherapies for cocaine abuse. Investigators frequently describe

their designs as evaluating drugs as adjuncts to “treatment as usual,”

which usually consists of psychotherapy or counseling. However, as

was suggested in our comparison of psychotherapy and pharmacotherapy

studies, in pharmacologic trials nonpharmacologic components are

likely to be deemphasized relative to the medications being evaluated.

Psychotherapy is likely to be implemented as a support to pharmacotherapy

rather than as a robust treatment in its own right. Thus, whereas the

research question may be posed as What is the incremental effectiveness

of adding pharmacotherapy to treatment as usual?,” in clinical trials of

pharmacologic agents, this often translates in practice to “What is the

relative effectiveness of active medication or placebo in the context of

minimal supportive clinical management?”

Limiting conception of psychotherapy to that of a minimal supportive

condition in pharmacologic trials is likely to have a number of effects,

because the effectiveness of a minimal supportive condition is rarely

equal to that of an active psychotherapy (Luborsky et al. 1975; Smith

and Glass 1977). In this context, psychotherapy is seen as essentially

inert; thus, the content, goals, and methods are typically not specified

or monitored, with the result that all psychotherapies are conceived

as uniform. Active or curative elements that would be included in a

psychotherapy condition in which treatment integrity was preserved

may be absent, thereby undercutting the efficacy of the therapy. The

unique contributions of psychotherapy are likely to go underemphasized

and unassessed. Conclusions regarding the efficacy of psychotherapy

based on pharmacologic trials (where psychotherapy plays a secondary,

supportive role) are likely to underestimate the potential efficacy of

nonpharmacologic treatments.

As a Complementary Treatment

In this model, the efficacy of psychotherapy or pharmacotherapy alone

typically is contrasted with the combination of the two. Here, each form

of treatment is conceived of as having specific and unique therapeutic

properties that may interact in a number of ways. Uhlenhuth and colleagues

(1989) have described four models for such effects: additive (in which the

effect of the combined treatments equals the sum of their individual effects),

potentiation (in which the effect of the combined treatments is greater

than the sum of the two individual treatment effects), inhibition (in which

the effect of the combined treatments is less than the sum of their individual

effects), and reciprocation (in which the effect of the combined treatments

equals the individual effect of the more potent intervention). In the treatment

126
of depression, most research on psychotherapy-pharmacotherapy

combinations has supported an additive or reciprocal model and has

tended not to find evidence supporting inhibition (Rounsaville et al.

1981) or potentiation (Conte et al. 1986) of effects.

There are several advantages to evaluating psychotherapy as a

complementary treatment to pharmacotherapy for cocaine abuse.

First, because psychotherapy is no longer relegated to a “supportive”

role, it can be administered at full strength and therefore allow maximal

effects to emerge and be detected. Psychotherapy and pharmacotherapy

are assumed to work through different mechanisms (e.g., DMI to reverse

cocaine-induced neuroadaptation and psychotherapies such as RP to

improve an abuser’s ability to cope with or avoid high-risk situations

and relapse) and affect different symptom areas.

Thus, a major potential advantage of psychotherapy-pharmacotherapy

combinations in which the integrity of each treatment is protected is that

there may be improved outcome for more symptom areas from integrative

treatments than from either treatment alone. Assuming psychotherapy

and pharmacotherapy differentially affect different symptom areas, by

increasing the number of symptom areas potentially improved through

combination treatments, it is possible to dramatically improve the “hit rate”

among cocaine abusers, who typically present with a heterogeneity of

symptoms and problems. Such a model also allows for detection of

treatment specificity and can guide future efforts toward patienttreatment matching.

Another advantage to evaluating combination treatments is that

potential drawbacks associated with either treatment may be offset

by the other. For example, the provision of support through psychotherapy

may reduce the potential negative impact of side effects arising from most

pharmacotherapies. Similarly, instillation of hope through administration

of a drug may support continuing participation in treatment during the early

stages of treatment when a developing therapeutic alliance may be fragile

or until coping skills are mastered and integrated.

If variations in severity of cocaine abusers who present for treatment are

considered-the multidimensionality of cocaine abusers’ problems and the

heterogeneity of cocaine abusers presenting for treatment-the potential

value of evaluating both psychotherapy and pharmacotherapy as effective

and unique treatment components is further underscored. Extein and Bowers

(1979) differentiate between state disorders, described as time-limited,

autonomous, and unresponsive to psychotherapeutic intervention (e.g.,

psychoses, severe anxiety, major depression), and trait disorders, defined

as “dysfunctional qualities which individuals tend to develop and carry

127
throughout life and which become manifest as predictable patterns for

interaction and response to stress. Such patterns tend not to be responsive

to medication but respond better to psychosocial treatment” (Extein and

Bowers 1979, pp. 690-691). State and trait disorders are conceived as

independent, but one or both may be present in any one individual.

Cocaine abuse (and other forms of substance abuse) can be conceived

as having attributes of both state and trait disorders, in varying degrees

among different abusers: Pharmacotherapy or other forms of medical

intervention are generally essential when “state” disorders are present (e.g.,

withdrawal symptoms associated with physical dependence, some forms of

drug craving, cocaine-induced psychoses) that would not be expected to

respond to psychotherapy. Similarly, psychotherapy may be indicated for

those trait aspects of cocaine abuse on which pharmacotherapy would be

expected to have little impact (e.g., fostering motivation to reduce substance

use, restricting availability of cocaine, avoidance of situations associated

with use, development of non-cocaine-using social supports).

With a state/trait model of substance use disorders, the unique action of

each form of a particular approach can be investigated toward developing a

model of treatment that is comprehensive and nonexclusionary. At lower

severity levels, in the absence of state disorders, psychotherapy alone may

be adequate. At higher levels of severity, the presence of state disorders may

indicate the need for a combination of psychotherapy and pharmacotherapy,

although in some cases the state disorder may be so dominant that it may be

futile to initiate psychotherapy until the state disorder resolves and the patient

becomes available for psychotherapy.

The potential advantages of evaluating both psychotherapy and

pharmacotherapy as robust treatments for cocaine abuse, in particular

the emergence of maximal effects of each treatment type, detection of

the unique contributions of each form of treatment, and the opportunity to

rigorously evaluate potential benefits of psychotherapy-pharmacotherapy

combinations, also introduce several complexities for researchers. There is

substantial literature outlining conceptual and methodological issues in such

comparisons, notably those related to differences in each approach’s nature

and timing of effects (Elkin et al. 1988a), mechanism of action and assessment

of outcome (Elkin et al. 1988b), and method of treatment delivery (Docherty

et al. 1977). These complexities are also instructive because they highlight

major conceptual differences in two unique treatment approaches. This line

of research has contributed to the understanding and treatment of depressive

disorders and may hold promise for the treatment of cocaine abuse.

128
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AUTHOR

Kathleen M. Carroll, Ph.D.

Assistant Professor of Psychiatry

Substance Abuse Treatment Unit

Yale University School of Medicine

27 Sylvan Avenue

New Haven, CT 06519

132
Behavioral Treatments of Cocaine

Dependence

John Grabowski, Stephen T. Higgins, and Kimberly C. Kirby

INTRODUCTION

Cocaine abuse has presented special problems in treatment. These arise

from the pharmacological, behavioral, and environmental factors surrounding

its use. Furthermore, most drug abuse treatment efforts to date have focused

on two legal drugs (alcohol and, more recently, tobacco) and on illegal use of

opiates. The stimulant abuse that has occurred over many decades has not

produced a focus on the development of effective treatments. Therefore, the

current focus of the National Institute on Drug Abuse on cocaine treatment

is particularly important. First, it will provide insight into the behavioral

pharmacology of cocaine use and the current problem. Second and equally

important, continued research will prepare us for future stimulant epidemics

as innovative pharmacological and behavioral modalities for treatment of this

subset of drug abuse problems are discovered. Behavioral interventions

constitute one important category from which these treatments will arise

and which will provide effective interventions either alone or in combination

with other strategies.

The terms “behavioral intervention,” “behavior modification,” “behavior

therapy,” and “behavioral treatment” describe a variety of approaches for

treatment of drug abuse. The terms often are used interchangeably. In

its original use, each emphasized some conceptual principles over others,

although all derived from the broader underlying behavioral framework.

As might be expected, each tended to focus on specific techniques from

the broader armamentarium. The emphasis of the scientists and clinicians

derived in part from specific empirical observations and theoretical

assumptions about the determinants of drug abuse. Nevertheless, these

approaches necessarily have many features in common. The most important

unifying elements are detailed analyses of specific events surrounding drug

abuse and a direct relation to a supporting body of basic scientific principles

of behavior. Thus, whether one focuses on respondents (classically

conditioned responses), those describable in the operant conditioning

(or “instrumental learning”) paradigm, or some combination of the two,

obvious similarities emerge.

133
The classical conditioning approach to opiate dependence and drug taking

has been thoroughly described and systematically applied to drug abuse

elsewhere (Wikler 1948, 1965, 1974; Wikler and Pescor 1967; Wikler et al.

1971; O’Brien 1975; O’Brien et al. 1974, 1977, 1980, 1981; Childress et al.

1989; also see reviews, Grabowski and O’Brien 1981; Grabowski and Cherek

1963) and by O’Brien and colleagues (this volume). This chapter focuses on

operant conditioning approaches, first presenting the general approach and

methods for evaluation and treatment plan development, then discussing

how these approaches have been employed for treatment of abuse of

a variety of drugs, and finally describing current behavioral treatment

research for cocaine abuse.

A BEHAVIORAL APPROACH TO DRUG ABUSE

Within the behavioral approach, drug taking is conceptualized as operant

behavior, that is, behavior that operates in its environment and is maintained

by its consequences. Drugs of abuse are considered to function as reinforcers

and in that regard share many of the same characteristics of other powerful

reinforcers such as food, water, and sex. Drug taking is considered to be an

orderly form of behavior that results from the interplay of fundamental biologic

and behavioral processes.

Empirical support for the behavioral approach to drug abuse treatment

stems from the observation that laboratory animals self-administer most of

the same drugs that are abused by humans (Griffiths et al. 1980). Cocaine,

amphetamines, opioids, sedatives, and ethanol are all self-administered by

laboratory animals. The animal need not have a prior history of exposure or

physical dependence on these drugs for them to function as reinforcers and

maintain drug-taking behavior. The temporal patterns of drug ingestion in

laboratory animals and humans are generally similar. Manipulations of drug

availability, drug dose, response requirement or cost factors, and other

environmental factors have similar effects on human and nonhuman drug

taking. Thus, the causes of drug self-administration and dependence must

lie at the level of basic biologic and behavioral processes that are shared

across species (Bigelow et al. 1981; Griffiths et al. 1980; Stitzer et al. 1983).

This model of drug abuse has permitted researchers and clinicians to

effectively extrapolate and apply scientific principles already available from

research on other types of behavior. The research has generated a great

deal of empirical knowledge concerning the dynamic role played by

environmental, pharmacological, and, more recently, genetic variables in

the reinforcing effects of drugs. This perspective also has fostered some

innovative treatment interventions, which are characterized below. Most

of the research has involved drugs other than cocaine, although promising

studies have been conducted in treatment of cocaine dependence as well.

134
Research with other drugs is discussed to provide an adequate sampling of

this approach to drug abuse treatment and some insights into the rationale

behind the behavioral work being conducted with cocaine. The critical feature

is the focus on the relationship between drug taking and its consequences

and establishing a similarly persistent relationship between treatment

attendance and its consequences.

Much of the existing work on operant approaches has been undertaken in

the examination of opiate dependence (Glosser 1983; lguchi et al. 1988;

Milby et al. 1978; Stitzer et al. 1986, 1977, 1983). This follows from three

features: First, the dominant drug problem and area of study with the

greatest momentum for many decades was that of opiate dependence;

second, components of standard opiate dependence treatment made this

drug-abusing population particularly attractive for clinical research; and third,

there was the practical, popular, and perhaps misguided impetus to find

effective, “nondependence-producing” analgesics. Operant strategies and

other treatment research probably focused on this population because of

the unique opportunity for continued access and followup resulting from

methadone treatment. The results of such research have strongly suggested

that behavioral interventions can be powerful tools in treatment. They may

“stand alone” in some cases or may be applied in a context of comprehensive

treatment that incorporates traditional strategies.

EVALUATION AND TREATMENT PLAN DEVELOPMENT WITHIN THE

OPERANT FRAMEWORK

Clinicians implementing operant behavioral interventions use many traditional

and well-validated instruments in their research and treatment strategies.

Thus, standard psychiatric diagnoses based on Diagnostic and Statistical

Manual of Mental Disorders (Third Edition, Revised) (DSM-III-R) (American

Psychiatric Association 1987) criteria are obtained, and standard instruments

such as the Profile of Mood States, the Beck Depression Inventory (Beck et

al. 1961), the Hamilton Scales for Anxiety and Depression, and the Addiction

Severity Index (McLellan et al. 1985) are among common elements of

evaluation. A hallmark of behavioral treatments is the use of objective

behavioral endpoints. Drug taking is often a clandestine activity, and

monitoring biological markers of drug use provides an objective endpoint

in lieu of direct behavioral observation. Therefore, drug screens are used

as an essential, powerful diagnostic and therapeutic tool.

Extensive, precise, and specific data surrounding the problem behavior

are another hallmark of behavioral interventions. A detailed analysis

of a patient’s current circumstances may aid in the development of the

intervention plan. Two broad categories of behavior are carefully examined.

First, drug seeking, drug taking, and their correlates are precisely described.

135
Second, alternative behaviors along with social adjuncts and environmental

modifications are specified in detail. This process permits drafting of

detailed individualized treatment plans. Beyond this, efforts often are made

to incorporate patient recording of ongoing behaviors before specification

of the final elements of treatment. Subsequent recording may permit

modifications of the intervention to facilitate achieving the treatment goals;

this feedback element is a ubiquitous and essential feature of behavioral

treatments. These procedures must be relatively simple and clear whether

recording by patients or significant others is required because they may

otherwise be quickly discarded or foiled.

The focus of treatment plan development is to alter major events and

reinforcers in the patient’s environment. Specific procedures provide

important access to behaviors that are difficult to observe or influence directly

because they occur in the natural environment. For example, drug screens

permit monitoring of otherwise inaccessible activity. Behavioral interventions

may make use of treatment adjuncts (such as methadone dosage or takehome privileges) that can provide powerful incentives and consequences

for modifying a spectrum of behaviors (Grabowski et al. 1984). Another

approach is to involve individuals (spouses, employers) or agents (licensing

boards) in the environment who provide unique control of positive reinforcers

and aversive consequences in the patient’s life (Grabowski et al. 1984).

REVIEW OF TREATMENT RESEARCH

Many treatment facilities implement procedures that are described as

behavioral interventions but clearly are not. For example, the edict “use

drugs and you’re out” is not a systematic behavioral therapy procedure,

although it certainly can alter behavior and reduce client load. In other

programs, which claim to adhere to the work of O’Brien and coworkers, the

statement “try to relax” is touted as a relaxation, desensitization procedure,

but it falls short of the careful systematic efforts characteristic of effective

behavioral treatments. The three examples discussed below underscore

the efficacy of behaviorally based contingency-management procedures in

treating alcohol and opiate abuse. There are no examples in the literature

of highly focused interventions involving cocaine and addressing only this

aspect of the patient’s behavior, but the general approach could be effective

with some patients exhibiting this form of drug dependence.

Contingent Application of Treatment Adjuncts

Higgins and colleagues (1986) examined the effects of contingent vs.

noncontingent delivery of a methadone dose supplement on relapse to illicit

opiate use in the context of a methadone outpatient detoxification program.

Following a 3-week methadone stabilization period, patients were randomly

136
assigned to a contingent, a noncontingent, or a control treatment group.

All patients received the identical dose reduction schedule. Members of

the contingent and noncontingent groups could obtain daily methadone

dose supplements up to 20 mg, but contingent group members could obtain

supplements only if their most recent urinalysis result was opiate-negative.

This clearly specified relationship between behavior and its consequences

defines a fundamental element of behavioral interventions. Control subjects

did not have dose increases available. The contingent group presented

significantly lower opiate-positive urines (14 percent positive) than the

noncontingent (36 percent positive) or control (50 percent positive) groups.

In addition, the availability of extra methadone improved treatment retention

and increased clinic attendance above levels observed in the control group.

Stitzer and coworkers (1986) directly compared positive and aversive

consequences for urinalysis results. For one group, dose increases were

contingent on negative urine screens. For the other, dose decreases were

contingent on positive urine screens. The results in terms of positive urine

screens were about the same. However, four of nine patients in the condition

emphasizing aversive control dropped out. Thus, the power of the positive

reinforcement procedure resided not only in maintaining comparable

drug-free urines but also in retaining patients in treatment. The ability

to sustain treatment-oriented behavior and retain patients is a critical

advantage in providing treatment and reducing human immunodeficiency

virus transmission and other drug and disease problems. These results

were replicated in a later study by lguchi and colleagues (1988). In this

systematic replication, access to methadone take-home doses was the

treatment adjunct manipulated.

Pickens and coworkers (1973) described an experimental intervention with

a 27-year-old alcoholic. The patient was hospitalized in a psychiatric ward

and was permitted to consume his preferred alcohol-containing beverage

ad lib. It was determined through observation and interview that virtually all

drinking involved social exchange. After a prolonged and stable baseline of

30 to 40 drinks per day, a specific contingency was implemented. The patient

was instructed that he could not socialize while drinking; he was required to

remain in his room and drink alone. Further, all patients and staff in the ward

were told to ignore him while he carried a drink. Over the next 30 days, his

intake gradually decreased to zero. Subsequent interventions included use

of disulfiram and providing assistance in obtaining employment. The critical

initial step of this intervention was precisely identifying the correlates and

consequences of alcohol consumption, followed by redefining the maintaining

behavior-consequence relationship to achieve the identified therapeutic

endpoint.

137
Involving Individuals/Agents in the Natural Environment

O’Brien and colleagues (1977) have described the utility and potential benefit

of including respondent extinction and relaxation procedures as behavioral

components of a broader cocaine treatment program. Aside from these

respondent-based interventions, only a few systematic interventions in the

literature use clearly defined operant behavioral techniques in combination

with other interventions; three examples are described.

Anker and Crowley (1982) and Crowley (1984) described a treatment for

cocaine-abusing professionals that included psychotherapy, pharmacological

treatment where appropriate, and contingency contracts for interactions in

ongoing relationships and for drug use. Contingency contracting regarding

drug use involved preparation of letters to significant boards, the Drug

Enforcement Administration, the professionals’ employers, or others who

could apply significant aversive consequences. The contingency was simple,

and the consequence substantial; the letter was mailed to the board, agency,

or significant individual if both halves of a divided urine sample were positive

for cocaine. The difference in results for patients on and not on the contract

was impressive for both studies. At 3 months none of the original 35 patients

who refused contracts were still in treatment, whereas 26 of 32 contract

acceptors were still in treatment and abstinent.

Two important points derive from this study. Anker and Crowley (1982)

maintained data on contract acceptance. They found that it increased from

10 percent of the initial sample to 70 percent of later patients. This suggests

that Anker and Crowley were investigating new territory and became more

persuasive at obtaining consent as they gained experience with the

procedure. Clearly, implementing behavioral-based approaches requires

careful clinical intervention.

The Crowley (1984) studies suggest that treatment plans with severe

consequences should be carefully planned with the patient who must be

informed of the advantages and disadvantages. Patients initially may be

refractory to participation in treatment plans with severe consequences,

Patients may be less hesitant in consenting to treatment plans that

emphasize positive reinforcement contingencies, Procedures such as

those first described by Boudin (1972) which involve a patient making

a deposit of items or cash that he or she “earns” back through negative

drug screens, may have more appeal than contracts that levy a negative

consequence for a positive screen. Two-edged contingencies involving

earning back a bit at a time through successive negative screens while

forfeiting a bit at a time for positive screens may have considerable power

and advantage in controlling cocaine use and promoting abstinence.

138
REVIEW OF ONGOING STUDIES

Most interventions described above utilize behavioral techniques in the

context of comprehensive treatment programs that provide additional

services such as counseling, psychotherapy, and medical care. However,

the behavioral techniques targeted just one aspect of the patient’s life—drug

taking. in cases in which drug taking is the dominant and perhaps only

problem, rather than one of many, the singular focus on drug taking may

suffice. When many aspects of a patient’s behavior and life have problems,

when he or she has few social skills, and when he or she requires vocational

and educational habiiitation, a program with much broader scope may be

essential to producing a meaningful therapeutic result (Thompson et al.

1984). Behavioral interventions may have more lasting influence if they are

used to bring about multiple changes outlined in an encompassing treatment

plan. The likelihood of success is highly dependent on the extent to which

major changes in the patient’s lifestyle are achieved: that is, reliance on drug

reinforcement must be suppressed, and alternative sources of reinforcement

for prosocial behaviors must be increased.

Community Reinforcement Interventions

A promising baseline treatment for cocaine dependence is that derived

from a Community Reinforcement Approach (CRA) described 20 years

ago by Hunt and Azrin (1973). Several subsequent studies (Azrin 1976;

Azrin et al. 1982; Sisson and Azrin 1989) were similarly systematic, and

others examined some parallel situations, but none with equivalent detail

and precision.

Higgins and coworkers (1991) have developed an intensive and

comprehensive outpatient program for cocaine dependence encompassing

Azrin and colleagues’ CRA with highly specific contingency-management

procedures. Treatment is 3 months in duration, and clients attend twiceweekly individual and marital therapy. Employment counseling is provided

to unemployed clients or those whose current employment, such as “drug

dealing,” supports cocaine use. The rationale behind the use of the

contingencies is to obtain initial cocaine abstinence, whereas the rationale

of the extended CRA is to make significant changes in lifestyle (i.e., increase

prosocial behaviors that are incompatible with a drug addict lifestyle) such

that therapeutic gains are maintained when the contingencies are removed.

The result is to ensure that the newly established behaviors can be sustained

in the patient’s environment by naturally occurring contingencies and

reinforcers beyond the period of treatment, in Higgins and coworkers’ (1991)

program, the contingencies are placed on cocaine use only. Urine specimens

are collected four times per week and analyzed onsite for the presence of

benzoylecgonine. Negative specimens earn vouchers redeemable for retail

139
items in the local community. The value of vouchers progressively increases

with each consecutive negative urine, and resets to the initial value with a

positive urine, to reinforce the target behavior of continuous abstinence from

cocaine. Purchases with the vouchers are supervised by clinic staff, and the

goal is to have clients use them to increase their involvement in new drugfree social and recreational activities.

A pilot study was conducted to begin assessing the efficacy of this

intervention. Thirteen consecutive admissions who met DSM-III-R criteria

for cocaine dependence were entered. For comparison purposes, results

obtained with those clients were compared with 15 subsequent consecutive

admissions who met the same diagnostic criteria and received standard

12-step-based alcohol and other drug counseling.

The only significant population differences were that the latter group reported

less cocaine use and had fewer intravenous cocaine users (the majority

in the behavioral treatment were intravenous users and in the standard

treatment were intranasal users) than clients in the behavioral treatment.

With regard to results, all clients who were offered the behavioral treatment

accepted it, whereas 12 of 15 offered the standard counseling did so.

Significantly more clients receiving behavioral vs. standard treatment

completed the 12 weeks of therapy (85 vs. 42 percent). Those in the

behavioral treatment also did significantly better with cocaine abstinence.

For example, 78 percent of the clients receiving behavioral treatment

remained continuously cocaine abstinent for 4 weeks vs. 25 percent in the

standard treatment (figure 1). At 6 weeks, those numbers were 60 percent

vs. about 10 percent, respectively. The behavioral treatment was clearly

superior to the standard treatment.

in considering these results, it is important to remember the results of Gawin

and colleagues’ (1989) controlled trial with desipramine, which might be

considered one of the better results for treatment of cocaine dependence.

They were able to obtain 3 to 4 weeks of continuous cocaine abstinence in

59 percent of the desipramine group vs. 25 and 17 percent in the lithium

and placebo groups, respectively. It appears that substantially fewer than

59 percent of those receiving desipramine were able to maintain continuous

abstinence for 6 weeks, although the exact proportion is difficult to determine

from the report.

Overall, the results obtained with this behavioral treatment appear to be at

least as efficacious, if not more, than the results obtained by Gawin and

coworkers (1989) with desipramine and psychotherapy. The treatment

appears to be acceptable to patients, retains them in treatment, and

maintains impressive cocaine abstinence. Of course, as with any new

treatment, final judgment on the efficacy awaits outcome of a controlled trial

140
FIGURE 1. Percent of subjects in each treatment who achieved periods of

continuous cocaine abstinence of 1 to 12 weeks duration.

Scheduled specimens that were not collected were treated as

cocaine-positive.

SOURCE: Adapted from Higgins et al. 1991. Copyright 1991 by American

Psychiatric Association (Washington, DC).

with random assignment. Such a controlled trial is now under way at the

University of Vermont.

Behavioral treatment may have an additional advantage with special

populations or when supplemental pharmacological interventions cannot be

used or convey no advantage. For example, many of the drugs commonly

used in drug abuse treatment are contraindicated, with the exception of

methadone, because of presumed fetal effects. Patients receiving the drugs

commonly used for treatment of inactive or active tuberculosis (TB) may

preclude concurrent administration because of hepatotoxic effects. Thus,

extensions and modifications of community-based approaches may prove

effective in the difficult population of drug-abusing pregnant women and

for TB-positive patients during drug abuse treatment (Elk et al., in press).

Specialized studies using elements of these procedures are being

implemented at the Substance Abuse Research Center, University

of Texas Health Science Center.

141
Community reinforcement programs have several potential difficulties. First,

they can be labor intensive and costly. Second, they have some potentially

intrusive elements. However, in response to the first concern, the cost is no

greater than that of many standard treatments implemented in traditional

treatment settings, and costs are considerably less than those incurred for

inpatient treatments. Furthermore, the cost of not providing treatment—or

worse, providing treatment of unknown efficacy or one with potential harm—is

greater than that of providing a costly but effective treatment (Havassy 1990).

The second criticism may have greater validity. That is, the community

reinforcement model can be intrusive (e.g., spouses or employers may be

informed of urinalysis results). Thus, for example, patients may agree to

participate at a time of particular vulnerability. Some argue the view that

any level of intrusiveness that produces a positive result is acceptable.

Nevertheless, it is essential that the clinician be aware that the cocainedependent population is particularly vulnerable. Vulnerability is not unique

to cocaine treatment: One need only consider the case of cancer patients

who agree to the misery and, often, low success rates of chemotherapy.

Patients may agree in their acute distress to unnecessarily invasive

treatments. Behavioral interventions must thus be tailored to ensure

maximum benefit with minimum intrusiveness.

Behavioral and Pharmacological Interventions

The framework of behavioral pharmacology and operant techniques permits

us to systematically focus on two complementary features of pharmacological

interventions. First, as with all other pharmacologically oriented disciplines,

possible direct pharmacological actions and interactions of drugs are

considered with due attention to sites of action and current theories of

neurochemistry. Second, therapeutic agents are examined in terms of their

functional properties with respect to behavior (table 1). Thus, an integral

component of selecting drugs for treatment should include consideration

of the functional properties and their application based on contingent

reinforcement, extinction, and punishment.

Many investigators are examining the efficacy of pharmacological agents

as adjuncts in the treatment of cocaine (Johnson and Vocci, this volume).

As noted by Bigelow (1990), there are currently no agents for which data

demonstrate clinically significant efficacy in heterogeneous populations of

cocaine users paralleling methadone in treatment of opiate dependence.

An example of consideration of functional properties is an ongoing study at

the Substance Abuse Research Center, University of Texas Health Science

Center, examining the efficacy of a treatment combination involving

behavioral procedures with fluoxetine as the pharmacological adjunct.

The rationale for the selection of this drug was based on consideration of

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TABLE 1. Examples of functional properties of abused drugs and

therapeutic medications

Property, Mechanism,

and Principle

Positive reinforcer

(replacement/agonist)

and reinforcement

Abused Drug Medication

Opiates Methadone

Cocaine Methylphenidate

Nicotine Nicotine

Alcohol Benzodiazepines

Positive reinforcer/neutral

(replacement/agonist and

blockade/antagonist)

Reinforcement/extinction

Opiates Buprenorphine

Aversive (metabolic inhibitor)

and punishment

Alcohol Disulfiram

Neutral (blockade/antagonist)

and extinction

Opiates

Nicotine

Naitrexone, LAAM

Mecamylamine

NOTE: This categorization is approximate and focuses on behavioral

characteristics; for example, LAAM is a partial agonist

pharmacologically but is behaviorally neutral in terms of the effect

sought by users: benzodiazepines have behavioral properties

overlapping with alcohol but are not pharmacologically parallel.

functional properties of drugs. First, the drug may have modest reinforcing

properties, although it cannot be viewed as a replacement therapy in the mold

of methadone for heroin. Second, the drug has few “noncontingent” punishing

effects (unpleasant side effects) when compared with other antidepressants.

Third, it has been suggested that it may attenuate cocaine reinforcement, and

thus, extinction may apply. Although none of these properties alone are of

sufficient strength to sustain treatment-oriented behaviors, they may contribute

to positive outcomes. The important issue is the focus on stimulus and

behaviorally relevant properties of agents used as adjuncts rather than

psychiatric effects or neurochemical actions alone. In fact, when psychiatric,

neurochemical, and behavioral analyses point to potential utility of the same

agent, the consideration again must be developing appropriate contingencies

for behavioral and pharmacological advantage.

143
FUTURE DIRECTIONS

There is substantial need to examine component behavioral interventions

singly and in combination for efficacy in the treatment of drug dependence

generally and cocaine dependence in particular. Refocusing some of the

traditional questions and determinants of treatment is also necessary.

Gawin and Ellinwood (1988) described a model of escalating treatment

involvement based on severity of dependence. Treatment research has

focused on this view in response to this traditional delineation of the problem.

Total drug taken and pattern of self-administration are important; however,

we recommend that the combination of historical and current circumstances

surrounding other features of behavior are equally important. Furthermore,

there is likely an interaction between severity as defined by pattern and dose

and the strength of other features of the behavioral repertoire. For example,

those patients who use cocaine moderately but who have few other reinforcers

(social supports, employment, opportunities derived from educational level)

may be much more difficult to treat and sustain drug free than someone

who regularly uses high doses but who has extensive personal resources.

Therefore, the need for careful analysis of individual behavioral characteristics

and differentiation of requisite elements of treatment becomes essential.

Following the traditional view, treatment research has focused on dose

and pattern of cocaine use as a dominant determinant of treatment form.

Treatment research should identify the need for treatment intensity based

on other factors. This direction for research is parallel to traditional matching

studies in psychiatric treatment,

In those cases that are most severe on all dimensions, the strength of the

community reinforcement model is of particular importance. It must be

thoroughly studied, and those elements useful to the treatment of drug abuse

should be used. As was mentioned, a controlled trial comparing community

reinforcement vs. standard drug counseling is under way. In addition,

behaviorally based interventions such as CRA will likely serve as an important

treatment context in which pharmacological agents may be used as adjuncts

to alleviate biologically based problems while taking full advantage of their

functional behavioral properties. Pharmacotherapy may or may not be a

necessary component of effective treatment for cocaine dependence, and

its utility is likely to vary across patients. These are empirical issues that

must be addressed in carefully controlled studies.

In the domain of pharmacological interventions, the breakthrough in approach

that must occur is conceptual. There is a need to attend to the functional

behavioral properties of the drugs and to conduct treatment research with

this perspective. Behavioral pharmacological research has demonstrated

that a major strength of methadone in treatment has been its usefulness as

144
a positive reinforcer that can be used to sustain treatment-oriented behavior

and shape new behaviors. The narcotic antagonist naltrexone has been

similarly discussed in terms of its behavioral effects; it can serve as a vehicle

for extinguishing drug self-administration, but like the current cocaine

pharmacotherapies, it will not sustain treatment-oriented behavior. Cocaine

treatment research must focus on taking advantage of effects of drugs that

can serve to enhance behavioral elements of treatment. Thus, for example,

some drugs with stimulant effects may have utility in the treatment of cocaine

dependence under well-defined behavioral regimens, although in the absence

of such regimens the results are equivocal (Khantzian et al. 1984; Gawin et al.

1985). In this case, the critical features of treatment using a replacement

model might be attributable in part to the joint action and structure of the

behavioral contingencies in relation to the medication that is a positive

reinforcer. The same analysis should be conducted when consideration is

given to examining the utility of other drugs in treatment. Clearly, it is difficult

to establish compliance with drug regimens when the agents have inherent

punishing side effects and few reinforcing effects. This analysis should be

a major point for discussion in treatment research and should supersede the

putative neurochemical theorizing that underlies most treatment research

discussions.

CONCLUSIONS

The systematic approach to establishing contingencies is a strength of

comprehensive behavioral approaches or the implementation of behavioral

approaches in combination with other therapeutic strategies. Within other

therapeutic conceptual frameworks, there is a similar need for systematic

analysis, The long-term goal will be development of more comprehensive

solutions to the wide range of possible drug abuse problems. It will also

contribute to understanding the mechanisms and possible treatment for other

biobehavioral disorders. Conversely, we should examine the armamentarium

of behavioral procedures used in treatment of behavioral medicine problems

as potential valuable tools in the treatment of drug abuse disorders because

many commonalities exist.

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AUTHORS

John Grabowski, Ph.D.

Director

Substance Abuse Research Center

Professor

Department of Psychiatry and Behavioral Sciences

University of Texas Health Science Center

1300 Morsund

Houston, TX 77030

Stephen T. Higgins, Ph.D.

Associate Professor

Department of Psychiatry

University of Vermont

Ira Allen School

38 Fletcher Place

Burlington, VT 05401

Kimberly C. Kirby, Ph.D.

Assistant Professor

Division of Addiction Research and Treatment

Hahnemann University

Mail Stop 403

Broad and Vine Streets

Philadelphia, PA 19102-1192

149
Day Hospital vs. Inpatient

Rehabilitation of Cocaine Abusers:

An Interim Report

Arthur I. Alterman, Charles P. O’Brien, and Marian Droba

INTRODUCTION

There have been few studies of the comparative effectiveness of standard

psychosocial treatments for cocaine abuse and dependence (Gawin and

Ellinwood 1989). Given the recency of the widespread abuse of cocaine,

the development of effective treatments for this disorder is clearly at an

early stage. The Philadelphia Veterans Affairs (VA) Medical Center was

not prepared in 1987 to deal with the problems posed by the influx of many

individuals seeking treatment for cocaine abuse and dependence. The

literature existing at that time on psychosocial treatments consisted of only

a few, largely uncontrolled studies on small numbers of patients (Anker and

Crowley 1982; Rawson et al. 1986; Siegel 1984; Washton 1986). Several

preliminary pharmacotherapy studies (Kosten 1989) also had been described.

Most impressive were Washton’s description (1986) and Washton and

colleagues’ (1986) findings (also see Washton and Stone-Washton, this

volume) for their intensive outpatient treatment program of cocaine abuse

and dependence. This treatment program basically represented an extension

of their work with alcoholic patients to the cocaine-abusing population.

Because there was a long-standing successful day hospital rehabilitation

program for alcohol-dependent men at the center, it was natural to consider

extending this intensive treatment form to cocaine patients. Also leading to

this conclusion were the discouraging results of initial efforts to treat patients

seeking treatment for cocaine abuse with several weekly outpatient groups.

Thus, in conjunction with the National Institute on Drug Abuse’s (NIDA)

award of a Treatment Research Center grant to the Addiction Research

Center (ARC) of the University of Pennsylvania, it was proposed to develop

a day hospital rehabilitation treatment for cocaine abusers. Following this

development, it was proposed to compare the effectiveness of this program

with that of standard inpatient treatment for cocaine abuse and dependence.

150
A randomized assignment comparison study of day hospital vs. inpatient

rehabilitation treatment for cocaine-abusing and cocaine-dependent men

has been conducted for 2 years. One hundred four subjects thus far have

entered into the study (52 day hospital and 52 inpatient). This chapter is an

interim report that describes baseline, 4- and 7-month posttreatment entry

outcome findings. Baseline findings are for 94 subjects (48 day hospital and

46 Inpatients); 4-month outcome findings are based on 78 subjects (41 day

hospital and 35 inpatient); and 7-month outcomes are based on 58 subjects

(28 in each group). The followup rates for both periods are more than 90

percent for each group. The lower numbers reported for the two followup

periods in this chapter reflect delays in data entry and followup time lags.

METHOD

Subjects

The research subjects were 94 men seeking treatment for cocaine abuse and

dependence at the Philadelphia VA Medical Center. Prospective candidates

had to meet the following requirements to qualify for study participation:

Be 59 years of age or younger.

Be eligible for and willing and able to accept either inpatient or day

hospital rehabilitation treatment for approximately 1 month.

Have a relatively stable residence for purposes of followup contact and

be willing and able to provide several informants who would be able to

help contact a participant for followup evaluations. The former

determination was made by the ARC’s intake unit.

Have no history of a psychotic disorder on the basis of psychiatric

examination.

Have no indication of dementia revealed by psychiatric examination.

Be determined, on the basis of medical examination, to have no major

medical problems requiring inpatient treatment.

Qualify for a Diagnostic and Statistical Manual of Mental Disorders

(Third Edition, Revised) (DSM-III) (American Psychiatric Association

1987) diagnosis of cocaine abuse both on the basis of an unstructured

psychiatric interview and on a computerized version of the National

Institute of Mental Health Diagnostic Interview Schedule (DIS) (Robins

et al. 1981).

151
Fail to qualify for any current substance abuse diagnosis other than for

cocaine, alcohol, or marijuana.

Be male.

Forty-eight subjects were randomized into day hospital treatment and 46 into

inpatient rehabilitation. Table 1 shows the sociodemographic and substancerelated historical characteristics of the two groups at intake to the study. With

one exception, the groups did not differ from each other. Inpatients were

more likely to have had previous drug treatment (54 percent) than subjects

assigned to the day hospital group (31 percent).

As a group, the subjects were males (in keeping with the presenting

population at our VA Medical Center), were about 33 years of age, had

about 12 years of education, and were almost entirely black. They averaged

less than 3 years of cocaine use, although they had been drinking alcohol to

intoxication for more than 7 years. There was little evidence of use of drugs

other than cocaine, alcohol, or marijuana.

More information on recent substance use is provided in table 2. The table

indicates that, at intake, the subjects in the study were using cocaine

about 13 times a month and were spending about $600 monthly for drugs.

Relatively few of the subjects had not consumed alcohol in the past 30 days.

TABLE 1. Baseline data on two groups of randomized cocaine patients

Variables

Day Hospital Inpatient

(n=48) (n=46) p

Sociodemographic

Age

Education (years)

Race (percent black)

Employment income-past 30 days

Percent currently married

Percent with stable living arrangements

Substance related

Percent ever treated for alcoholism

Percent ever treated for drug abuse

Years of alcohol use

Years of drinking to intoxication

Years of cocaine use

Years of marijuana use

33.9±6.1 33.4±5.2

11.9±2.0 12.3±1.2

97.9 95.7

466±538 361±395

14.6 21.7

95.6 93.5

20.8

31.3

10.1± 8.39

8.8±8.4

2.7±2.4

9.2±7.7

28.3

54.3

8.7±6.7

6.5±5.8

3.2±2.9

7.5±17.1

ns

ns

ns

ns

ns

ns

0.04

ns

ns

ns

ns

152
TABLE 2. Four-month substance abuse findings for two cocaine treatment

groups

Variables

Day Hospital Inpatient

(n=41) (n=35) p*

Intake 4 mo. Intake 4 mo. Group Time G x T

Abstinent from

alcohol (%)

Days intoxicatedpast 30 days

Not intoxicated (%)

Days cocaine usepast 30 days

Did not use

cocaine (%)

Days of marijuana

use

Dollars spent on

alcohol past

30 days

Dollars spent on

drugs past 30 days

Alcohol composite

score †

Drug composite

score †

1.8 55 6 53

7.3 2.5 6.2 2.2

40 68 29 68

13.1 2.0 12.6 2.3

0 65 0 61

3.8 0.8 5.2 1.2

48 10 34 6 ns

609 57 599 99 ns

0.23 0.12 0.22 0.10

0.26 0.09 0.26 0.10

ns

ns

ns

ns

ns

d,i

<.001

d,i

<.001

d,i

0.001

0.003

<.001

<.001

<.001

ns

ns

ns

ns

ns

ns

ns

ns

ns

ns

*G x T=group by time interaction effect

†Composite scores range from 0.00 to 1.00, with 1.00 being the most severe

KEY: d=day hospital (p<.05); i=inpatient (p<.05)—McNemar test for the

significance of changes

Information on other areas of functioning at baseline is provided in table 3.

Individuals in both groups had worked an average of 10 days in the past

month and reported having psychological problems 10 days out of the past

30. Again, it can be seen that the day hospital and inpatient groups did not

differ significantly at baseline.

153
TABLE 3. Four-month non-substance abuse findings for two cocaine

treatment groups

Variables

Day Hospital Inpatient

(n=41) (n=35) p*

Intake 4 mo. Intake 4 mo. Group Time G x T

Days workingpast 30 days

Employment

income-past

30 days (in dollars)

Illegal income-past

30 days (in dollars)

Days psychological

problems-past

30 days

Medical problems

composite score

Employment

composite score

Legal problems

composite score

Family/social

composite score †

Psychological

composite score †

9.40 12.22 10.03 15.45 ns

405 606 353 722 ns

86 38 118 0

9.87 5.15 11.14 5.24

0.25 0.22 0.16 0.17 ns

0.65 0.63 0.68 0.59 ns

0.09 0.05 0.07 0.00 ns

0.25 0.13 0.33 0.14 ns

0.26 0.15 0.25 0.15 ns

ns

ns

0.004 ns

0.005 ns

0.081 ns

0.002 ns

ns ns

0.054 ns

0.001 ns

<.0005 ns

<.0005 ns

* G x T=group by time interaction effect

† Composite scores range from 0.00 to 1.00, with 1.00 being the most severe

problem level

In conjunction with this study, data also have been collected on the baseline

characteristics of study nonparticipants. At this time, these data have been

examined in only the most preliminary fashion. The impressions are

that about 40 percent of the patients eligible for participation accepted

randomization into the study. The major reason for nonparticipation was

a strongly verbalized desire to be treated in a particular treatment setting.

Relatively few individuals were disqualified on the basis of residential

instability or for the existence of serious medical or psychiatric problems.

154
General Procedure

Prospective subjects were provided with complete information about

the project before they signed informed consent forms. They were then

randomized (Gellerman series) to 1 month of either day hospital (n=48)

or inpatient (n=46) treatment by a project research technician.

Day hospital subjects were given $15 for completing a baseline assessment

test battery and $10 for providing urine samples and completing each

followup interview. They also were given tokens for daily weekday travel

to the program as well as coupons to be exchanged at the canteen for lunch.

Inpatient subjects were given the same compensation for the study

assessments and were provided roundtrip train fare to the inpatient treatment

program at the VA Medical Center at Coatesville, PA, 35 miles away.

Research Assessments

A 3-hour baseline battery of tests was administered by a research technician

to all subjects during the first study week. This battery consisted of the

Addiction Severity Index (ASI) (McLellan et al. 1991), the DIS, measures

of social stability/support/resources, measures of Alcoholics Anonymous

involvement, and counselor ratings of patients’ motivation for susceptibility

to treatment. During the course of treatment, some of these measures were

obtained again, supervised urine samples were obtained for drug urine screens,

records of attendance were kept, and patients’ reports of treatment received

and treatment-cost data were obtained. The modified followup ASI

was administered 4, 7, and 13 months following entry into treatment.

Urine samples were obtained at these times to the extent possible.

This chapter reports on the treatment completion rates for the programs

and on treatment outcomes at 4 and 7 months for the patients as reflected

in ASI scores and urine drug screen data.

Because the ASI is critical to the study, this instrument will be described

in further detail. The ASI is a 45-minute semistructured interview that

provides sociodemographic and substance use history information as

well as recent problem level in seven areas of functioning-alcohol use,

other drug use, medical, employment, family/social relations, legal, and

psychological. Composite or factor-like scores can be derived in each

of these areas and can provide an overall summary of problem level.

Several studies have shown that the ASI yields reliable and valid data

(Kosten et al. 1985; McLellan et al. 1985; Rogalski 1987). An abbreviated,

20-minute version of the ASI is used to assess subject status at a given

period after entry into treatment.

155
Treatments

Except for the difference in settings, the two programs are quite similar.

The day hospltal program is in operation for 27 hours weekly during

weekdays (6 hours each Monday through Thursday and 3 hours on

Friday), whereas inpatient treatment is obviously residential and provides

approximately 48 hours of treatment weekly. Both programs are 28 days

to a month in duration. The major therapeutic modality in both programs

is group meetings that focus on overcoming denial and helping patients

learn to cope with everyday problems and stresses. Individual counseling

is available on an as-needed basis, and ancillary psychotropic medication

is available in both programs when needed. Both programs provide

education about the effects of addiction; both provide recreational therapy

and encourage participation in self-help groups. Such groups are provided

on the grounds in the inpatient program, whereas attendance in community

meetings is required and monitored in outpatient treatment. Both programs

offer medical care, although more care usually is provided in the inpatient

program.

RESULTS

This chapter reports program completion data and baseline vs. followup

ASI and urine drug screen data. Change was analyzed using two-way

repeated measures analysis of variance procedures for continuous data.

The McNemar test for the significance of change was applied to categorical

data for each of the groups (e.g., percentage abstinent), and x

2

 was

employed to compare the two groups for rate of change.

Treatment Completion

Inpatients (40 of 46, or 87 percent) were significantly more likely (x2=11.81,

1 df [degree of freedom], p=.0006) to complete treatment than were day

hospital patients (25 of 48, or 52 percent).

Four- and Seven-Month Substance Abuse Outcomes

Table 2 (4-month outcomes) and table 4 (7-month outcomes) reveal

considerable self-reported (ASI) reduction in virtually all alcohol- and

other drug-related behaviors at both 4 and 7 months following entry

into treatment. An indication of these improvements can be seen in

the finding that, whereas virtually none of the subjects had been abstinent

from cocaine at baseline, more than 60 percent reported abstinence at

the 4-month followup. Another example is the reported reduction in the

frequency of cocaine use from 13 to 2 times in the past 30 days at the

4-month followup evaluation.

156
TABLE 4. Seven-month substance abuse finding for two cocaine treatment

groups

Variables

Day Hospital Inpatient

(n=28) (n=28) p*

Intake 7 mo. Intake 7 mo. Group Time G x T

Abstinent from

alcohol (%)

Days intoxicatedpast 30 days

19 56 7 44

6.1 2.2 5.7 2.7

Not intoxicated (%) 48 63 37 56

Days cocaine use— 12.8 3.2 11.6 3.3

past 30 days

Did not use cocaine (%) 0 59 0 46

Days marijuana use 3.6 2.5 3.9 1.3

Dollars spent on alcohol- 34 6 33 15

past 30 days

Dollars spent on drugs- 521 79 476 358

past 30 days

Alcohol composite score† 0.20 0.06 0.20 0.11 ns <.001 ns

Drug composites score† 0.25 0.10 0.24 0.09 ns <.001 ns

d,i ns

ns 0.012 ns

ns ns

ns <.001 ns

d,i ns

ns ns ns

ns 0.003 ns

ns 0.012 ns

*G x T=group by time interaction effect

†Composite scores range from 0.00 to 1.00, with 1.00 being the most severe

KEY: d=day hospital (p<.05); i=inpatient (p<.05)—McNemar test for

significance of changes

The two groups were found not to differ significantly on any substance

abuse variable at either the 4- or 7-month periods. The reductions

reported at 4 months generally appear to have been maintained at

7 months, with one exception. The amount of money spent on drugs

appears to have increased at 7 months for the subjects who had

received inpatient treatment. It should be noted, however, that this

effect did not achieve statistical significance.

Urine drug screen data were available for about two-thirds of the subjects

at each of the followup periods. Forty-nine urine drug screens (of 78, or 64.5

percent) were available at the 4-month followup evaluation. Seventeen of

157
twenty-seven (63.0 percent) of those obtained for day hospital patients were

negative for cocaine as contrasted with 12 of 22 (54.5 percent) of

those obtained from the inpatient subjects. The two groups did not differ

significantly in this respect. Thirty-nine urine drug screens (of 56, or 69.8

percent) were available at the 7-month followup evaluation. Eleven

of nineteen urine drug screens (57.9 percent) obtained for the day hospital

group were negative for cocaine as contrasted with 13 of 20 (65 percent)

of those for the inpatient group. Again the groups did not differ significantly.

Thus, the ASI (self-report) findings with respect to abstinence from cocaine

generally were supported by the urine data. Additionally, the urine data

support the ASI finding of little decline in the level of functioning from the

4- to 7-month followup evaluation,

With respect to non-substance-related functioning (tables 3 and 5), the

ASI data indicate significant improvements for both groups at both followup

periods with respect to family/social, psychological, and employment

problem levels. Group differences were not found in these areas (see

interaction terms [labeled G x T in the tables]). There was little indication

of improvement in medical problems at either period. There was some

indication at the 7-month followup period of superior employment functioning

for the inpatient subjects as shown in the significant interaction effects for

employment income and for the employment composite score.

DISCUSSION

Although inpatient treatment resulted in a markedly higher rate of program

completion than day hospital treatment, the interim findings of this study

revealed few differences in the status of the two groups 4 and 7 months

after entry into treatment. Similar findings were revealed by interview-based

ASI and urine drug screen data. This finding of no differences in the outcome

of inpatient and outpatient rehabilitation for cocaine dependence is consistent

with a small body of random-assignment comparison studies of inpatient vs.

outpatient rehabilitation treatment for alcohol dependence (Miller and Hester

1986). Regarding the failure to find outcome differences between the two

groups, preliminary data on treatments received in the two programs have

been based on a measure recently developed by McLellan and colleagues

(1992), the Treatment Services Review. This B-minute interview obtains

weekly patient-reported information on treatment received in the seven ASI

areas. Preliminary analysis of these data indicated that inpatients received

significantly more medical treatment and day hospital patients received more

psychiatric treatment, but they did not differ in the quantity of treatment

received in the remaining five areas. Thus, if amount of treatment determines

the effectiveness of treatment, there is little reason for expecting superior

results from inpatient rehabilitation.

158
TABLE 5. Seven-month non-substance abuse findings for two cocaine

treatment groups

Variables

Day Hospital Inpatients

(n=28) (n=28) p*

Intake 7 mo. Intake 7 mo. Group Time G x T

Days working— 12.87 12.70 11.15 17.15

past 30 days

Employment income- 484 518 393 923

past 30 days

Illegal income— 52 437 95 0

past 30 days

Days psychological 8.89 4.58 12.42 3.04

problems—

past 30 days

Medical problems 0.23 0.13 0.14 0.14

composite score

Employment composite 0.60 0.58 0.68 0.53

score

Legal problems 0.05 0.04 0.08 0.03

composite score

Family/social composite 0.23 0.13 0.32 0.17

score †

Psychological composite 0.23 0.08 0.24 0.07

score †

ns

ns

ns

ns

ns ns ns

ns 0.021 0.052

ns ns ns

ns 0.003 ns

ns <.0005 ns

0.105 0.109

0.013 0.042

ns ns

<0.0005 ns

* G x T=group by time interaction effect

†Composite scores range from 0.00 to 1.00, with 1.00 being the most severe

problem level

Several other questions related to the effectiveness of the two treatments

need to be addressed. One question is whether patients whose prlmary

route of cocaine administration is smoking respond more poorly to treatment

than those reporting intravenous or intranasal use. This question cannot

be evaluated at this point because all but 6 of 94 patients in the study

reported smoking to be their primary route of cocaine administration.

A second question is whether patients who are also alcohol abusers or

alcohol dependent respond more poorly than those who do not receive

an alcoholism diagnosis. Of the 94 subjects in the study, 52 (55 percent)

were determined also to be either alcohol abusers or alcohol dependent

on the basis of the DIS and DSM-III (American Psychiatric Association

159
1987) criteria. Preliminary analysis of these data revealed few differences

in outcome between these two subgroups of cocaine patients. It is instructive

that the substance use differences found between these two subgroups

at entry into the study were primarily restricted to years-of-use measures.

The groups did not differ significantly in the quantity or frequency of recent

use of cocaine, marijuana, or alcohol. Thus, the failure to find status

differences in the subgroups 4 and 7 months after treatment entry may

not be surprising. Finally, the explanation for the better employment

outcome for inpatients at 7-months posttreatment entry is not entirely

clear at this time, although discussions with the staff members of both

programs suggested that more emphasis was placed on postrehabilitation

employment in the inpatient program.

CONCLUSIONS

The findings of this interim report revealed the following:

Randomized day hospital patients and inpatients were found to differ

on only one of numerous historical, demographic, and baseline

characteristics,

Inpatients were more likely to complete the initial 1 month of

rehabilitation treatment.

Significant reductions in substance-related problem levels were found

for both groups at both the 4- and 7-month ASI followup evaluations.

No group differences were revealed. Improvements shown at 4 months

were generally maintained at 7 months. These conclusions were

supported by urine drug screen data.

Significant reductions in legal, family/social, and psychological problem

levels were revealed for both groups at both followup periods. There

was no reported improvement with respect to medical problems. At the

7-month evaluation, there was some indication of a superior level of

employment-related functioning in those subjects who had received

inpatient treatment.

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Anker, A.L., and Crowley, T.J. Use of contingency in specialty clinics for

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Problems of Drug Dependence, Inc. National Institute on Drug Abuse

Research Monograph 41. Washington, DC: Supt. of Docs., US. Govt.

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Gawin, F.H., and Ellinwood, E.H. Cocaine dependence. Ann Rev Med

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ACKNOWLEDGMENTS

This research was supported by NIDA grant DA-05186 and the Veterans

Administration Medical Research Service.

AUTHORS

Arthur I. Alterman, Ph.D.

Scientific Director

Charles P. O’Brien, M.D., Ph.D.

Director

Addiction Research Center

Veterans Affairs Medical Center/University of Pennsylvania School of

Medicine

Philadelphia, PA 19104-6078

Marian Droba, M.D.

Staff Physician

Pennsylvania Hospital

Philadelphia, PA 19107

162
Cocaine Abusers in Therapeutic

Community Treatment

George De Leon

INTRODUCTION

The pervasive use of drugs at all levels of society and particularly the shift

in drug use patterns are well established. Most evident is the predominance

of cocaine/crack use within a context of polydrug abuse, including alcohol.

These changes in drug use raise new questions concerning the relevance

and effectiveness of the existing drug treatment modalities. They emphasize

the need for different approaches, both outpatient and residential, for

treatment of cocaine abusers. As yet, however, there are no firm conclusions

about treatment effectiveness for cocaine abuse, although data on this

question are developing in a number of ongoing studies.

Therapeutic communities (TCs) have always treated clients with histories

of cocaine use. Studies of admission profiles in the 1970s indicate that

cocaine use was not the primary drug of clients, but rather one substance

in a general pattern of polydrug abuse (De Leon 1971,1976,1980). For

example, approximately 60 percent of the 1974 residents and 73 percent of

the 1971 residents in one large urban TC reported some use of cocaine in

their lifetimes, and many had used cocaine in the year before entering the TC.

However, there is little known now about the efficacy of the TC for primary

cocaine abusers. The effectiveness of long-term residential TC treatment has

been documented in a number of studies (Hubbard et al. 1984; Simpson and

Sells 1982; De Leon 1984, 1985). Results are most favorable for primary

opiate abusers, although significant reductions are obtained for other drug

use, including alcohol, cocaine, and amphetamines (De Leon 1964, 1987).

However, these findings precede the cocaine epidemic of the 1980s.

Notwithstanding the lack of outcome studies, expectations are that the

effectiveness of the TC should not differ remarkably for cocaine abusers.

The TC approach to treatment remains essentially the same regardless of the

primary drug of choice. This approach is described in other writings on the TC

perspective of addiction, the addict, and the recovery process (De Leon 1986;

De Leon and Rosenthal 1989). Substance abuse is a disorder of the whole

163
person, requiring a multidimensional approach to treatment. The drug of

abuse is less relevant than the behavior, attitudes, values, and lifestyle of

the abuser.

These assumptions concerning the effectiveness of the TC for cocaine

abusers highlight the need for scientific data on the clients. Thus, this

chapter provides a comprehensive description of the profiles of individuals

admitted to the TC, a significant majority of whom are primary cocaine

abusers. Findings are presented from several studies that focus on three

major issues: (1) trends in primary drug and psychological profiles of

admissions to TCs, (2) psychopathology and cocaine abuse in terms of

psychiatric diagnoses and clinical indicators, and (3) the relationship

between cocaine abuse and retention in TC treatment.

Material is drawn from a series of recently completed National Institute on

Drug Abuse-supported studies on psychopathology and retention in TC

treatment (De Leon 1988a, 1988b; Jainchill 1989). Details of methodology

and statistics are contained in the original reports and publications cited in

the references. The initial section of the chapter reviews the main findings

in the text, illustrated by tables and figures. The last section discusses some

implications for treatment and research.

TEN-YEAR TRENDS IN DRUG USE AND PSYCHOLOGICAL PROFILES

AMONG ADMISSIONS TO THERAPEUTIC COMMUNITIES

Do the substance abusers now entering TCs differ from admissions in

previous years? This question was addressed through a large-scale

objective study to determine the extent to which the demographic, primary

drug, and psychological profiles of substance abusers admitted to TCs have

changed over a 10-year period. The study provided comparisons of the

profiles across three cohorts of admissions to TCs: the 1974-75 and 1984-

85 entries to a large traditional urban TC (i.e., the New York TC) and the

1979 entries to a consortium of seven other residential drug-free programs

of Therapeutic Communities of America (TCA) from the northeast and

southeast regions of the Nation. All agencies studied were long-term

residential programs self-described as adhering to the traditional TC model

described in other writings (De Leon and Rosenthal 1989).

The instruments, data collection procedures, and investigative team were

the same for all three cohorts. Four standardized psychological tests were

administered within the first 2 days of admission to residential treatment.

These consisted of the Shortened Schizophrenia Scale (Clark and Danielson

1956) the Shortened Manifest Anxiety Scale (Bendig 1956), the Beck

Depression Inventory (Beck et al. 1961) and the revised Beta IQ test

(Kellogg and Morton 1976). The Socialization Scale of the California

164
Personality Inventory (Gough 1969) was administered to the 1974-75 and

1984-85 cohorts. Additionally, a Tennessee Self-Concept (Fitts 1965) and

a full Minnesota Multi-Phasic Personality Inventory (MMPI) (Hathaway

and McKinley 1948) were given to the three cohorts. The results from

administering these instruments are described in other writings (De Leon

1976,1980,1988 a, 1989).

Demographic and Primary Drug Profiles

There were few changes in demography across the 10 years during the

period 1974-75 to 1984-85. Racial/ethnic differences were obtained between

TCA (1979) and the New York TC that reflect regional differences, because

the latter serves a larger urban, nonwhite majority population, There was a

sharp rise in the number of primary cocaine abusers accompanied by a

decrease in primary heroin and alcohol abusers. This difference in the

comparison between the 1974-75 and 1984-85 New York TC cohorts is

striking and removes any factors relating to program or regional differences.

Clearly, the change in the proportion of primary cocaine abusers reflects the

increased use of this drug reported in recent years.

Changes In the Psychologlcal Proflle

Table 1 contains data for the three cohorts on the symptom scales that

were common to all cohorts. The 1974-75 (New York) and 1979 (TCA)

psychological scores are significantly different on IQ only. Differences are

most striking between the two entry cohorts, evaluated 10 years apart. The

more recent 1984-85 admissions obtained significantly poorer scores on

all but the socialization scale. Thus, the 1984-85 cohort reveals symptom

scores that are worse than either of the two earlier cohorts, most evidently on

depression and IQ. Figure 1 plots the data for the three cohorts on selected

variables, graphically depicting the trend. The large changes occurred in the

1984-85 cohort, but there was evidence of a negative trend on most of the

scales between 1974 and 1979.

Psychological Differences by Demography and Primary Drug

With few exceptions, the psychological scores obtained for the most recent

cohort are worse when compared with earlier cohorts regardless of sex, age,

or race. Psychological differences by demography and primary drug within

each cohort are described in other writings (De Leon 1976, 1980, 1984).

Briefly, within the 1974-75 and 1979 cohorts, the scores are worse for

females, whites, Hispanics, older clients, and nonopiate abusers (but not

cocaine abusers). These differences exist for similar groups in the 1984-85

cohort, except that the sex differences are of smaller magnitude.

165
TABLE 1. Comparisons on four measures of psychopathology and Beta IQ for three admission cohorts: 1974-75, 1979,

and 1994-85*

KEY: SD=standard deviation; NS=not significant

*The Socialization Scale was not obtained on admissions to the seven programs of the 1979 TCA Consortium.

†The t-test for independent samples was used to assess group diierences.

‡p<.001.

§p<01.
187
FIGURE 1. Symptoms, IQ, and self-concept for the three admission cohorts

to the New York TC 1974-75, the seven-program consortium of

TCA 1979, and the New York TC 1984-85. Scores on all scales

and in all years are deviant, but a negative trend is evident,

particularly on depression, IQ, and self-esteem.

The 1974-75 and 1979 admission groups had relatively few primary cocaine

abusers, limiting their comparisons within and across cohorts. As noted, the

1984-85 primary cocaine abusers were a large plurality. In general, their

psychological profiles were deviant and were indistinguishable from the

other primary drug groups. Within this cohort, the cocaine abusers did

reveal significantly better scores on several of the Tennessee Self-Concept

and MMPI scales, particularly compared with the primary heroin users (not

shown),

168
Overall, the results of the 10-year-trend study point to a worsening of the

psychological profile across 10 years, evident in the most recent entries

into residential treatment. The trend is indicated on a large majority of

psychological scales but is particularly apparent in the depression, IQ, and

self-concept scores. The 1974-84 change is striking, although significant

shifts occurred between 1974 and 1979. It is noteworthy that the worsening

trend in the recent cohort is more prominent among the males in general

and heroin abusers in particular. Primary cocaine abusers yield a deviant

psychological picture that is generally indistinguishable from the other primary

drug groups.

DIAGNOSTIC STUDIES OF COCAINE ABUSERS

Findings are presented from a comprehensive study of the prevalence and

type of DSM-III-R (Diagnostic and Statistical Manual of Mental Disorders

[Third Edition, Revised]) diagnoses (American Psychiatric Association 1987)

among admissions to the long-term traditional TC (De Leon 1988b; Jainchill

1989). Research utilizing the Diagnostic Interview Schedule (DIS) (Robins

and Helzer 1985) generated the distribution of diagnoses on a sample of

approximately 360 admissions to the New York TC during the period 1985

through 1987. The sample differed from the usual residential population in

that it contained a higher proportion of females (purposefully selected) and

fewer clients younger than 19 years (inasmuch as the DIS is recommended

for individuals 18 years or older). The DIS was administered by a research

psychologist after an individual had been admitted to long-term treatment

but prior to transfer to a residential facility. Results are reported separately

for the full sample and primary drug groups.

Prevalence and Type of Diagnoses

Tables 2 and 3 show the prevalence of type of psychiatric diagnoses

obtained lifetime and during the month prior to interview (current) for three

self-reported primary drug groups: cocaine abusers, opiate abusers, and

“other” (usually marijuana and/or alcohol) abusers. Results are first

summarized separately for the full sample and then by comparisons by

primary drug.

In table 2, more than 97 percent of the full sample obtained at least one

diagnosis in their lifetimes (last column). About 19 percent obtained either

a drug (14.7 percent) or psychiatric (nondrug) (4.2 percent) diagnosis only.

The remaining admissions (78.3 percent) obtained a drug diagnosis plus at

least one other nondrug diagnosis. Of these, approximately one-half had

multiple nondrug diagnoses (not shown). Thus, virtually all admissions

received at least one lifetime diagnosis, with most receiving dual or multiple

diagnoses.

169
TABLE 2. Comparative distributions of current and lifetime diagnoses

by primary drug: substance, psychiatric, and

substance+psychiatric*

Diagnosis

Cocaine Opiates/Heroin Other Totals

n % n % n % n %

Lifetime Diagnosis

No diagnosis 7 3.0 0 0.0 3 3.8 10 2.8

Substance diagnosis only 35 15.2 7 13.7 11 14.1 53 14.7

Psychiatric diagnosis only 13 5.7 0 0.0 2 2.6 15 4.2

Substance+psychiatric 175 76.1 44 86.3 62 79.5 281 78.3

diagnoses

Current Diagnosis

No diagnosis 51 22.2 7 13.7 15 19.2 73 20.3

Substance diagnosis only 74 32.2 23 45.1 24 30.8 121 33.7

Psychiatric diagnosis only 27 11.7 6 11.8 11 14.1 44 12.3

Substance+psychiatric

diagnoses

78 33.9 15 29.4 28 35.9 121 33.7

*Table modified from Jainchill (1989).

NOTE: Cocaine, n=230; opiates, n=51; other, n=78; total, n=359. There are

no significant x

2

 differences across the three primary drug groups.

A current diagnosis (drug or nondrug) was obtained for nearly 80 percent

of the study sample. About 46 percent of these had either a current drug

diagnosis only (33.7 percent) or a nondrug psychiatric diagnosis only

(12.3 percent). A third revealed both drug and nondrug psychiatric diagnoses

in the month before admission. Most of these clients were symptomatic in

both the past (more than 1 year before treatment) and present, although the

diagnosis may have changed.

170
TABLE 3. Distribution of DSM-III-R diagnoses among admissions to residential drug treatment by primary drugt

Cocaine Opiates/Heroin Other Totals

Chi-Square

Diagnosis n % n % n % Probability n %

Organic brain syndrome

Affective disorders

Mania

Major depression

Dysthymia

Bipolar disorder

Atypical bipolar disorder

Schizophrenic disorders

Schizophrenia

Sohizophreniform

Anxiety disorders

Obsessive compulsive

Phobic disorders

Agoraphobia

Simple phobia

Social phobia

Panic disorder

Generalized anxiety

Other disorders

Antisocial personality

Somitization

Anorexia

8 3.69 6 4.38 1 1.96 15 3.9

4 1.75 0 0.00 3 3.85

2 5 11.21 7 14.00 11 14.47

3 6 16.14 9 18.00 1 4 18.42

0 0.00 0 0.00 1 1.28

5 1.79 2 4.00 1 1.32

4 1.75 0 0.00 5 6.41

0 0.00 0 0.00 0 0.00

9 3.95 2 3.92 8 10.26

5 9 25.88 1 7 17.17 2 3 29.49

2 9 12.72 9 17.65 1 9 24.36

2 9 12.72 11 21.57 1 5 19.23

2 2 9.65 8 15.69 8 10.26

5 2.19 2 3.92 2 2.60

6 6 31.73 1 7 42.50 2 4 36.92

9 7 42.92 2 0 40.00 3 9 50.00 156 44.1

0 0.00 0 0.00 0 0.00 0 0.0

0 0.00 0 0.00 0 0.00 0 0.0

7 2.0

4 3 12.3

5 9 16.9

1 0.3

8 2.3

9 2.5

0 0.0

19 5.3

9 9 27.7

5 7 16.0

5 5 15.4

3 8 10.6

9 2.5

107 34.2
TABLE 3. (continued)

Diagnosis

Cocaine Opiates/Heroin Other Totals

Chi-Square

n % n % n % Probability n %

Pathological gambling 1 0

Psychosexual dysfunction 9 8

Bulimia 0

Posttraumatic 1 6

stress disorder

Ego dystonic homosexual 4

Transsexualism 1

Substance abuse; dependence disorders

Alcohol 7 7

Abuse 2 4

Dependence 9

Abuse+dependence 4 4

Barbiturates 2 3

Abuse 3

Dependence 11

Abuse+dependence 9

Opioids (heroin) 3 4

Abuse 1

Dependence 11

Abuse+dependence 2 2

Cocaine abuse 193

4.42 5 9.80 7 8.97

42.29 21 42.00 2 4 31.17

0.00 0 0.00 1 1.52

9.41 2 9.52 7 15.56

2.40 0 0.00 1 2.17

1.05 0 0.00 0 0.00

34.07 22 44.00 4 2 53.85

10.62 8 16.00 13 18.67

3.98 0 0.00 4 5.13

19.47 14 28.00 3 2 32.95

10.18 16 31.77 12 15.38

1.32 1 1.96 0 0.00

4.85 3 5.88 8 10.26

3.96 12 23.53 4 5.13

14.91 47 92.18 17 21.80

0.44 1 1.96 1 1.28

4.82 4 7.84 5 8.41

9.65 42 82.35 11 14.10

85.02 29 56.85 8 2 79.49

2 2 6.2

141 39.8

1 0.3

2 5 10.6

5 2.1

1 0.8

141 39.3

4 5 12.5

13 3.8

9 0 25.1

51 14.2

4 1.1

2 2 8.1

2 5 7.0

9 8 27.3

3 0.8

2 0 5.8

7 5 20.9

284 79.1
TABLE 3. (continued)

Diagnosis

Cocaine Opiates/Heroin Other Totals

Chi-Square

n % n % n % Probability n %

Amphetamines 13 5.73 12 23.83 11 14.10 3 8 10.0

Abuse 2 0.88 1 1.96 3 3.85

***

8 1.7

Dependence 7 3.08 5 9.80 4 5.13 1 6 4.5

Abuse+dependence 4 1.76 8 11.78 4 5.13 1 4 3.9

Hallucinogen abuse 14 8.17 4 7.84 1 4 17.95 * * 3 2 8.9

Marijuana 7 4 32.46 2 8 50.98 4 3 55.13 * * 143 39.8

Abuse 3 0 13.16 11 21.57 1 8 20.51 5 7 15.9

Dependence 18 7.89 8 15.89 8 10.26 3 4 9.5

Abuse+dependence 2 8 11.40 7 13.73 1 9 24.36 5 2 14.5

*p<.05; **p<.01; ***p<.001

†Table modified from Jainchill (1989).

*The chi-square must be interpreted with caution because more than 25 percent of the cells have expected counts less

than five.

NOTE: Cocaine, n=223-227; opiates/heroin, n=50-51; other, n=78-77.

Column values represent incidence of disorder and therefore can exceed 100 percent within a category such as

anxiety disorder. Row totals represent prevalence or number of diient people in each group dig the

disorder and can be added across columns to the totals.

Generalized anxiety: cocaine, n=208; opiatesl/heroin, n=40; other, n=65

Bulimia: cocaine, n=213; opiates/heroin, n=41

Posttraumatic stress disorder cocaine, n=170; opiates/heroin, n=21; other, n=45

Ego dystonic homosexual: cocaine, n=167; opiates/heroin, n=21; other, n=46

Transsexualism: cocaine, n=95; opiates/heroin, n=15; other, n=21
Table 3 shows the prevalence of all diagnoses for the full sample of longterm residential admissions (last column). Among the nonsubstance abuse

diagnoses, the order of occurrence was antisocial personality (44.1 percent),

psychosexual dysfunction (39.8 percent), phobias (27.7 percent), generalized

anxiety (34.2 percent), and all affective disorders (33.8 percent [mania, major

depressive disorder, dysthymia, bipolar disorder, and atypical bipolar

disorder]). The percentages for other diagnoses were small.

Among the substance abuse diagnoses, the order of occurrence was

cocaine abuse (79.1 percent; there is no dependence diagnosis for this drug

in DSM-III-R), alcohol abuse/dependence (39.3 percent), marijuana abuse

(39.8 percent), and opioid abuse/dependence (27.3 percent). Diagnoses

were similar by demography (not shown), although univariate analyses of

lifetime diagnoses yielded several gender-related differences. Proportionately

more females obtained a diagnosis of major depressive disorder, all phobic

disorders, and psychosexual dysfunction. A greater proportion of males

were diagnosed with antisocial personality and with multiple substance

abuse diagnoses.

There were no statistically significant ethnic differences on any of the

nondrug psychiatric diagnoses, although nonblacks showed higher incidence

in virtually all diagnoses (e.g., all depressions, phobias, and general anxiety).

Moreover, the nonblacks revealed a significantly higher prevalence of all

substance abuse diagnoses other than cocaine abuse. Overall, nonblacks

appear to be generally worse than blacks in prevalence of both nondrug and

drug diagnoses.

Diagnoses Among Cocaine and Noncocalne Abusers

Tables 2 and 3 provide a statistical comparison among three self-reported

primary drug of abuse groups. Lifetime and current diagnoses rates did not

differ by primary drug, although more primary opiate abusers revealed dual

disorders. Type of nondrug diagnoses did not differ among the groups, with

the exception of schizophrenia (most frequent in primary “other”) and phobias

(least frequent in primary cocaine abusers and most frequent in the primary

“other” group, particularly agoraphobia).

The distribution of substance abuse diagnoses indicates that the majority of

the sample were frequent users of more than one drug. However, there were

significant differences by primary drug. Among cocaine abusers, a diagnosis

of alcohol, amphetamine, and marijuana abuse/dependence was less

frequent. Among the primary heroin abusers, a diagnosis of barbiturate

and amphetamine abuse/dependence was more frequent. And among the

primary “other” drug group, a diagnosis of hallucinogen abuse was more

frequent.

174
Thus, the primary cocaine abusers revealed a generally lower prevalence

of all other drug diagnoses. However, a diagnosis of cocaine abuse

remained prominent regardless of primary drug. More than half the primary

opiate abusers obtained a diagnosis of cocaine abuse. A greater proportion

of the primary “other” group also obtained a diagnosis of cocaine abuse

(79 percent) than a diagnosis of marijuana abuse (55 percent). Notably,

a diagnosis of alcohol abuse/dependence was frequent in all groups but

least so among cocaine abusers (34.1 percent) than among the primary

opiate and other groups (44 and 54 percent, respectively).

Overall, the large majority of admissions to the TC revealed at least one

nondrug psychiatric disorder in their lifetimes in addition to substance abuse

or dependence. More than a third of admissions had a current or continuing

history of mental disorder in addition to their drug abuse. The most frequent

nondrug diagnoses were phobias, generalized anxiety, psychosexual

dysfunction, and antisocial personality. There were only a few cases of

schizophrenia, but lifetime affective disorders occurred in more than a third

of the sample.

Primary cocaine abusers (self-reported) revealed a diagnostic picture that

was similar to that of the primary opiate and primary “other” groups, although

the overall prevalence of all their diagnoses was generally less. Thus,

diagnostically, all drug of abuse groups are considerably disordered, but

primary cocaine abusers entering the TC appear less disturbed.1

CLlNlCAL INDICATORS OF PSYCHOPATHOLOGY

Two related studies further explored psychopathological changes assessed

on clinical indicators among clients seeking admission to the New York TC.

The first assessed the incidence of violent behaviors, suicide attempts, and

inpatient psychiatric hospitalizations. The second study provided a more

direct inquiry into the association between primary drug and suicide in the

1986 cohort.

Study 1. Suicide Attempts, Psychiatrlc Hospitalizations, and

Violent Behaviors

The incidence of three clinical indicators was assessed across the

4 consecutive years (1983 through 1986) for representative samples

of admissions. The demographic and primary drug characteristics are

similar across each year (except for a dramatic increase in primary cocaine

abusers in 1986). Results showed that there was a significant increase in

two indicators—suicide and violent behavior—for the 1986 admissions

compared with those in the previous year. There was only one significant

difference by demography. Nearly twice as many females as males had

175
attempted suicide at least once (27 vs. 14 percent; p<.05). A similar sex

difference occurred in the percentage reporting a psychiatric hospitalization,

although it is not significant (because the absolute percentages are small).

The results did not reveal significant differences in any of the indicators

by primary drug.

The clinical indicator study provided only indirect evidence of a relationship

between cocaine abuse and clinical problems. It examined changes in

rates of indicators in sequential samples of admissions with increasing

proportions of primary cocaine abusers. Nevertheless, the increase in

violence and suicide rates in the 1986 cohort appears to be associated with

the predominance of cocaine abusers seeking admission to the TC during

that year. This hypothesis was directly tested for suicide rates in study 2.

Study 2. Suicide Attempts, Cocaine and Crack Abuse

This study focused on differences in suicide rates among three self-reported

primary drug groups: cocaine abusers, crack abusers, and noncocaine abusers,

(Analysis of violent behavior In this subsample is yet to be completed.?) The

sample consisted of all successive admissions to the New York TC over a

3-month period (October 1 through December 31, 1986; n=240).

Table 4 shows that the demographic characteristics were male (72 percent),

black (68 percent), and 19 to 26 years of age (50 percent). Almost 75.8

percent of the sample reported cocaine as their primary drug of abuse; most

were crack abusers (50.8 percent of the sample); 67 percent were cocaine

abusers. The demographic distribution within each primary drug group was

similar, although there were some differences in proportions (e.g., more

females and blacks in the crack group and fewer younger clients in the

noncrack/cocaine group). Except for higher proportions of primary cocaine

abusers, the characteristics of this 3-month admission sample were reflective

of all admissions in 1986.

Table 4 presents the suicide attempt rates (at least one suicide attempt

during an individual’s lifetime) and the psychiatric hospitalization rate across

three primary drug of abuse groups: cocaine/crack abusers, cocaine/

noncrack abusers, and noncocaine abusers. Suicide attempt rates were 18

percent overall; the attempt rate among crack abusers was two to four times

greater than those of the other primary drugs of abuse (26.2 percent, cocaine/

crack; 11.7 percent, cocaine/noncrack; 6.9 percent, noncocaine).

The suicide attempt rate was similar by demography, with the exception of

gender. Females revealed significantly higher rates.

176
TABLE 4. Crack vs. noncrack: A profile by demography and selected

psychiatric indicators (admissions to New York City TC,

October through December 1986)

Cocaine

Demographic Crack Noncrack Noncocaine Totals

Factors n % n % n % n %

Sex

Males 80 65.6 50 63.3

Females 42 34.4 10 16.7

Race

Black 91 74.6 36 60.0

Hispanic 22 18.0 13 21.7

White 9 73.4 11 18.3

Age (years)

<19 33 27.0 7 11.7

19-26 59 46.4 34 56.7

>27 30 24.6 19 31.7

Psychiatric indicators

Attempted suicide 32 26.2* 7 11.7

Psychiatric hospital 9 7.4 2 3.3

Totals 122 50.6 60 25.0

42 72.4 172 71.7

16 27.6 68 28.7

35 60.3 162 67.5

14 24.1 49 20.4

9 15.5 29 12.1

20 34.5 60 25.0

27 46.6 120 50.0

11 18.9 60 25.0

4 6.9 43 17.9

1 1.7 12 5.0

58 24.2 240 100.0

*Significantly greater (x2=5.066, p<.05)

The percentages of suicide attempts persisted across all drug groups (not

shown). Thus, the results indicate that, among primary crack abusers, a

significantly higher percentage report at least one suicide attempt compared

with the other primary drug groups, Moreover, their rates do not appear to

be confounded by demography.

The pattern for psychiatric hospitalizations was similar to that of suicide attempts

in showing highest rates for crack abusers and lowest for noncocaine abusers,

However, the percentages were too small for statistical significance.

Overall, in the initial study, an increase in violence and suicide attempt

rates appeared to be associated with the predominance of cocaine abusers

seeking admission to the TC in 1983 through 1986. A second study more

directly confirmed a relationship between suicide attempt rates and crack

abuse.

177
RETENTION IN TREATMENT FOR COCAINE ABUSERS

Do cocaine abusers reveal differential tenure in residential treatment? The

importance of this question is highlighted by well-documented research

showing a direct relationship between posttreatment success rates and

length of stay in residential TC treatment. The main findings are reported

for univariate and multivariate analyses of retention in treatment. The study

cohort consisted of all admissions to the New York TC during the period

from January 31, 1986, to April 30, 1987 (table 5). They were primarily

male (67.4 percent) and black (84.3 percent), and a small majority was

older than 20 years (56.0 percent). Most individuals (90.3 percent) had

entered treatment voluntarily (not legally referred, i.e., probation or parole),

and most (93.1 percent) were first-time admissions (not shown).

The sample reflected a spectrum of drug abusers with pluralities among those

claiming their primary drug to be cocaine (32.7 percent), crack (31.8 percent),

heroin (7.4 percent), and marijuana (20.9 percent). Primary cocaine plus

crack abusers constituted more than 63 percent of the cohort, but there were

differences by primary drug with respect to demography. Proportionately

higher percentages of crack and cocaine abusers were obtained for females

and blacks and higher percentages were obtained for primary marijuana

users among clients younger than 21 years of age.

Short- and Long-Term Retention by Primary Drug

Table 6 presents the retention results for all primary drug groups. The

30-day, 90-day, 180-day, and 300-day retention rates for the full cohort

were 72.5, 53.7, 41.2, and 34.0 percent, respectively. There were few

statistically significant differences in short- or long-term retention by primary

drug. However, primary alcohol and crack abusers showed the highest 30-

day retention rate.

Multiple regression analyses examined client predictors of retention, (“Crack

abuser” was not separately coded in these analyses.) The magnitude of

the multiple correlations was modest, and the variance explained was small.

The client variables that were significantly related to longer retention were

legal referral, higher baseline employment, higher IQ, client readiness for

treatment, and client estimate of needed length of stay. Notably, primary

drug was not a consistent predictor of retention with the contribution of

these other client variables removed.

Overall, primary cocaine and crack abusers were a large majority of the

recent admissions to the New York TC. Univariate and multivariate analyses

of approximately 1,200 admissions revealed that short- and long-term

178
TABLE 5. Primary drug and demographic characteristics of all admissions to the New York TC: January 31, 1986,

through April 30, 1987

Demographic Cocaine Crack Opiates Marijuana Alcohol Polydrug Other Totals

Factors n % n%n%n % n%n%n%n%

Sex

Males

Females

262

130

Race/ethnic

Black

Hispanic

whites

Other

aGE

<19 7 0 17.9 9 2 24.1 8 9.0 112 43.2 11 21.6

19-20 7 8 19.9 61 16.0 9 10.1 61 23.6 11 21.6

21-26 129 32.9 136 35.7 20 22.5 60 23.1 17 33.3

2 7 115 29.3 9 2 24.1 52 58.4 17 6.6 12 23.5

Total

251 64.0 265 74.8 30 33.7 158 61.0 34 66.7 7 58.3 6 25.0 771 64.3

7 7 19.6 6 0 15.7 33 37.1 60 23.2 7 13.7 4 25.0 7 29.2 248 20.7

6 2 15.6 3 5 9.2 25 28.1 31 12.0 9 17.7 1 8.3 11 45.8 174 14.5

2 0.5 1 0.3 1 1.1 1 0.4 1 19.6 0 0.0 0 0.0 6 0.5

66.8 235 61.7 68 76.4 174 67.2 39 76.5 9 75.0 21 67.5 608 67.4

33.2 146 38.3 21 23.6 76 32.6 12 23.5 3 25.0 3 11.5 391 32.6

32.7 381 31.8 89 7.4 250 20.9 51 4.3

1 8.3 5 20.8 299 24.9

3 25.0 6 25.0 229 19.1

4 33.3 8 33.3 374 312

4 33.3 5 20.8 297 24.8

392 12 1.0 24 2.0 1,199 100.0
TABLE 6. Retention in treatment by primary drug for all admissions to the

New York TC: January 31, 1986, through April 30, 7987

Primary Drug

30 Days 90 Days 180 Days 300 Days*

n % n % n % n %

Cocaine 272 69.4 194 49.6 139 35.5 115 29.3

Crack 299 78.5 216 56.7 165 43.3 135 35.4

Opiates 66 74.2 50 56.2 40 44.9 33 37.1

Marijuana 169 67.6 136 54.4 111 44.4 95 38.0

Alcohol† 42 82.4 31 60.8 25 49.0 21 41.2

Polydrug† 2 16.7 2 16.7 1 8.3 1 8.3

Other† 19 79.2 15 62.5 13 54.2 6 33.3

Total 869 72.5 644 53.7 494 41.2 408 34.0

*Ten months represent the retention potential for the full cohort of 1986-87

admissions during the study period (see De Leon [1989] for a discussion of

the RFP).

†Excluded from statistical analysis because of sample size.

retention did not relate to primary drug differences. Other client factors

such as readiness for treatment, however, were of some importance.

IMPLICATIONS FOR TREATMENT AND RESEARCH

This chapter reports findings from several studies on psychopathology and

retention among admissions to the TC, the majority of whom were primary

cocaine abusers. The research was completed mainly in one large urban

TC in New York, although one study compared data obtained on 1979

admissions to a consortium of seven other TCs.

Although the present findings are stable, generalization of conclusions

concerning cocaine abusers in other TCs or other treatment modalities may

be limited. The New York TC is representative of long-term traditional TCs

in urban areas. As noted earlier, other treatment settings—inpatient and

outpatient, public and private-are serving clients of different socioeconomic

backgrounds. Thus, similarly designed studies are needed to identify the

varieties of cocaine abusers in terms of psychological status, retention, and

treatment outcomes. Nevertheless, the research presented provides some

implications for treatment and research. These are discussed in terms of

the major areas of inquiry.

180
RESEARCH IMPLICATIONS

General Psychopathology

The psychological profiles of all entry cohorts are in the deviant range

regardless of the testing year. The main characteristics of depression,

anxiety, poor socialization, and low self-esteem are similar in each year,

across demography and primary drug, including cocaine. Moreover, these

profiles do not differ from those of substance abusers in general (Rounsaville

et al. 1985; De Leon 1984, 1989). The constancy of the symptom picture

and MMPI personality profiles (not shown) corroborate clinical observations

and research that TCs have always treated substance abusers who have

displayed a variety of psychological problems in addition to their drug abuse.

The diagnostic findings also support the general conclusion that regardless

of drug preference, substance abusers who come to the TC reveal a

considerable degree of psychological disturbance in addition to their drug

problems. Multiple diagnoses are prevalent, including Axis I (nonpsychotic)

and Axis II (mainly antisocial personality) disorders (American Psychiatric

Association 1987). The relatively infrequent incidence of schizophrenic

diagnoses and the moderate frequency of affective disorders reflect the TC’s

exclusionary criteria for clients with these disorders. Notwithstanding these

criteria, multiple disorders are prevalent in the overwhelming majority of

admissions.

Broader multimodality studies are needed to assess the differences in

psychopathology by primary drug, particularly among cocaine abusers. Of

special importance is the issue of clarifying the psychological differences

among the increasing numbers of “well-socialized” cocaine abusers seeking

treatment in fee-for-service outpatient drug treatment, mental health settings,

and with private practitioners.

Cocaine Abuse and Psychopharmacological Effects

The psychological and diagnostic profiles are similar across the primary

drug of abuse groups. This fact substantiates the general conclusion that

most drug abusers share common psychological symptoms and personality

characteristics. The primary cocaine abusers reveal fewer occurrences

of multiple disorders, suggesting that primary cocaine abusers may have

somewhat less pervasive psychological problems. However, there may be

drug-specific effects that precipitate violence and/or suicide attempt episodes.

For example, TC staff and clients report on the destabilizing effects of crack

use that appear to lower thresholds of tolerance for irritation, frustration, or

provocation.

181
The clinical impressions in the TC accord with developing

psychopharmacological research on mood states and neurotransmitter

relations. However, further research must clarify these relations in terms

of interactions among dosage/extent of use, situational parameters, and

individual psychological factors.

Outcome and Retention in Treatment

Outcome data are not reported in the present review. However, the cocaine

abusers reveal no differential retention rates compared with other drug of

abuse groups. If retention persists as the main predictor of outcomes, then

cocaine abusers should yield outcomes that are similar to those of previous

studies on other drug abusers. This hypothesis awaits confirmation in

posttreatment followup studies of cocaine abusers treated in TCs.

Such investigations may also require different criteria for assessing favorable

outcomes to reflect the special risk features of cocaine/crack addiction

such as craving, cross-addiction to alcohol, and the pervasive social use

of both alcohol and cocaine. These features obviously affect the stability

of outcomes and overall success rates, and they underscore relapse and

aftercare issues for cocaine abusers in recovery.

The present studies confirm that short- and long-term retention rates in

long-term TCs have been increasing in the past decade (Therapeutic

Communities of America 1988) regardless of primary drug. Some reasons

for this positive trend in “holding power” are discussed elsewhere (De Leon

1989). Nevertheless, dropout still remains the rule in all treatment modalities.

Experimental investigations are needed to maximize retention in treatment

among drug abusers in general and cocaine abusers in particular.

TRENDS AND BROADER RESEARCH ISSUES

The 10-year-trend study shows few differences in the demographic profiles

of admissions to the TC, but the dramatic shift in primary drug to cocaine

abuse is evident, Indeed, the yearly increments in the number of cocaine

abusers are highlighted in the successive admissions from 1964 through

1967 in the New York TC. These trends parallel those observed in survey

results of prevalence of cocaine use in nontreatment samples (e.g., national

household and high school surveys). They indicate that the drug use patterns

among TC admissions are reflective of those in the population, although the

extent of the drug problems of those seeking treatment at TC is obviously

more severe.

Most disturbing and perplexing is the increasing trend in psychological

disorder among TC admissions, particularly the decline in IQ. The change

182
between the IQ of those admitted in 1974 and those admitted in 1979 is

partly artifactual, attributable to a change in test norms of the revised Beta II

IQ test. (The 1974-75 cohort was administered the Beta I test, whereas the

1979 and 1984-85 cohorts were administered the Beta Il.) However, the

difference in IQ between the 1979 and 1984 groups is not artifact because

the same revised Beta II was used in these testing years. Moreover, the

steady decline in Beta II IQ was further confirmed in additional data of the

1986-87 entries to the New York TC (not reported).

The fact of the decline in IQ cannot be questioned, but its interpretation

remains unclear. One hypothesis points to selection factors across

generations of drug abusers. The increased variety and number of current

drug treatment options attracts the more advantaged/functional drug abusers

away from long-term urban residential treatment. Thus, compared with

1974-75 admissions, the recent entries to the TC may represent a more

dysfunctional group of addicts with greater social and psychological deficits.

Although plausible, the selection hypothesis is contradicted by some

evidence in the present studies. For example, comparisons between the

1974 and 1984 admissions to the New York TC indicated no significant

differences in socioeconomic status (SES) levels (family education and

adjusted family income variables). Second, a sample of clients (not

reported earlier) evaluated but not admitted to the New York TC also

revealed the worsening trend in the clinical indicators and the poorest

diagnostic picture (De Leon 1988b). Thus, the psychopathology findings

were not specific to entries, but to all those seeking admission to the TC.

And the most dysfunctional drug abusers were the nonadmissions to the

TC. Notwithstanding this evidence, the selection hypothesis remains to be

systematically tested. Trend studies are needed to assess the psychological

(IQ) changes in other treatment modalities controlling for SES and other

factors (e.g., education and employment).

An alternative hypothesis implicates broader social factors as contributors

to the decline in IQ. Indeed, the decline may not be specific to drug abusers

entering treatment, but may reflect consequences of the deepening of drug

use in American society during the past 25 years. This enculturation of drug

use has been characterized in other writings (De Leon 1990) in terms of three

empirical facts: the increasing proportion of people at all levels of society

who are involved in drug use; the expanding range of substances used; and,

most relevantly for the present context, the steady decline since the 1970s

in age of onset of regular use in the population.

These factors, particularly the earlier onset and longer period of substance

use, may correlate with developmental gaps in social learning, intellectual

functioning, and general psychological growth. Such developmental effects

183
would cumulate among the youth of the past two decades, those in and out

of drug treatment settings.

Support for the hypothesis of increasing intellectual deficit is found not only

in the drug treatment data but in educational reports that also point to a

declining trend in IQ among entries into the school system in the 1980s.

Nevertheless, considerably more research is needed to assess an association

between the enculturation of drug use and specific psychological changes.

TREATMENT IMPLICATIONS

The findings reported and the suggested hypotheses also contain implications

for modifying treatment in residential TCs for admissions in general and for

cocaine abusers in particular.

Treatment Modifications

TCs have always treated psychological symptoms in addition to substance

abuse. Indeed, the TC perspective views improvement in psychological status

as essential to stable recovery from substance abuse (De Leon and Rosenthal

1989). Research documents the effectiveness of the TC in improving the

psychological status of many clients (Biase et al. 1988; De Leon and Jainchill

1981-1982; Holland 1986). However, the more favorable outcomes are

among those whose psychological symptoms are mainly associated with their

drug abuse lifestyle rather than reflecting chronic, serious psychiatric disorder.

The worsening profile underscores the need for TCs to address issues

of diagnosis, treatment modification, and staff composition and training.

For example, treatment procedures may involve changes in the maximum

planned duration of stay, use of modified encounter groups, greater

emphasis upon psychotherapy, policy reconsiderations concerning

psychopharmacological adjuncts, and so forth. In this regard, general

changes in practice and staffing should be introduced within the basic

framework of the TC model that has documented effectiveness,

Treating Cocaine/Crack Abusers

With respect to cocaine, and crack abusers in particular, some specific

modifications are needed. These involve management and treatment of

violent and suicidal behaviors, which in traditional TCs have usually

been grounds for discharge and referral of the client. Clinical experience,

supported by the research thus far, now recognizes that special

psychopharmacological properties of cocaine/crack dependency (e.g., craving,

severe mood alterations, and shifts in energy level) affect the course of the

184
recovery process during residential treatment as well as the relapse rates

after residential treatment.

Several TCs have introduced the use of antidepressants early in treatment

to counter the dysphoria and mood swings of the detoxifying cocaine abuser

toward reducing the likelihood of premature dropout. Other programs have

instituted curriculum-based relapse prevention courses in the later stages

of primary treatment or as part of aftercare programming to minimize slips

or full-blown relapse. These efforts are viewed as additions to, rather than

modifications of, the fundamental multidimensional TC approach to recovery.

This approach addresses substance abuse as a “whole-person disorder”

requiring a profound change in lifestyle and identity.

Females and Crack Abuse

The studies reported and the general literature point to an increase in

female admissions (most of whom are cocaine/crack abusers) to TCs. This

material has highlighted the special needs of females in long-term residential

treatment. Modifications of TC programming have centered on the issues

of primary health care for females in general and child care and parenting

for addicted mothers in particular. Some of these efforts are discussed in

a recent review of studies of females in TCs (De Leon and Jainchill 1991).

Additionally, some outpatient models have been launched for crack-addicted

mothers who cannot or will not enter residential treatment. These are modified

TC models implemented as ambulatory or day treatment programs affiliated

with community-based TCs or with urban hospitals (Galanter et al. 1992).

Staffing and Training

TCs are currently serving an influx of cocaine abusers with a wide range

of social and psychological problems that appear to be even more severe

than those of previous generations, The general modifications needed to

address the needs of these clients require altering the TC staff composition

to include more mental health, medical, and educational professionals to

complement the nontraditional recovered professionals. Moreover, staff

training efforts need to be considerably expanded to effectively integrate the

theory and methods of the TC with mental health practices. The challenge

of modification is to retain the self-help perspective and effective elements

of the TC.

CONCLUSION

In the TC perspective, recovery refers to rehabilitation, returning individuals

back to a drug-free, socially acceptable lifestyle that was rejected or lost.

For many others, it refers to habilitation, developing a positive drug-free

185
lifestyle that has never been known or acquired (De Leon and Rosenthal

1989). The research reviewed on cocaine admissions confirms the common

clinical observations in TCs that the clients during the 1980s displayed more

psychological difficulties than in previous generations. In addition to alcohol

and other drug abuse, problems arising from developmental gaps in

intellectual functioning, marketable skills, and social learning emphasize

the multidimensional needs of these clients. In this regard, the long-term

residential TC remains the main treatment modality charged with habilitating

increasing numbers of substance abusers, regardless of their primary drug.

NOTES

1. A report currently in preparation presents findings on the prevalence

and patterns of multiple nondrug diagnoses (e.g., antisocial personality

and depression). It also provides some discussion of comparisons

with results from other modalities. For example, the prevalence of

posttraumatic stress disorder in this large TC sample appears to be

less than that reported in some non-TC studies.

2. The clinical indicator study was based on the treatment program’s

admission files, which differ from the research files. The former did not

code separately for crack abuse. The latter did contain suicide-crack

data, but not information on violent behavior.

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AUTHOR

George De Leon, Ph.D.

Director

Center for Therapeutic Community Research at

National Development and Research Institutes, Inc.

11 Beach Street

New York, NY 10013

188
Research Associate Professor

Department of Psychiatry

New York University School of Medicine

551 First Avenue

New York, NY 10010

189
Community Outreach for Injection

Drug Users and the Need for Cocaine

Treatment

Clyde B. McCoy, James E. Rivers, and Dale D. Chitwood

INTRODUCTION

It is now widely recognized that substance abusers are not a homogeneous

group; there are subpopulations that are akin to subcultures, with selfacknowledged membership. In addition, researchers and planners construct

subcategories of substance abusers for analytic purposes. Among these

is the often-discussed dichotomy that contrasts drug abusers “on the street”

to those identified by institutional screens. This report examines two such

samples: injection drug users (IDUs) in treatment in the Miami area and

street IDUs enrolled in the Miami National AIDS Demonstration Research

(NADR) Program. The data are analyzed with particular attention to the

cocaine use of these IDUs and the implications of these data for treatment

for cocaine abuse problems.

THE STUDY GROUPS

Treatment Study Sample

Between June 1987 and August 1988, 604 IDUs from treatment programs

in Dade County, FL, were enrolled in a longitudinal study to determine

human immunodeficiency virus-1 (HIV-1) serostatus and associated risk

behaviors. The majority (n=366) of treatment study subjects were in

methadone maintenance programs. All subjects had used a drug or drugs

intravenously at some time in approximately the decade prior to the interview

(i.e., since January 1, 1978). All subjects participated on a voluntary basis,

gave informed consent, were tested for HIV-1 serostatus, and received

pretest and post-test counseling. As part of a structured interview, all

participants answered questions concerning present and past drug use.

Subjects were followed at 6-month intervals after the baseline interview.

At each followup, subjects were questioned concerning drug use in the

6-month period since the last interview. This report examines the drug use,

190
particularly cocaine use, of 490 IDUs recruited from treatment facilities

who completed both the 6-month and 12-month followups. (Of all original

subjects, 102 had completed either none or only one of the followup

questionnaires, and 12 of the original panel were deceased at the time

of the 12-month followup.)

Outreach Study Sample

The National Institute on Drug Abuse, recognizing the critical need to address

the high-risk population of IDUs not enrolled in a treatment program, initiated

a major intervention effort targeting this group. The resulting NADR Program,

inaugurated at 63 sites throughout the United States and in Puerto Rico,

focuses on IDUs not in treatment and sex partners of IDUs. This coordinated

network of research projects in high-prevalence areas is evaluating

prevention and intervention programs designed to encourage and assist

these individuals to change behaviors that place them at risk for HIV infection.

The Miami study site was among the first five locations in the United States

to receive NADR funds, The University of Miami research team, with more

than 15 years of experience in research involving street IDUs, commenced

recruitment and interviewing of study subjects in March 1988.

IDUs who had injected drugs during the preceding 6 months and sex partners

of IDUs were recruited from street settings by indigenous outreach workers.

After an initial pretest counseling session during which informed consent was

given, each individual received a blood test to determine baseline serostatus

with regard to HIV antibodies. A standardized NADR questionnaire was

then administered by trained interviewers to obtain information on drug

use, needle sharing, needle cleaning, and sexual practices as well as

demographic characteristics, health status, acquired immunodeficiency

syndrome (AIDS) knowledge, and followup locator information.

Study subjects were randomly assigned to either a standard or an enhanced

intervention (figure 1). The enhanced intervention provided both intensive

individual and group counseling (three sessions) as well as training in

condom use and needle-cleaning procedures as further instrumental skills

that could prevent HIV infection. The standard intervention was a single

counseling session. Study subjects were reinterviewed and seronegatives

retested at 6-month intervals to assess the effectiveness of the interventions

in modifying high-risk drug use, needle use, and unsafe sexual behavior.

191
FIGURE 1. Study design

KEY: IV=intravenous

SOURCE: Chitwood and McCoy 1990

192
RESULTS

Demographic characteristics from the 6-month followup of the two study

groups are presented in table 1. As shown, the sample of IDUs from

treatment was less predominantly male and black (more likely to be white

or Hispanic), more likely to consist of high school graduates or individuals

having postsecondary educational experiences, and more likely to be

employed than the sample of street IDUs. Although not shown in the

tables, about 16.5 percent of the treatment IDUs were found to be HIV

positive at the 6-month followup compared with nearly double that

percentage for the street IDUs. There was fairly close correspondence

in the employment status and age distribution between the two samples

(although the street sample was somewhat more likely to be 35 or older).

It is possible that the racial and ethnic differences between these two

samples are a reflection of differential demand for treatment by IDUs,

differential ability to afford treatment fees, and the particular locations

and target populations of local methadone maintenance clinics, the

major source of treatment IDUs in this sample.

TABLE 1. A comparison of demographic characteristics of IDUs from

treatment and outreach groups at 6-month followup (percent)*

Treatment Group Outreach Group

Characteristic (n=599) (n=722)

Age 30 and older 79.5 76.5

Gender

Male 65.4 78.3

Race/ethnicity

Non-Hispanic black 21.2 75.6

Hispanic 13.5 6.8

Non-Hispanic white 63.6 16.8

Other 1.5 0.8

Education

High school graduate or 77.6 51.9

higher

Currently employed 63.4 51.8

*Differences between the treatment group and the street group are significant

at p<.01 level for all variables except “Age.”

SOURCE: Chitwood and McCoy 1990

193
The frequency and methods of cocaine and other drug use of the two

samples prior to baseline are presented in table 2. Use by the treatment

sample was collected for the year prior to baseline, and use by the

outreach sample is for the d-month period preceding baseline interview.

Table 2 shows that higher percentages of subjects in the street IDU

sample than in the treatment IDU sample were cocaine users during their

TABLE 2. Frequency of drug use by IDUs in treatment and on the street

(percent)

Drug/Frequency

Treatment Group Outreach Group

(n=599) (n=722)

Noninjected drugs

Alcohol

Never

Less than daily

Daily or more

Crack cocaine

Never

Less than daily

Daily or more

Cocaine hydrochloride

Never

Less than daily

Daily or more

Injected drugs

Cocaine

Never

Less than daily

Daily or more

Heroin

Never

Less than daily

Daily or more

Cocaine and heroin

(Speedball)

Never

Less than daily

Daily or more

20.9 9.1

51.8 42.2

27.4 48.6

56.6 23.5

23.2 39.2

20.2 37.3

70.3 39.9

25.7 40.4

4.0 19.7

59.8 10.0

29.5 56.4

10.7 33.7

47.9 38.0

36.6 40.6

15.5 21.5

67.9 39.9

22.0 35.3

10.0 24.6

194
respective baseline periods and that street IDUs were more frequent users

of noninjected drugs such as alcohol, crack, and cocaine hydrochloride.

Cocaine injection was much more common among the street IDU sample

than among the treatment IDU sample; within the street sample, cocaine

injection was more prevalent than heroin injection. During the baseline

period, 90 percent of the street sample had injected cocaine; 62 percent

had injected heroin; and 60 percent had injected both in combination (i.e.,

speedball).

The demographic information on the cocaine-using subsamples from the IDU

street outreach and treatment samples is presented in table 3. Similar to the

data for the entire samples shown in table 1, the subsample of cocaine users

in the IDU treatment sample shown in table 3 was less predominantly male,

TABLE 3. Demographic information (percent) of cocaine users

Characteristic

Treatment Sample Outreach Sample

(n=270) (n=237)

Gender

Male

Female

Ethnicity

White

Black

Hispanic

Other

Age

24 or younger

25-29

30-34

35 or older

Education

Less than high school

High school graduate

Higher than high school

Employment

Employed

Unemployed

63.7 81.4

36.3 18.6

50.5 12.7

25.6 82.7

14.4 4.2

1.5 0.4

7.4 5.9

16.7 19.4

35.9 26.2

40.0 46.5

23.7 34.6

40.0 59.9

36.3 5.5

57.4 55.7

42.6 44.3

195
less predominantly black (more likely to be white or Hispanic), and more likely

to have postsecondary educational experience than the sample of cocaine

users in the IDU street sample. There was fairly close correspondence in the

employment status and age distribution between the two samples (although

the street sample was somewhat more likely to be 35 or older).

The frequency of cocaine use by route of ingestion prior to baseline interview

is described in table 4 for each study subsample. The IDU outreach cocaineusing subsample showed a higher percentage using daily or multiple times

per week for all forms of cocaine than did those IDU cocaine users in the

treatment sample.

TABLE 4. Frequency of cocaine use by route of ingestion: Baseline

(percent)

Drug/Frequency

Treatment Sample* Outreach Sample†

(n=270) (n=237)

Crack cocaine

Had not used

Less than weekly

Less than daily, more than weekly

Daily or more

Snorted cocaine

Had not used

Less than weekly

Less than daily, more than weekly

Daily or more

IV cocaine only

Had not used

Less than weekly

Less than daily, more than weekly

Daily or more

Speedball

Had not used

Less than weekly

Less than daily, more than weekly

Daily or more

50.4 26.6

1.9 13.5

16.7 21.1

31.1 38.8

78.5 43.0

1.5 18.6

14.8 19.0

5.2 19.4

63.0 10.1

4.1 24.5

17.0 31.6

15.9 33.8

58.5 44.3

14.4 19.0

10.7 18.1

16.3 18.6

*Year prior to baseline

†6 months prior to baseline

KEY: IV=intravenous

196
The use of cocaine by route of ingestion for the 6 months prior to baseline

and the following 6 to 12 months for participants in the outreach study

is described in table 5. Decreased use (i.e., fewer using daily or multiple

times per week) of cocaine by each route is shown for each of the two

followup periods.

The same information for the cocaine-using IDU treatment subsample

is displayed in table 6, except the baseline measure describes use for the

year prior to entry into the study. As with the outreach group, decreased

frequency of use is seen in each followup period for each ingestion route,

but the declines were greater among the treatment group.

TABLE 5. Frequency of cocaine use by route of ingestion at baseline, 6

months, and 12 months: Outreach sample (percent) (n=237)

Drug/Frequency Baseline 6 Months 12 Months

Crack cocaine

Had not used

Less than weekly

Less than daily,

more than weekly

Daily or more

Snorted cocaine

Had not used

Less than weekly

Less than daily,

more than weekly

Daily or more

IV cocaine only

Had not used

Less than weekly

Less than daily,

more than weekly

Daily or more

Speedball

Had not used

Less than weekly

Less than daily,

more than weekly

Daily or more

26.6 32.9 40.5

13.5 14.3 12.2

21.1 24.1 21.9

38.8 28.7 25.3

43.0 55.7 67.1

18.6 18.6 13.1

19.0 13.1 13.5

19.4 12.7 6.3

10.1 41.4 55.7

24.5 23.2 16.5

31.6 19.8 16.9

33.8 15.6 10.9

58.5 62.0 69.2

14.4 14.8 10.5

10.7 9.3 11.8

16.3 13.9 8.4

197
TABLE 6. Frequency of cocaine use by route of ingestion at baseline, 6

months, and 12 months: Treatment sample (percent) (n=270)

Drug/Frequency Baseline 6 Months 12 Months

Crack cocaine

Had not used

Less than weekly

Less than daily,

more than weekly

Daily or more

Snorted cocaine

Had not used

Less than weekly

Less than daily,

more than weekly

Daily or more

IV cocaine only

Had not used

Less than weekly

Less than daily,

more than weekly

Daily or more

Speedball

Had not used

Less than weekly

Less than daily,

more than weekly

Daily or more

50.4 54.8 63.7

1.9 18.9 9.6

16.7 8.1 12.2

31.1 18.1 14.4

78.5 82.2 80.0

1.5 9.3 11.9

14.8 8.7 4.8

5.2 1.9 3.3

63.0 74.4 78.9

4.1 15.2 11.1

17.0 4.4 5.6

15.9

58.5 84.4 88.5

14.4 3.0 1.5

10.7 8.1 5.9

16.3 4.4 4.1

5.9 4.4

The frequency of cocaine use for the year prior to baseline and 6 to

12 months following baseline for the 366 treatment subjects enrolled

in methadone maintenance clinics at the time of entry into the study is

described in table 7. A considerable number of methadone maintenance

patients continued to use cocaine in one form or another. The largest

decrease was in the use of speedball, the most common form; crack

cocaine showed no reduction.

196
TABLE 7. Frequency of cocaine use by route of ingestion: Clients of

methadone maintenance programs: Treatment sample

(percent) (n=366)

Drug/Frequency Baseline 6 Months 12 Months

Crack cocaine

Had not used

Less than weekly

Less than daily,

more than weekly

Daily or more

Snorted cocaine

Had not used

Less than weekly

Less than daily,

more than weekly

Daily or more

IV cocaine only

Had not used

Less than weekly

Less than daily,

more than weekly

Daily or more

Speedball

Had not used

Less than weekly

Less than daily,

more than weekly

Daily or more

77.3 67.8 70.2

4.4 14.5 11.5

8.2 7.4 9.0

10.1

83.6 82.0 83.1

6.6 10.9 10.4

7.4 4.9 4.1

2.5 2.2 2.5

71.3 79.2 83.6

9.6 12.3 8.2

10.1 3.8 3.0

9.0 4.6 5.2

69.9 88.5 90.4

14.5 2.2 1.6

6.5 6.0 5.2

9.1 3.3 2.7

10.4 9.3

The percentages of subjects who were in drug treatment during the

6 months after baseline and the following 6 to 12 months are shown in

table 8. Eighty-nine percent of the outreach sample were not in treatment

during the first 6 months of followup, and 89.4 percent had no treatment

in the following 6 months. The treatment sample, as would be expected,

had considerably more subjects in treatment during both followup periods.

However, by the end of 1 year, 47.4 percent had received no treatment in

the last 6 months of that year.

199
TABLE 8. Months in drug treatment (percent)

Time in Treatment

Baseline to 6 Months to

6 Months 12 Months

Outreach sample

No treatment

1 month

2 months

3 months

4 months

5 months

6 months

Treatment sample

No treatment

1 month

2 months

3 months

4 months

5 months

6 months

89.0 89.4

6.8 6.4

1.3 1.7

0.8 1.3

1.3 0.9

0.0 0.0

0.8 0.4

6.3 47.4

25.9 5.6

4.8 5.9

6.7 2.6

3.3 4.1

20.4 10.4

32.6 24.1

The numbers of cocaine users from each study who had increased and

decreased cocaine use during the two followup periods are shown in

table 9. More individuals decreased cocaine use in each ingestion

category than increased use during each followup period.

DISCUSSION

IV drug use has been identified as a major risk factor in the transmission of

HIV through sharing of needles. During the past 2 years, more than 1,300

IDUs (including the sample of 722 reported in this chapter) have been

recruited from the street population into the AIDS risk reduction outreach

program conducted by the University of Miami. Sixty percent of these

participants reported having received no drug abuse treatment services

at any point during the 5-year period preceding the enrollment interview.

Significant proportions of this street outreach IDU sample have given

positive signals that they are candidates for drug abuse treatment:

40 percent had previously enrolled in treatment; all agreed to enter the

University of Miami risk reduction program; and significant percentages

200
TABLE 9. Changes in cocaine use: Numbers of cocaine users

Sample Drug Use

Baseline to 6 Months 6 Months to 12 Months

Decreased Increased Decreased Increased

Outreach sample (n=237)

Crack cocaine

Snorted cocaine

Injected cocaine

Speedball

Treatment sample (n=270)

Crack cocaine

Snorted cocaine

Injected cocaine

Speedball

73 47 61 41

54 34 65 36

124 19 73 38

76 26 58 25

93 50 56 41

52 26 28 41

81 30 40 29

48 15 26 18

of the sample either had unsuccessfully sought or actually gained admission

to treatment programs. At the 6-month followup reinterview, approximately

14 percent of these outreach clients indicated that they had unsuccessfully

sought treatment admission since this initial interview. Another 11 percent

were successful in gaining admission to treatment in the 6-month period

following enrollment in the program, including 18 individuals admitted from

waiting lists.

It is reasonable to expect that the percentages of participants enrolled

in these community outreach efforts who seek, enter, and complete

substance abuse treatment can be increased by adding more placement

staff members (and perhaps relapse prevention personnel). Anecdotal

support for this thesis comes from those participants in the Miami program

who have entered and stayed in treatment and who report that they are

there because “someone cared.”

As shown above, a documented pool of IDUs are eligible for treatment

and willing to enter. However, as is often the case, many have limited

financial resources to pay for treatment services. The Federal

Government recognized IDUs as a priority treatment target population

until recently, setting aside a percentage of block grant funds for their

treatment. Nevertheless, a sizable number of participants in the Miami

community outreach project who sought treatment either were placed

on a waiting list or report that they were refused treatment admission.

201
Historically, IDUs have been associated mainly with heroin use, and

the treatment for heroin-using IDUs has most often been methadone

maintenance. These programs have admission criteria based on

documented length of use, current use, etc. But the treatment IDUs

in the Miami study shoot cocaine as their primary drug. In addition,

there are some former IDUs who continue to use non-IV drugs, primarily

cocaine. They are still addicted and tend to engage in unsafe sexual

practices, thus maintaining the risk of contracting or transmitting the

AIDS virus.

Ideally, a protocol should be developed, implemented, and evaluated

that would include a thorough client services needs assessment; a

“readiness for treatment” assessment; and referral and active assistance

with enrollment, case management, treatment retention support, and

followup interviews and measures. Minimally, funding for treatment

services dedicated to HIV high-risk drug abusers of the type recruited

into the Miami AIDS risk reduction programs is needed.

REFERENCE

Chitwood, D.D., and McCoy, C.B. Comparison of street and treatment IVDUs.

Network 2(1):1-4, 1990.

AUTHORS

Clyde B. McCoy, Ph.D.

Director

James E. Rivers, Ph.D.

Deputy Director

Dale D. Chitwood, Ph.D.

Associate Director

Comprehensive Drug Research Center

University of Miami

Miami, FL 33136

202
Relapse to Cocaine Use: Conceptual

Issues

Barbara E. Havassy, David A. Wasserman, and Sharon M. Hall

INTRODUCTION

Relapse to alcohol and other drug use is of paramount theoretical and practical

importance. Assembled research findings and clinical experience indicate that

many users who cease drug use eventually relapse, frequently after only limited

periods of abstinence. To date, experience with cocaine users is no different;

however, in contrast to the accumulation of data about recurrence of use in

alcoholics, cigarette smokers, and opiate users, information on cocaine users

is minimal. For this reason the authors have not attempted to present a

comprehensive review of extant cocaine relapse studies. Such a review would

be premature and yield few conclusions. However, it is timely to undertake a

conceptual examination of relapse to cocaine use, with the hope that this effort

will assist in establishing parameters for future empirical and theoretical work.

Thus, this chapter examines definitional issues in relapse to cocaine use,

background factors that have been linked to cocaine relapse, and promising

theoretical variables.

WHAT IS RELAPSE?

Generally, relapse denotes a resumption of drug use after a period of

abstinence. Defining relapse in cocaine users is complex because many

compulsive users of cocaine engage in binge use and other styles of periodic

consumption. Short intervals of abstinence are the rule for these intermittent

users. How, then, is relapse to be distinguished from a pattern of periodic use?

Several clinical investigators have tried to tackle this problem. Rawson and

colleagues (1990) assert that the term should be restricted to a resumption

of cocaine use that occurs after an extended period of abstinence, usually a

month or more. Washton and Stone-Washton (1990) suggest an even longer

period of 3 months. Although these definitions may be useful clinically, they

are problematic in research because occasions of cocaine use frequently occur

well before several months of abstinence have been achieved. For example,

in a relapse study we conducted with 104 cocaine patients who completed

203
treatment, 31 percent lapsed during the first month following discharge (Hall et

al. 1991a; Havassy et al. 1991a). Independent of how these lapses are labeled

or clinically interpreted, they merit serious study.

A related question is the duration and extent of resumed cocaine use that is

necessary before the use is considered a relapse. A relapse criterion based

on a specified number of consecutive days of use is appropriate for most other

abused drugs because these drugs typically are used daily (e.g., Ossip-Klein et

al. 1986). Because many cocaine users do not have a pattern of daily use, this

approach to defining relapse is not meaningful. Only 21 percent of subjects in

the authors’ cocaine relapse study typically used cocaine on a daily basis (Hall

et al. 1991a; Havassy et al. 1991a).

To accommodate the variety of cocaine use patterns in our research, the first

occasion of resumed use (or first lapse) was chosen as the primary outcome

variable, regardless of the amount used on that occasion or whether there

were subsequent occasions of use (Hall et al. 1991 a; Havassy et al. 1991 a).

This criterion was appealing for several reasons. First, lapses frequently lead

to continued use, possibly caused by priming effects (Jaffe 1989). Second,

unlike relapse, the first lapse is conceptually unambiguous. Third, a lapse

can be reliably and validly measured with frequent biochemical verification

of self-reported abstinence.

These reasons notwithstanding, the first lapse is not an ideal outcome criterion.

It provides only limited information, particularly if it is the only outcome variable

assessed. Furthermore, it is not yet known whether a lapse inevitably predicts

continued use: it is not even clear that a lapse is an unequivocally negative

outcome. Some clinicians suggest that a lapse, if thoughtfully examined, can

facilitate long-term abstinence by helping the person identify the circumstances

and situations that led to cocaine use.

For research purposes, it would be advantageous to achieve a consensus

about what constitutes relapse in cocaine users. This definition should

address (1) the duration, or range of durations, of periods of abstinence that

are necessary before relapse can be said to occur and (2) the extent of

resumed use that constitutes a clinically significant outcome. Using the first

lapse as the dependent variable has generated heuristic findings in our work

(Hall et al. 1991a; Havassy et al. 1991a). If this approach continues to be

productive, and if it is demonstrated that first lapses frequently result in

continued use, we would recommend that the first lapse be included

among the outcome variables to be studied.

204
BACKGROUND FACTORS ASSOCIATED WITH RELAPSE

Several patient background factors appear to affect treatment outcomes and,

therefore, may influence relapse.

Route of Cocaine Administration

In our cocaine relapse study (Hall et al. 1991a; Havassy et al. 1991a),

intranasal users (snorters) had significantly higher rates of continuous

abstinence for two periods than a group primarily composed of freebase/crack

smokers and intravenous users-during the first 12 weeks after treatment

completion (83 vs. 29 percent) and at 8 months following treatment (57 vs.

19 percent). Washton and Stone-Washton (1990) cite similar findings:

lntranasal users had higher abstinence rates than cocaine smokers. Miller

and colleagues (1989, p. 390) have speculated that cocaine smoking may

have the highest addiction potential because of “the faster and higher peak

blood levels” attained.

Ethnicity

Data from our cocaine relapse study showed that African-American and

Caucasian patients differed in route of administration and in treatment outcome.

Sixty-three percent of Caucasian subjects used cocaine primarily intranasally,

but only 2 percent of African-Americans did so. African-Americans tended to

smoke crack (82 percent), whereas only a minority of Caucasians (17 percent)

were primarily crack users. Furthermore, Caucasian subjects were at lower risk

for relapse during the first 12 weeks and were more likely to be continuously

abstinent at 8 months. The confounding of ethnicity with route of administration

unfortunately prevents the disentangling of potential ethnicity effects from route

effects in this sample. However, the data analysis suggested that only route

of administration contributed unique variance to the prediction of treatment

outcomes.

Gender

Data from Griffin and coworkers (1989) and our work suggest that, on average,

one woman presents for cocaine treatment for, at minimum, every two to three

men. Gender differences also are found in cocaine use patterns. For example,

in the cocaine relapse study, route of administration differed by gender, with

females more likely than males to use cocaine intranasally. Also, female

patients in treatment had slightly higher abstinence rates than men, even

when route of administration was statistically controlled.

205
Polysubstance Use

Abuse of other substances is common in cocaine treatment patients. “Almost

invariably, cocaine abusers use other drugs to enhance the euphoriant

properties of cocaine or to alleviate some of its dysphoric psychoactive

effects” (Millman 1988, p. 27). The abused drug is usually alcohol. In an

ongoing study of the efficiency of inpatient and outpatient treatment for

cocaine dependence led by Havassy, psychoactive substance use disorders

(as defined in the “Diagnostic and Statistical Manual of Mental Disorders,

Third Edition, Revised” [DSM-III-R] [American Psychiatric Association 1987])

are assessed using the Diagnostic Interview Schedule (DIS-III-R) (Robins et

al. 1981). Polysubstance dependence has been prevalent. Of the first 80

subjects meeting criteria for cocaine dependence, 59 percent met criteria

for lifetime alcohol dependence and 58 percent for lifetime cannabis

dependence. Thirty-eight percent were diagnosed as both alcohol- and

cannabis-dependent; 41 percent were dependent on one but not the other.

Miller and colleagues (1990) assessed three samples of cocaine-dependent

patients and found slightly lower rates of cannabis dependence (42 to 51

percent) but higher rates of alcohol dependence (88 to 92 percent). Although

the use of any abusable drug is believed to increase the risk of cocaine relapse,

supporting data are lacking. If future data indicate that the use of other drugs

precipitates relapse to cocaine, several processes may be responsible,

including priming, disinhibition, and conditioned craving (Jaffe 1989; Pollack

et al. 1989).

PSYCHOSOCIAL INFLUENCES ON ABSTINENCE AND RELAPSE

Distinct from the stable background factors just described, several

psychosocial variables have emerged as potentially important in cocaine

relapse. These variables may be responsive to intervention and often are

the focus of treatment. Variables that currently offer the most promise for

further investigation are having something to lose, commitment to absolute

abstinence, social support, coping with drug-related cues, psychopathology,

and positive moods/well-being.

Having Something To Lose

Relapse is believed to be less likely if something of great value could be lost if

drug use is resumed. Potential losses include family and friends, jobs, health,

reputation, and freedom. In support of this proposition, negative contingencies

for resumption of cocaine use have been applied successfully in therapeutic

settings. All cocaine users are not equally vulnerable to contingent losses,

however. For those who have few resources or have “hit bottom,” powerful

negative contingencies may be difficult to identify (Kleber 1989; Rawson 1990).

206
The power of adverse contingencies to prevent relapse in cocaine patients

was first addressed in research by Anker and Crowley (1982). In this study,

patients were asked to enter into contracts stipulating severe consequences

(e.g., notification of one’s employer) in the event of relapse. Eighty-one percent

of 32 patients agreeing to the contracts stayed in treatment and remained

abstinent for 3 months or more. Despite several limitations, including a selfselection bias and possible lack of generalizability because of the mostly

affluent, Caucasian sample, this study showed that contracts can be extremely

effective with consenting patients. However, to succeed, contingencies must

be selected that are “sufficiently potent to counteract the reinforcing properties

of drugs or the conditioned reinforcing properties of drug-related stimuli”

(Stitzer et al. 1983, p, 116).

Aversive-contingency contracting has been criticized for several reasons.

Contracts are seen by some as unnecessarily coercive or punitive,

particularly when used with voluntary patients. Furthermore, to be effective,

contingencies must continue to be applied: Behavior change often decays

when contingencies are no longer in force. Finally, some clinicians view lapses

as expected events in early abstinence, possibly instructive to the patient, and,

therefore, undeserving of punishment or withdrawal of reinforcers (Rawson

1990).

Positive contingencies for abstinence from cocaine use have received less

attention than negative contingencies. Higgins and coworkers (1991) recently

adapted the community reinforcement approach (CRA) (Azrin 1976; Azrin et al.

1982; Hunt and Azrin 1973), a technique initially developed for alcoholics, for

use with cocaine users. The hallmark of CRA is the creation of an environment

rich with positive and negative contingencies. Numerous reinforcers are

provided by spouses, employers, and friends to reward abstinence. When

drug use occurs, a time-out from this high-density reinforcement is instituted.

Early results from Higgins and colleagues (1991) are encouraging, although

future studies will need to clarify which of the many components of this

approach account for the positive outcomes,

The possibility of using CRA with cocaine-using individuals who have few

economic or social resources is intriguing. If part of the difficulty of motivating

these patients is the scarcity of meaningful contingencies, then providing them

with new reinforcers at the beginning of treatment might give clinicians added

leverage in influencing their drug use. Developing new reinforcers entails

helping the patient to acquire “positive gains interpersonally, vocationally,

and economically” (Kleber 1989, p. 82).

Modest positive contingencies seem ineffective with cocaine users. For

example, Magura and colleagues (1988) found that methadone “take-home”

privileges contingent on decreased use of cocaine failed to alter methadone207
maintenance patients’ use of the stimulant. This outcome was surprising

because similar interventions have been successful in modifying other illicit

drug use in this population (e.g., Stitzer et al. 1980). Perhaps methadone

dose increases were not effective reinforcers for decreased use of cocaine. In

addition, as suggested by Magura and colleagues (1988) a multiple-reinforcer

approach might prove more powerful. Multiple reinforcers increase the general

level of reinforcement (Cautela 1984) and also minimize the effects of “reward

erosion,” which is a decrease in how rewarding a stimulus is with repeated

administrations over time.

Operant techniques such as contingency contracting and CRA are thought

to be more useful in assisting the initiation of abstinence than in helping to

maintain abstinence over time (Stitzer et al. 1983). if this is so, it may be

because such approaches are extrinsically rather than intrinsically motivating.

Extrinsic and intrinsic motivation refer to the origins of the desire or intent to

engage in or to cease a particular behavior (Curry et al. 1990). Extrinsic

motivators include external reinforcement and punishment. Common intrinsic

motivators are good health, self-determination, and psychological congruence.

in a recently published study of cigarette smokers, stronger intrinsic, relative to

extrinsic, motivation was found to predict abstinence at 3 and 6 months after

quitting (Curry et al. 1990). According to Curry and colleagues, extrinsic

motivation “can be detrimental to sustained performance” (Curry et al. 1990,

p. 315). Gawin and Ellinwood noted the superiority of intrinsic motivation

in long-term abstinence from cocaine, and they recommended gradual

reduction of "the external controls that were placed on the abuser during the

initiation of abstinence, with the goal of facilitating the development of the

abuser’s internal controls . . .” (Gawin and Eliinwood 1988, p. 1177). If

intrinsic motivators indeed are more important in later abstinence, then it

would seem advisable to begin to identify these early in treatment.

The role of urine monitoring in contingency-management procedures with

cocaine users is critical. The effectiveness of contingency strategies depends

on the valid detection of cocaine use when it occurs. Failure to detect use

results in the inappropriate application of contingencies and, thus, renders

interventions ineffective. Because urine testing provides a valid indicator of

drug use, it is strongly recommended as an adjunct to these methods.

Commitment to Absolute Abstinence

The rigorousness of abstinence goals chosen by drug patients at the end of

treatment is correlated with later abstinence. Our work has shown that patients

who report that they are committed to absolute (i.e., total and permanent)

abstinence from their problem drug are more likely to remain abstinent than

those who subscribe to a less stringent goal such as periods of abstinence with

208
occasional slips. Hall and coworkers (1990), in a study of relapse in alcoholics,

cigarette smokers, and opiate users who had completed treatment, found that

patients with a commitment to absolute abstinence were at lower risk for a lapse

during the first 12 weeks posttreatment. Data from the authors’ study of treated

cocaine users (Hall et al. 1991a) indicated the same association. Because

subjects from both studies were drawn from programs endorsing the 12-step

model and strict abstinence, the results may not be generalizable to persons

completing other types of treatment, especially programs that provide

instruction in dealing with lapses.

Social Support

By “social support” we mean resources provided by other persons (Cohen and

Syme 1985), a concept more inclusive than the administration of contingencies

by social-network members. In considering drug use, social support may be

either specific to abstinence or more general (i.e., not limited to drug use or to

abstinence). Greater perceived emotional support, a type of general support in

which subjects report being valued and accepted by one’s intimates, predicted

abstinence in the cocaine relapse study (Havassy et al. 1991b). In a study

of relapse in alcoholics, cigarette smokers, and opiate users, we found that

greater social integration (i.e., being socially involved with more people) at the

end of treatment predicted a lower risk of relapse (Havassy et al. 1991b).

in the cocaine relapse study, this finding was replicated for Caucasian subjects

but not for African-Americans (Havassy et al. 1991a). The interaction of social

integration with ethnicity suggests that the protective elements of social

integration may differ for Caucasian and African-American cocaine users.

Further work is required to develop hypotheses about the mechanisms by

which social support influences maintenance of abstinence.

Clinical experience indicates that social support may be enhanced by family

therapy, social-network therapy, and such self-help programs as Alcoholics

Anonymous. Skills-training interventions (e.g., assertiveness training) that

teach patients ways of eliciting additional support also may be useful. Focused

interventions that teach a significant other to provide more support (e.g., spouse

training) have not been promising when used with other populations such as

cigarette smokers (Lichtenstein et al. 1986). The results of these focused

interventions are disappointing, as studies have demonstrated consistently that

abstinence and support covary. Support-enhancing interventions may need

to target a wider universe of helpful behaviors as well as involve multiple

network members. Interventions also might be enhanced by targeting cognitive

processes that affect how enacted support is perceived (Lakey and Cassady

1990).

209
Coping With Drug-Related Cues

External and internal cocaine-related cues frequently are cited as relapse

precipitants (e.g., O’Brien et al. 1988). External cues include the drug, drug

paraphernalia, known cocaine users, places where cocaine has been used,

and ready cash. Internal cues include moods or feeling states, such as

boredom, performance anxiety, elation, and depression, as well as sexual

arousal. Training in coping with these cues, whether by escape/avoidance,

assertion, self-talk, or other means, is now incorporated into many treatment

programs.

Clinicians have dealt with the problem of cues in a variety of ways. One has

been to reduce or eliminate cue exposure temporarily through hospitalization or

a stay in another restrictive setting. The long-term value of complete isolation

from drug cues is uncertain because most patients ultimately must return to

cue-laden environments. Alternatively, patients can be helped to respond more

adaptively to drug cues. A major strategy for changing patients’ responses is

cue exposure treatment, which combines cue exposure with extinction and has

been studied extensively by researchers at the University of Pennsylvania and

the Philadelphia Veterans Affairs Medical Center (O’Brien et al. 1988, 1990).

These investigators have demonstrated that conditioned responses to cocaine

stimuli can be extinguished through repeated exposure in a safe laboratory

environment. Preliminary data showed that extinction trials increased treatment

retention and the number of in-treatment drug-free weeks (O’Brien et al. 1990).

Nevertheless, the value of cue exposure in preventing posttreatment relapse

in cocaine users appears limited, at least when the technique is used alone.

Findings have not been encouraging-nor has cue exposure been shown to

be effective with other drug populations. An article by Drummond and

colleagues (1990) concluded that cue exposure has not been shown to reduce

drinking in alcoholics and, furthermore, that no demonstrated link has been

found between conditioned responses to alcohol-related cues and relapse.

According to Drummond and coworkers (1990), if cue exposure eventually is

shown to be effective, it may be caused by the critical mediators such as

enhanced self-efficacy and diminished positive outcome expectancies for drug

effects rather than true extinction or habituation. Marlatt (1990) also points to

the likely importance of these latter factors in cue-exposure treatment.

To enhance the value of cue exposure, researchers have recommended

several strategies, which include using more realistic stimuli (e.g., actual

cocaine), phasing out “safety signals” (i.e., the therapist and other reassuring

cues that may be present in artificial laboratory situations), embedding exposure

trials in the context of high-risk situations in the natural environment (in vivo),

and combining cue exposure with coping skill training (Drummond et al. 1990;

Marlatt 1990; O’Brien et al. 1990).

210
Psychopathology

Several studies have documented a high prevalence of mental disorders,

particularly depression and various personality disorders, among cocaine users

in treatment (e.g., Kleinman et al. 1990). Measures of psychopathology have

included both psychiatric diagnosis and dimensional symptom scales. In the

first author’s current multisite cocaine treatment-efficacy study, the prevalence

of DSM-III-R (American Psychiatric Association 1987) antisocial personality

disorder in the first 80 subjects recruited was 49 percent. Posttraumatic stress

disorder was also common (lifetime prevalence=27.5 percent), although there

were pronounced site differences in prevalence. In contrast, in the cocaine

relapse study, psychological symptom levels as measured by the SCL-90-R

(Derogatis 1983) were fairly low. Mean scores on the nine primary symptom

dimensions and the Global Severity Index were higher than those for the

nonpatient normative cohort for the SCL-90-R but were lower than the scores

for the psychiatric inpatient and outpatient normative groups. SCL-90-R data

from another study of cocaine patients were comparable (Kleinman et al. 1990).

It is as yet unclear whether psychopathology (1) is present before cocaine

initiation, (2) precipitates cocaine abuse, or (3) attenuates cocaine treatment

effects. With respect to the third issue, preliminary analyses from the cocaine

relapse study indicated no relationship between psychological symptoms and

relapse. However, diagnoses were not obtained. Recent evidence in the area

of smoking cessation (e.g., Glassman et al. 1990; Hall et al. 1991b) suggests

that persons with a diagnosis of major depression are less successful in their

efforts to stop smoking. Parallel findings have been reported for alcoholics and

users of other abused substances (e.g., Hatsukami and Pickens 1982). If these

data can be generalized, then untreated depression and other psychiatric

disorders could limit treatment effectiveness and facilitate relapse in cocaine

users as well.

Posltlve Moods/Well-Being

Research from several different perspectives points to the importance of

variables labeled as subjective well-being (Diener 1984). These variables

include positive moods, optimism, and life satisfaction, Note that well-being is

not simply the “flip side” of general dysphoria, depression, or perceived stress;

rather, positive and negative states are at least partially independent (Diener

and Emmons 1986). Peele (1988) and Longabaugh and Lewis (1988) have

emphasized the importance of well-being in abstaining from problem drinking:

“Personal well-being is important because people are likely to hope that they

will feel better about themselves and their lives after treatment; if this does not

occur, a patient is more likely to be at risk for relapse” (Longabaugh and Lewis

1988, p. 172). Strack and colleagues (1987) showed that dispositional

optimism in alcoholics predicted completion of a halfway house program.

211
Hail and coworkers (1990) found that higher posttreatment positive mood

levels were marginally (p<.06) related to decreased relapse risk in a sample

of alcoholics, cigarette smokers, and opiate users.

Subjective well-being may be especially important in cocaine users. One

phase of the cocaine abstinence syndrome, which Rawson and associates

(1990) have called “the wall,” is characterized by anhedonia and anergia.

This stage, specific to stimulant abuse (Gawin and Ellinwood 1988), is widely

believed to heighten vulnerability to relapse. Data from the cocaine relapse

study suggest that this hypothesis is correct. The absence of positive moods

predicted relapse more reliably in cocaine users than in users of other drugs

(Hall et al. 1991a).

There has been little work done pertaining to the enhancement of subjective

well-being in drug users and specifically in cocaine users. if subjective wellbeing aids in prolonging abstinence, then ways of developing it in cocaine

treatment patients should be explored. It may be possible to help patients

develop a repertoire of behaviors and reinforcing activities that do not involve

drug use and that can compete successfully with drug use behavior. “The two

major positive reinforcers for many people that are effective over time involve

developing close relations with significant others and having a rewarding

vocational and/or educational position” (Kleber 1989, p. 91).

CONCLUSIONS: TREATMENT IMPLICATIONS FOR RELAPSE PREVENTION

With some exceptions, much of the extant research on cocaine relapse

may have limited generalizability because of design limitations and because

middle and upper-middle socioeconomic status (SES) Caucasians were

overrepresented in the samples (Means et al. 1989). These SES groups

were the first to encounter difficulties with cocaine in this most recent cocaine

“epidemic.” However, with the advent of crack, addicts are increasingly lower

SES persons. Because of these limitations, and the resulting necessity

of extrapolating from research with other drug groups, the following

recommendations for cocaine relapse prevention are offered with caution.

1. Identification and provision of positive and negative reinforcers and

penalties that can compete with the reinforcing effects of cocaine appear

to be central. Early in treatment, reinforcers should be under the control of

treatment personnel and designated significant others as much as possible,

with urine monitoring used to confirm abstinence. The use of reinforcers

and urine monitoring should be coupled with the removal or amelioration of

conditions that make cocaine use attractive and with the provision of coping

skills for circumstances that are more intractable. Lower SES patients will

need initial assistance in training for, finding, and keeping meaningful jobs;

arranging child care; and accessing affordable medical care. Similarly,

212
2.

3.

4.

5.

6.

Goldstein and Kalant (1990, p. 1518) state that members of groups with

exceptionally severe drug problems who are also socially and economically

disadvantaged need “opportunities for economic advancement within a licit

social framework and for enhanced self-respect through reinforcement of

traditional social and cultural values.” As longer periods of abstinence are

achieved, intrinsic motivators should be identified and emphasized.

Reinforcers for middle and upper class persons usually can be less

oriented to survival needs and more toward psychological comfort and

growth.

Patients should be encouraged to adopt a goal of absolute abstinence from

cocaine. This goal may be difficult for patients to accept at the beginning of

treatment. Over time, however, patients appear more amenable to

adopting stringent goals,

Multiple potential sources of familial and nonfamilial social support should

be identified, and the patient’s perceptions of the availability and usefulness

of that support should be enhanced. The most effective sources of support

may differ by racial and ethnic groups and by gender.

Skills for coping with drug-related cues should be taught in meaningful

contexts that contain external cues or evoke strong internal cues for drug

use. The natural environment should be used frequently for training.

Thorough evaluation for psychiatric disorders may be advisable. Currently

depressed patients, those who have been depressed in the past, and

those with other psychiatric disorders may be at higher risk for relapse.

Concomitant treatment for cocaine dependence and mental disorders may

increase the likelihood of continued abstinence.

Ways of enhancing a sense of well-being should be identified for each

patient. Improved well-being may be targeted directly through activities

like exercise and also may follow as a byproduct of previously discussed

interventions such as increasing social support. Subjective well-being

achieved without the aid of cocaine or other drugs may be thought of as

a kind of “final common pathway” through which successful interventions

exert their positive effects.

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216
ACKNOWLEDGMENTS

Preparation of this chapter was supported in part by National Institute on Drug

Abuse grants DA-05582, DA-03082, and DA-06097 and by an RAG grant

(SMH) from the Department of Veterans Affairs.

AUTHORS

Barbara E. Havassy, Ph.D.

Associate Professor

David A. Wasserman, Ph.D.

Assistant Research Psychologist

UCSF Treatment Outcome Research

University of California, San Francisco

Suite 320

5 Third Street

San Francisco, CA 94103

Sharon M. Hall, Ph.D.

Professor

Psychiatry Service (116A)

University of California, San Francisco

San Francisco Department of Veterans Afffairs Medical Center

4150 Clement Street

San Francisco, CA 94121

217
Pretreatment Natural History of

Cocaine Addiction: Preliminary

1 -Year Followup Results

M. Elena Khalsa, M. Douglas Anglin, Alfonso Paredes,

Penny Potepan, and Carolyn Potter

INTRODUCTION

Treatment for cocaine dependence has increased dramatically in the past

decade throughout the United States for individuals of all characteristics

and backgrounds. The effectiveness of different cocaine treatment efforts

is under study, but only minimal results are available as yet. Generally,

information on the effectiveness of cocaine treatment has come primarily

from clinical experience and from surveys of higher socioeconomic

populations. The University of California, Los Angeles, Cocaine Treatment

Evaluation study was designed to evaluate the effectiveness of three

common treatment approaches for cocaine addiction and to study the

natural history of cocaine dependence (i.e., the characteristics of users

and their patterns and progression of use). It was also the authors’

purpose to develop prognostic indicators based on the demographic,

personality, and diagnostic characteristics of users.

Although a randomized treatment assignment was planned for the

experimental design, two-thirds of patients rejected such assignment,

Thus, a mixed design evolved in which patients accepting random

assignment were placed in an inpatient ward or outpatient services

or were referred to community self-help organizations (e.g., Cocaine

Anonymous). In addition, other subjects were randomly selected from

patients with an expressed preference for either inpatient or outpatient

treatment. Baseline assessments were performed on all subjects at

acceptance into the research protocol. Outcome data collection was

completed at 1 -year followup in December 1990, and a 2-year followup

began in October 1990 and was completed in December 1991,

A natural history approach was used to examine the psychological,

environmental, and sociocultural variables that support the maintenance

of addiction over time (Winick 1962). In addition to conventional

218
sociodemographic, personality, and other background data, a complete

drug history with emphasis on cocaine use was obtained for each subject

following a strategy developed by one of the authors and his associates

(McGlothlin et al. 1977; Anglin and McGlothlin 1984).

The natural history interview, adapted in part from a schedule developed

by Nurco and colleagues (1975) has been described in detail elsewhere

(Anglin and McGlothlin 1984). Briefly, a schematic time chart is prepared

before the interview showing all known arrests and intervals of incarceration,

legal supervision, and treatment. With subject cooperation, the interviewer

then establishes the date of first cocaine use (FCU) on the time chart and

proceeds chronologically from 12 months before FCU to the time of the

interview. Data are then collected on the use of cocaine, alcohol, and

other drugs: employment: criminal behavior; and other variables for that

period. Subsequent periods are demarcated by significant life changes,

such as changes in level of cocaine use or changes in the respondent’s

legal or treatment status. The interviewer proceeds to each successive

homogeneous period, repeating the systematic process of data collection

for each period until reaching the interview date.

In this initial report, natural history results are reported for the period

between FCU and treatment entry (TE) for 285 cocaine-dependent males.

In addition, 1 -year followup results are reported for the 98 subjects whose

first-year followup interviews have been completed and data entered.

CHARACTERISTICS OF THE SAMPLE

Data were collected from cocaine-dependent male veterans who applied

for treatment at the West Los Angeles Medical Center between April 1988

and September 1989. All requested treatment voluntarily. Patients with

a history of psychiatric treatment were selected out by the hospital’s triage

system. For the majority of selected subjects (approximately 95 percent),

this was a first experience seeking help from a treatment agency for their

cocaine problem.

The mean age at the time of interview for these male veterans was

36.7 years; 32 percent were 40 years of age or older, and 11 percent

were younger than 30. Sixty-six percent of the subjects were black:

26 percent, white: and 7 percent, Hispanic. The patients as a group had

an educational background higher than the level observed in the general

male population of veterans: 44 percent had postsecondary schooling,

42 percent had completed high school, and only 14 percent reported less

than a 12th grade education. Because of disruptive circumstances

associated with treatment application, a high proportion of subjects were

unemployed at the time of the intake interview (43 percent), and 13 percent

219
reported being homeless. Sixty-seven percent had been married at least

once, and 65 percent had fathered children. Eighty-six percent reported being

arrested at least once in their lives. The mean age of first arrest was 20 years,

but most first arrests (41 percent) occurred before age 18.

Drug use history was extensive for this group: 98 percent had used

marijuana or hashish (82 percent regularly); 69 percent, amphetamines

(32 percent regularly): 67 percent, hallucinogenics (21 percent regularly);

65 percent, phencyclidine (PCP) (17 percent regularly): 58 percent, downers

(21 percent regularly); 53 percent, crystal methamphetamine (18 percent

regularly); 40 percent, heroin (16 percent regularly): 36 percent, tranquilizers

8 percent regularly): and 26 percent, glue (7 percent regularly). Mean age

of first drug use was younger than 18 for marijuana and glue; between

18 and 20 for hallucinogenics, amphetamines, and downers; and between

21 and 25 for crystal methamphetamine, heroin, tranquilizers, and PCP.

A high lifetime rate of criminal behaviors was reported, including early

deviant behaviors (e.g., 58 percent had been expelled from school).

The proportion of subjects reporting stealing and/or shoplifting was high

(66 percent), and involvement with the illegal economy (buying or fencing

stolen goods) was high as well (48 percent). There was a small increase

in the proportion of subjects involved with stolen goods after initiating

cocaine use. Involvement with force and weapons was common

(49 percent), whereas involvement with threatened violence against

persons was less frequent (29 percent). Most of those activities

occurred before the individuals had used cocaine.

A high degree of involvement in the drug subculture was also reported:

65 percent of the sample had sold illicit drugs, and 47 percent carried

drugs for others. Although these activities often occurred before the

use of cocaine, there was an increase in these activities after the use

of cocaine (of those who sold or carried drugs, 46 and 41 percent,

respectively, did so only after using cocaine).

HISTORY OF COCAINE USE

The mean age of FCU was 24. For 76 percent of the sample, FCU was

influenced by a friend or acquaintance; for 8 percent, by a parent or other

relative (excluding siblings); for 4 percent, by a girlfriend or wife: for 4 percent,

by a sibling: and for 8 percent, by either a dealer or prostitute or other. In

40 percent of the cases, the person influencing the subject’s first cocaine

use was cocaine dependent. The reasons reported for FCU were curiosity,

36 percent: social reasons (at parties, for fun and celebration), 34 percent:

psychological reasons (depression, loneliness anxiety), 15 percent: wanting

to get high, 7 percent; reasons related to sex (sexual partner using, to have

220
better sex, and to get sexual partners), 3 percent; and easy availability of

street cocaine, 6 percent. The route of first administration utilized was

intranasal (IN) for 77 percent, smoking crack for 11 percent, intravenous

(IV) for 4 percent, freebasing for 3 percent, and other for 5 percent (“primo,”

smoking cocaine combined with marijuana; “rails,” smoking cocaine with

tobacco; or oral). In 84 percent of the cases, the cocaine consumed was

given to the subjects, and 15 percent of the sample bought it themselves.

PRETREATMENT NATURAL HISTORY

Table 1 summarizes the pretreatment history of all 285 subjects and

postdischarge results for 98 subjects. This data overview is presented

as column 1, for the 1 year before FCU (baseline behaviors): column 2,

the full period from FCU to TE; column 3, from first severe use (FSU) to

the halfway mark (midpoint) before TE; and column 4, from midpoint to

TE. Column 5 summarizes behavior for the full followup year after

treatment discharge (TD); column 6 shows the 3-month period before

followup interview: column 7, the initial month after TD; and column 8,

the initial 3-month period after TD.

The average total time in the pretreatment career, from FCU to TE,

was 11.5 years (standard deviation [SD]=5.9 years). As table 1 shows,

at some point during their pretreatment career, 278 subjects (98 percent)

used cocaine at a severe level, and the mean percent nonincarcerated

time using at this level was 45 percent. A high proportion of the subjects

(86 percent) were abstinent at some point in this period, and the mean

percent time abstinent was 32 percent, whereas some subjects were

never abstinent from FCU to TE. In other words, on the average, in the

11.5 years of the cocaine addiction career prior to treatment, subjects

used cocaine, in the aggregate, at a severe level for approximately

4.5 years, at a mild level for a year and 8 months, and at a moderate

level for more than 7 months and were abstinent for almost 5 years.

The average length of the period from FSU to TE was 83 months, and

the average longest continuous period of severe use was 37 months.

In table 1, this period has been subdivided (columns 3 and 4) into one

period from FSU to the midway point before treatment and another

period from midway to TE. As opposed to the full pretreatment period

(FCU to TE), during the overall period from FSU to TE, the mean percent

time using at a severe level across the full FSU to TE period increased to

70 percent, whereas the mean percent time of abstinence decreased to

18 percent.

221
TABLE 1. Overview of pretreatment histoty and postdischarge results
For the overall pretreatment career (FCU to TE), most of the subjects

used more than one route of administration, the most popular being

IN (74 percent) and smoking crack (72 percent). Freebasing was less

prevalent (38 percent), and IV use (16 percent) was less common.

During the FSU to TE period, there was a shift in mode of administration

from IN to crack. Whereas 42 percent used crack in the 3.5 years after

FSU, 70 percent did so during the 3.5 (nonoverlapping) years before TE

(midpoint to TE period). The mean percent time uslng crack increased

as well, from 30 to 44 percent. Other routes of administration remained

stable, with the exception of IN and primo, which decreased to one-half

the earlier levels.

From FCU to TE, alcohol was heavily used: 76 percent of the sample

drank alcohol excessively (at least 4 ounces per day) for 51 mean

percent time during their pretreatment career. Marijuana was used for

a mean percent time of 25 percent at a daily level and 28 percent at a lessthan-daily level. Narcotics and amphetamines were used by about onefourth of the sample but at a lower mean percent time than marijuana or

alcohol (4 percent for narcotics and 5 percent for amphetamines). The

mean percent time using marijuana both daily and less than daily, drinking

alcohol excessively, and using narcotics and amphetamines progressively

decreased during the period from FSU to TE, particularly during the

3.5 years before TE (midpoint to TE, column 4).

Although 61 percent reported dealing drugs at some point during FCU to

TE, the mean percent time doing so was low (19 percent). The proportion

of the sample reporting dealing decreased to 44 percent during the 3.5

years before TE (midpoint to TE, column 4), but the mean percent time

dealing remained stable at 19 percent, suggesting that those dealing were

doing so for longer periods. Income-generating illegal activities (property

crimes) were reported by 35 percent from FCU to TE, but at a relatively low

mean percent time of involvement (5 percent). For the full period, almost

twice as many subjects (61 percent) reported dealing than those reporting

property crime activities.

The proportion of subjects employed was high (99 percent) at 79 mean

percent time during the entire pretreatment career and decreased only

slightly in the period before TE (midpoint to TE, column 4) to 94 percent

of the sample at 75 mean percent time as subjects engaged in more

severe cocaine use in the 3.5 years before TE. However, although not

shown in table 1, the period just prior to TE was one of disruption, and

43 percent were unemployed at admission, Eighty-two percent had been

involved in marriage and/or common law relationships during FCU to TE

at 43 mean percent time. As subjects approached TE, the proportion of

223
those so involved decreased to 64 percent, but the mean percent time

involved did not change significantly.

Overall, this sample represented a highly functional population, able to

maintain employment and relationships durlng most of their pretreatment

cocaine-using career.

POSTTREATMENT PERIOD

Although followup data are still being processed, columns 4 and 5 in

table 1 enable a comparison of behavioral patterns, using 98 completed

followup interviews, during the midpoint-to-TE period and during the

12 months after TD period, 1 month after the beginning of the index

treatment. The percentage of the sample using cocaine at a severe

level after treatment decreased to 42 percent. The mean percent time

period of abstinence for cocaine increased from 20 to 60 percent,

whereas the mean percent time of severe use decreased from 87 to

22 percent. Route of administration, which was multiple in the period

before TE, shifted to mainly crack after TE (i.e., most of those who used

cocaine after TD used crack). Marijuana use (both daily and less than

daily) decreased precipitously after treatment, as did amphetamine use,

whereas narcotic use decreased but not so dramatically.

The percentage of the sample drinking alcohol excessively dropped from

60 to 42 percent for the full 1 -year followup period, and the mean percent

time drinking excessively was reduced by half. Deviant behaviors such as

dealing drugs and committing criminal activities were reduced considerably

after treatment, both in the percentage of people involved in such activities

and in the mean percent time.

Working and involvement in relationships also seem reduced after

treatment. However, it should be kept in mind that the midpoint-to-TE

period, used as a comparative baseline, is 3.5 years long. More

specifically, during the month before treatment, 43 percent of the sample

reported being unemployed for that month; by 1 month after treatment

discharge, only 26 percent did not have a job, indicating that marked

improvement in the pretreatment to posttreatment period did occur.

The overall performance of the sample (not shown in table 1) can be

expressed as 26 percent remained abstinent from cocaine use for the

entire 1-year followup period; 4 percent used at a severe level throughout:

and 70 percent relapsed to at least one episode of use.

224
COCAINE USE PATTERNS

The overview presented in table 1 does not reveal different types of use

patterns for sample subgroups. To explore different patterns of use, the

authors divided the sample according to the sequence of the initial pattern

of cocaine use. Figure 1 shows four patterns of progression found for the

pretreatment cocaine career: One pattern began with mild, occasional

use, increasing to moderate, but not out-of-control use, and progressing

to severe use (mild-moderate-severe, group 1); a second pattern was

found as a mild-to-severe progression, without an intervening period of

moderate use (group 2); a third pattern demonstrated a moderate-tosevere progression (group 3); and the last pattern was one of instantly

severe use (group 4). The definitions used for mild, moderate, and

severe levels of cocaine use were based on the frequency and amount

of cocaine used and on the length of the abstinence between cocaine

use episodes. For example, a severe level of use would be daily use

(any amount) for at least a month, weekly binges of at least 3 days for

at least 1 month, or very heavy (at least 10 g of cocaine) biweekly binges

Patterns of Progression N %

(FCU) Mild - - - Moderate - - - - - Severe - - - - - TE (Group 1) 47 17

MA=24 MA=28 MA=30 MA=35

<52 months> <36 months> <54 months>

SD=50 SD=29 SD=50

(FCU)Mild- - - - - - - - - - - - - - - - - Severe- - - - - TE(Group2) 125 44

MA=24 MA=29 MA=35

<64 months> <78 months>

SD=53 SD=59

(FCU) Moderate - Severe - - - - - TE (Group 3) 28 10

MA=26 MA=29 MA=35

<39 months> <70 months>

SD=45 SD=58

------------------- (FCU) Severe----- TE(Group4) 84 30

MA=27 MA=36

<111 months>

SD=81

KEY: MA=mean age; SD=standard deviation

FIGURE 1. Initial sequencing patterns

225
(also known as the paycheck “blow-off”). The most prevalent pattern

(44 percent of the sample) consisted of starting cocaine use at a mild

level and subsequently escalating abruptly to a severe use level.

Overall, the mean time from FCU to TE was 141 months for groups

1 (mild-moderate-severe) and 2 (mild-severe) and 109 and 111 for groups

3 (moderate-severe) and 4 (instantly severe), respectively. For subjects

who started using cocaine at a mild level, the average overall time to

TE was 2 years longer than for those subjects who started at a higher

(moderate or severe) level. As flgure 1 shows, the shortest average

length of time at any one stage corresponded to the group 1 progression

from a moderate-to-severe level, and the longest was the group 4

progression from FSU to TE. The results indicate that the majority

of subjects were generally able to maintain mild use for a considerable

length of time, but once they reached a moderate level of use, escalation

to severe use occurred comparatively rapidly.

Table 2 shows levels of cocaine use, routes of administration, other drug

use, and different behaviors for the progressive stages represented by the

four different groups. Although the initial sequencing patterns of cocaine

use were markedly different for the four groups, the progression-related

shifts in cocaine use, other drug use, and the behavioral domains did not

differ significantly. All groups were similar in terms of the types of shifts

and distribution of levels among the cocaine routes of administration.

That is, all showed increasing cocaine involvement over time in smoking

routes and less involvement in other drug use. The differences among

groups typically occurred in the baseline levels of drug use and behavior.

In terms of the demographic characteristics, the four groups were very

similar. Statistical differences were not found with the exceptions of the

number of arrests and convictions (groups 3 and 4 included a higher

proportion of subjects who had been arrested more than five times).

When the four groups are compared in terms of their characteristics during

the year prior to FCU, some differences emerge. Group 1 is characterized

by the highest level of less-than-daily marijuana use, the lowest level of

excessive alcohol drinking and narcotic use, the highest level of criminal

activity, and the lowest involvement in relationships. Group 2 is characterized

by the highest level of daily marijuana and amphetamine use, the lowest

level of criminal activities, and the highest level of working. Group 3 is

characterized by a high level of less-than-daily marijuana use (similar to

group 1), the highest level of narcotic use, a high level of amphetamine

use (similar to group 2), and the lowest level of dealing and working. Group

4 is characterized by the lowest level of marijuana and amphetamine use

and the highest level of dealing, working, and involvement in relationships.

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TABLE 2 Pretreatment history postdischarge results by groups according to the initial sequencing patterns

of cocaine use
TABEL 2. (continued)
Patterns in behavior after FCU showed few major differences (see table

2). Groups 2, 3, and 4, constituting 83 percent of the sample, began their

cocaine careers with generally higher use levels of alcohol, amphetamine,

and narcotics than did group 1. (Only the “instantly severe” group 4 had

lower levels of marijuana use.) As they progressed in their cocaine

involvement, subjects in group 1 used fewer narcotics and amphetamines

than subjects in other groups: they also used slightly less alcohol and

marijuana. Furthermore, group 1 subjects were less involved in antisocial

behaviors such as criminal activities and dealing and were more involved

in socially desirable activities such as working. Although fewer group 1

subjects had a marriage/common law relationship, those who did

were involved for longer periods.

After their FCU, group 2 subjects were characterized by a slightly higher

level of freebasing, a low level of narcotic use, and a slightly lower level

of excessive alcohol drinking. Group 3 subjects used cocaine severely

and for longer periods, and fewer used mildly or were ever abstinent. For

this group, the preferred cocaine form was crack and fewer used marijuana

and alcohol.

Subjects in group 4 were characterized by a higher level of abstinence

and lower levels of moderate use. This group was distinctive in that the

IN and IV routes of administration were more prevalent than in any other

group and the proportions of crack and freebase users were lower. More

subjects in this group used narcotics and amphetamines than those in the

other groups.

In summary, these results show that the pretreatment cocaine career

lasted an average of 11.5 years and subjects were able to maintain a

severe level of cocaine use for an average of 8.5 years. Four different

sequences of escalation to severe cocaine use were described. As

subjects approached TE, the mean percent time of severe use increased,

and a shift occurred to crack use from other routes of administration.

Despite this progression, antisocial behaviors (dealing and property

crime) did not increase, socially desirable activities (working and

relationships) did not decrease significantly (except in the period of

the month immediately prior to treatment entry), and excessive alcohol

and other drug use decreased. Generally, subjects’ pretreatment

functional levels were high.

The 1-year followup (post-TD) data for these four groups are based on

numbers of 13, 35, 37, and 13, respectively. Because of the low numbers

in groups 1 and 4, the following results should be interpreted cautiously.

The proportions of subjects using at a severe level at some point during

the followup year were 31, 43, 46, and 39 percent for the four groups,

229
respectively. The percentages of subjects who were abstinent for some

period were 100, 89, 97, and 100 percent for the four groups, respectively.

In all groups, the predominant route of administration after treatment was

crack (mean percent time from 31 to 36 percent); the daily use of marijuana

decreased dramatically after treatment (mean percent time from 0 to

3 percent); however, marijuana use less than daily was still prevalent (from

7 to 14 mean percent time). The excessive use of alcohol decreased after

TE for the four groups (from 14 to 29 mean percent time) as did amphetamine

use (from 0 to 1 mean percent time). Narcotic use decreased for groups 3

and 4 (to 0 and 3 mean percent time, respectively) but increased for groups 1

and 2 (to 3 and 4 mean percent time for 8 and 11 percent of subjects,

respectively) after treatment compared with the level of narcotic use before

TE. Both the proportion of subjects dealing and the time they spent doing so

decreased after TE for the four groups (from 0 to 2 mean percent time for

groups 1, 2, and 3 and to 12 mean percent time for group 4).

Crime also was reduced for the four groups (to 1 or less mean percent

time for groups 1, 3, and 4 and 5 mean percent time for group 2). Working

and involvement in relationships increased across the four groups after TE

(87 to 100 percent of the subjects reported working after TE and 26 to

52 percent reported relationships).

Overall, results show that 1 month after TE the use of cocaine and other

drugs decreased considerably (with the exception of narcotics), deviant

behaviors decreased, and socially desirable behaviors (e.g., working)

increased to an adequate level of functioning.

GROUPS ACCORDING TO LENGTH OF COCAINE CAREER

Further analyses were made grouping the sample according to the

pretreatment length of the cocaine career (LCC): 18 percent of the

sample had used cocaine for 5 years or less before TE, 29 percent for

more than 5 years to 10 years, 27 percent for more than 10 years to

15 years, and 26 percent for more than 15 years.

In terms of the demographic characteristics of these four LCC groups,

statistically significant differences were found for three variables:

Age: Group 1 included higher proportions of the youngest subjects

and subjects older than 50 years, whereas group 4 included higher

proportions of subjects between 40 and 49 years of age.

Race: Group 1 included higher proportions of blacks, and group

3 included higher proportions of whites.

230
Education: Group 4 included the highest proportion of subjects with

more than 12 years of education.

Data on the pretreatment career (table 3) show that a greater proportion of

the two longer term LCC groups used cocaine at a severe level during the

midpoint-to-TE period. They were also much more likely to use cocaine

intravenously than the less-than-lo-year LCC groups. The long-term groups

had higher levels of marijuana use, amphetamine use, excessive alcohol

drinking, narcotic use, dealing, and being involved in a relationship. The

four LCC groups were similar in terms of property crime and working.

Results for the 1 -year followup period (1 year post-TD, table 3) showed that

the degree of improvement was relatively equivalent across LCC groups:

Their levels of drug use and of deviant and socially desirable behaviors were

different at pretreatment, and the levels after treatment were proportional to

what they were at pretreatment.

Severe cocaine use decreased for all the groups (more for group 4). The

route of administration was predominantly crack, although groups 2, 3, and

4 still had some IV use at followup. Daily marijuana use decreased for all

groups, less-than-daily marijuana use did not decrease significantly for group

1, and the largest decrease occurred for group 4. Narcotic use decreased for

group 1 but increased for groups 2, 3, and 4. Amphetamine use decreased

for all groups, and dealing decreased for all groups, especially for group 4.

GROUPS ACCORDING TO AGE AT FIRST COCAINE USE

The sample was also divided according to age at FCU. Group 1 included

subjects 20 years of age or younger (34 percent); group 2, subjects 21

to 28 years old (42 percent); and group 3, subjects 29 years old and older

(24 percent). No significant differences were found for demographic

characteristics among the three groups.

Data on the pretreatment cocaine career (table 4) show that the groups

ranked from group 3 to group 1, from higher to lower, in terms of the mean

percent time using cocaine at a severe level during the midpoint-to-TE period,

in terms of the mean percent time subjects used crack as the main route of

administration, and in terms of the mean percent time subjects were involved

in a relationship. On the other hand, the groups ranked from group 1 to group

3, from higher to lower, in terms of using cocaine intranasally, marijuana use,

amphetamine use, excessive alcohol drinking, dealing, crime, and work.

231
TABLE 3. Pretreatment and followup periods for groups according to LCC
TABLE 4. Pretreatment and followup periods for groups according to age at FCU
Results for the posttreatment period (table 4) showed that the rate of

improvement was equivalent across groups: Their levels of drug use

and of deviant and socially desirable behaviors were proportional to

what they were at pretreatment.

In the posttreatment period, severe cocaine use decreased for all groups,

and the route of administration was predominantly crack. Daily marijuana

use decreased for all, with substantial decreases in the proportions of

subjects involved in less-than-daily use occurring in groups 1 and 2,

but not for group 3. Narcotic use decreased for group 3 but stayed at

the same level for groups 1 and 2. Amphetamine use decreased for all

groups, and dealing decreased, especially for group 3. Working was

relatively stable for groups 1 and 2 but decreased somewhat for group 3.

CONCLUSIONS

The cocaine career of the subjects investigated from onset of use to

treatment entry averaged 11.5 years. Severe use of cocaine was

maintained for an average of 6.5 years. Four different sequences of

escalation to severe cocaine use were identified.

Cocaine use at severe level increased and became more prolonged in

the period just prior to entry into treatment, and a shift to more efficient

methods of drug delivery, such as crack smoking, increased. Surprisingly,

in spite of this progression in cocaine use, antisocial behavior (dealing and

property crimes) increased only marginally, and constructive social activities

(work and close interpersonal relationships) did not decrease significantly

until just before TE. Excessive alcohol and other drug use declined as the

dependence on cocaine progressed. Overall, treatment could be considered

effective in that the use of cocaine at a severe level decreased and both the

proportion of abstinent subjects and the mean percent time of abstinence

increased; other drug use decreased after treatment, and dealing and

criminal behaviors decreased as well.

Most relapses, 51 percent, occurred within the first month after TD. In the

3 months just prior to the followup interview, 16 percent were using cocaine

daily, 25 percent reported other than daily use, and 61 percent reported no

use.

In general, the pretreatment level of social functioning of the subjects

investigated was high. These patients had a significant potential for

rehabilitation, although they displayed relatively high levels of deviant

behavior during the pre-FCU period, including aggressive behavior.

234
Data derived from our study indicated no prominent variation among the

various groups defined for more specific analysis. Such homogeneity in

progression of use must be considered as we select relevant outcome

variables to investigate. More extensive multivariate analyses must be

performed to determine variables that predict specific outcomes.

NOTE

1. Mean percent time is the number of months involved in a behavior

or in a specified status divided by the number of nonincarcerated

months between the critical dates of interest, times 100 (for

example, for a subject engaging in a specific behavior 5 months

out of a 10-month period, the mean percent time would be 50 percent).

REFERENCES

Anglin, M.D., and McGlothlin, W.H. Outcome of narcotic addict treatment in

California. In: Tims, F.M., and Ludford, J.P., eds. Drug Abuse

Treatment Evaluation: Strategies, Progress, and Prospects. National

Institute on Drug Abuse Research Monograph 51. DHHS Pub. No.

(ADM)86-1326. Washington, DC: Supt. of Docs., U.S. Govt. Print.

Off., 1984. pp. 106-128.

McGlothlin, W.H.; Anglin, M.D.; and Wilson, B.D. A follow-up of admissions to

the California Civil Addict Program. Am J Drug Alcohol Abuse 4:179-

199,1977.

Nurco, D.N.; Bonito, A.J.; Lerner, M.; and Baeler, M.B. Studying addicts over

time: Methodology and preliminary findings. Am J Alcohol Abuse

2:107-121, 1975.

Winick, C.S. Maturing out of narcotic addiction. Bull Narc 14:1-7, 1962.

ACKNOWLEDGMENT

This study is supported by National Institute on Drug Abuse grants DA-04268

and DA-06250.

AUTHORS

M. Elena Khalsa, M.D., Ph.D.

Senior Research Associate

M. Douglas Anglin, Ph.D.

Director

235
Penny Potepan, B.S.

Programmer

Carolyn Potter, M.A.

Data Manager

Drug Abuse Research Group

Neuropsychiatric Institute

University of California, Los Angeles

Suite 763

1100 Glendon Avenue

Los Angeles, CA 90024-3511

Alfonso Paredes, M.D.

Chief

Substance Abuse Rehabilitation

Brentwood Veterans Administration Medical Center

Building 298

11301 Wilshire Boulevard

Los Angeles, CA 90073

236
Combinations of Treatment Modalities

and Therapeutic Outcome for Cocaine

Dependence

M. Elena Khalsa, Alfonso Paredes, M. Douglas Anglin, Penny

Potepan, and Carolyn Potter

INTRODUCTION

Although the theoretical and practical importance of longitudinal “natural

history,” “life cycle,” or “addict career” approaches to the understanding of

the process of drug dependence has been repeatedly emphasized, this

methodology has been applied primarily to the study of alcoholism or heroin

addiction (Anglin et al. 1986, 1987; Anglin and Speckart 1986; Brecht et al.

1987; Hser et al. 1990; Kandel et al. 1985; Simpson et al. 1986; Valliant

1970). Long-term followup studies of dependent cocaine users employing

this approach are lacking. Such studies are important not only to understand

the etiology and clinical course of cocaine dependence but also to understand

the role played by therapeutic interventions in recovery.

The importance of determining effective treatment for cocaine users became

urgently apparent with the dramatic increases in cocaine use, peaking at an

estimated 5 million regular users in 1985 (Abelson and Miller 1985). Although

recent estimates show a decline in cocaine use by the general population

(National Institute on Drug Abuse 1991) high prevalence rates among

groups such as arrestees have persisted (O’Neil 1992). The escalation

in the observed numbers of people seeking cocaine treatment may be

attributable to increased use at severe levels among current users

(Johanson and Fischman 1989).

Evaluation studies of treatment protocols specifically designed for cocaine

users have been undertaken only recently. Intensive outpatient treatment

has been shown to be the most effective treatment for cocaine dependence

in several studies. Evaluated outpatient programs differed in terms of their

elements or treatment components. In one study, the highest success rates

corresponded to subjects who attended group therapy five times per week,

combined with individual psychotherapy and family therapy sessions

(Hoffman et al. 1993). Washton and Stone-Washton (1990) also found

237
intensive outpatient treatment effective for a highly structured program with

behavioral counseling, cocaine-specific education, supervised urine testing,

and encouragement to utilize self-help groups. Rawson and coworkers

(1990) found that outpatient treatment was better than inpatient treatment

or no treatment. The outpatient program studied by Rawson and colleagues

followed the neurobehavloral model of cocaine dependence treatment, which

includes strategies to address four dlfferent areas of functioning by using

relapse prevention techniques, individual and family therapy, 12-step

involvement, and urine testing. In contrast, one study of cocaine treatment

found that once-a-week psychotherapy, family therapy, or group therapy was

ineffective and that there was no association between number of outpatient

treatment sessions and improved outcome (Kang et al. 1991). However,

these cited studies differ in the length of the followup periods and in the

criteria used to define effectiveness. Therefore, results should be

interpreted cautiously because of methodological issues.

Other authors have studied treatment process and outcome more generally,

without an exclusive focus on cocaine dependence. Guydish and colleagues

(1993) found that day treatment for drug users in general, although less

intense than residential or inpatient but more intense than traditional

outpatient treatment, was a more accessible and less expensive form of

drug rehabilitation. Nevertheless, they found traditional outpatient treatment

to have higher attrition rates than residential treatment (Guydish et al. 1993).

Wallace (1990) focused on a multidimensional approach that recognized

biopsychosocial variables underlying the development and maintenance of

drug dependence. She found that an approach combining pharmacological

adjuncts, psychoeducation on the multideterminants of relapse, and

psychotherapy produced the best outcomes,

Based on their individual studies, different authors (Kleinman et al. 1992;

Miller and Pechacek 1987) have recommended various strategies to improve

treatment effectiveness. Kleinman and coworkers (1992) have encouraged

greater focus on therapist and program variables (vs. client characteristics)

as more likely to improve treatment outcome. Miller and Pechacek (1987)

have recommended assessing and addressing psychological dependence

patterns to increase treatment effectiveness.

The purpose of this study is to provide further information about the

effectiveness of different combinations of treatment modalities for cocaine

dependence. The present study on cocaine treatment evaluation (CTE)

examines a sample of cocaine-dependent males admitted to treatment

through the West Los Angeles Department of Veterans Affairs (VA)

Hospital. The authors’ findings are reported in two phases: First, the

behavioral changes seen within the group as a whole are presented;

second, we compare the course followed by patients grouped according

238
to the combinations of treatments in which they participated within the

1-year followup period. This second phase allows us to determine which

combinations of treatment are associated with more favorable outcomes.

METHODS

Subjects

Subjects were veterans who requested treatment for cocaine dependence

at the West Los Angeles VA Hospital. Given that the population served by

this hospital includes only a small proportion of women, all subjects were male.

Sixty-three of the patients in the intake group who were asked to participate in

the study refused. The main reasons given were lack of interest, skepticism

about assurances of confidentiality, unwillingness or apprehension to disclose

past drug use and/or criminal history, and lack of time to devote to the research

interview. All 325 participants met Diagnostic and Statistical Manual of Mental

Disorders (Third Edition, Revised) (DSM-III-R) (American Psychiatric

Association 1987) criteria for cocaine dependence and signed a consent

form approved by the Human Subjects Protection Subcommittee from the

VA medical center.

The majority of the subjects were more educated and older than samples

typically derived from urban cocaine users (Siegel 1985; Washton et al.

1984). However, subjects reported diverse characteristics in many respects:

In addition to cocaine use, most patients reported extensive experimentation

with other substances, including alcohol. Regarding their sociodemographic

profile, 28 percent were single, 30 percent married, 17 percent separated and

24 percent divorced. Eighty-eight percent had completed at least grade 12 in

school. Only 5 percent had completed fewer than 10 years in school, and 22

percent had completed 14 or more years of education. Forty-four percent had

not worked during the 4 weeks before treatment entry; 21 percent had worked

full time, and the remaining 35 percent had worked less than full time. Eightysix percent reported a history of arrest, and 31 percent had been incarcerated

30 days or more. Thirteen percent of the patients were on probation at the time

of the intake interview. A large proportion of these patients reported socially

deviant behavior during adolescent and adult periods. Other characteristics

of the sample have been presented in detail elsewhere (Khalsa et al. 1992).

Research Design

The original research design required random assignment to one of three

treatment options: 21-day inpatient care, immediate outpatient care, or

referral to community self-help groups. However, by the time patients applied

for treatment, most had developed a preference for inpatient care. Fewer

than 30 percent of the patients were willing to accept a random assignment.

239
Excluding patients who rejected the random assignment procedure introduced

a bias that would have made the sample considerably less representative of the

population of patients seeking admission. For instance, patients who were

employed, married, and had less severe symptoms of dependence were more

likely to accept the random assignment. Furthermore, because the number of

patients who rejected this experimental condition was large, only a few would

be available for meaningful statistical analysis. Therefore, a mixed design was

introduced. In addition to the randomly assigned sample (n=75), a group of

patients who voluntarily chose inpatient treatment was added (n=225). Results

by randomly assigned groups will be reported elsewhere.

The VA inpatient treatment program was 21 days in length and included

activities such as individual counseling, group therapy, and drug education.

The VA-based outpatient treatment consisted of one to four initial visits with

a physician, plus individual counseling sessions on an as-needed basis and

weekly group sessions using methods espoused by Alcoholics Anonymous

(AA). Both modalities emphasized the 12-step treatment philosophy. Self-help

consisted of attendance at community-based AA and/or Cocaine Anonymous

meetings. The variables that were investigated included use of cocaine and

other drugs, alcohol use, measures of social performance such as work tenure

and maintenance of interpersonal relationships, and deviancy such as property

crime and drug dealing. Data were collected at the time of admission to the

project and at two followup points, 1 and 2 years after treatment entry. Ninety

percent of the subjects who participated in this research were located and

interviewed at 1-year followup. Two-year followup data are in the process

of being analyzed and will be reported later. The initial VA treatment episode

(index treatment) was followed in most instances (78 percent) by involvement

in other modalities of treatment selected by patients based on their own

personal criteria as well as treatment availability and accessibility. Using

data collected at the 1-year followup, the sample was grouped according to

the combination of treatments in which the patients had participated. Although

the 1-year followup timeframe is a relatively brief period in which to properly

assess therapeutic outcome, the information generated by this study provides

an indication of the changes that may be expected following conventional

treatments.

Patients were grouped as receiving one of the following six combinations

of treatment: (a) only one 21-day episode of inpatient care, (b) multiple

episodes of residential care (admissions to therapeutic communities or

inpatient treatments lasting more than a month), (c) an episode of inpatient

care of at least a 21 -day duration with high-intensity outpatient care and with

participation in self-help meetings (high intensity is defined as participation

in either an outpatient or self-help session at least once a week for at least

6 months), (d) no inpatient care but high-intensity outpatient and/or highintensity self-help participation, (e) one episode of inpatient care and low240
intensity outpatient and/or self-help (participation less than once a week for

less than 6 months), and (f) low-intensity outpatient and/or self-help. Some

subjects in the sample were not included in the six groups because they

belonged to treatment combinations with a number of subjects too small to

be amenable to statistical analysis or for other idiosyncratic reasons. Those

subjects who spent most of the followup year incarcerated or admitted to

psychiatric hospitals for any psychiatric illness (e.g., schizophrenia, major

mood disorder) also were excluded. Therefore, data on these men (n=50)

were excluded from statistical analyses.

Data Collectlon Instrument and Measures

At intake (treatment entry), specially designed interview schedules were

used to collect sociodemographic data, developmental history, and assessment

of social function and history of treatment. The Natural History Interview was

the main source of detailed information, obtained in chronological order,

concerning the cocaine use career. This assessment instrument is an

adaptation of a schedule developed by Nurco and colleagues (1975) and has

been described in detail elsewhere (Anglin and McGlothlin 1984). Briefly, with

the assistance of the patient, a schematic time chart is prepared before the

interview showing all known important events In the patient’s life, such as

treatment episodes, arrests, and periods of incarceration and legal supervision.

These events are used as time-anchoring points to facilitate review of

significant aspects of the patient’s drug and social history. In addition, the

interviewer establishes the date of the first cocaine use, recording it on the time

chart, and proceeds chronologically from 12 months before the first use to the

time of the interview. Data are collected on the use of cocaine, alcohol, and

other drugs; health status; drug treatment experience; employment: family

adjustment; criminal behavior; and other social adjustment variables for the

initial period. Subsequent periods are demarcated by changes in levels of

cocaine use and significant life events such as a change in the respondent’s

drug treatment or legal status. The interviewer proceeds to review each

successive homogeneous period, repeating the systematic process of data

collection on each time segment until the interview date is reached. The

collected data can be plotted in time series graphs covering the periods of

interest such as the development and course of dependence and posttreatment

followup. The first-year followup interview consisted of an update of the

Natural History Interview and completion of a treatment evaluation form. At this

point, a urine specimen was collected to analyze for cocaine metabolites and

assess the validity of recent self-reported drug use.

241
RESULTS

The first phase of our analyses examined overall response to treatment for

the entire sample.

Total Sample Response to Treatment

The longer term pretreatment history describing the development and

course of the dependence career is reported elsewhere (Khalsa et al., in

press). Results reported here focus on the cocaine use behavior of the

total sample in the 12 months before entry to the index treatment episode

compared with behavior reported during the 12-month followup period. The

mean percent time in each month of cocaine use provides an indicator of

cocaine consumption. According to this measure, severe use throughout a

month would be rated 100 percent involvement at this level of use. Fewer

days of severe use during the month were computed proportionally; for

example, if cocaine was used 15 days during the month, the mean percent

time using at a severe level was 50 percent.

Figure 1 shows the monthly mean percent time for severe cocaine use in

any form, and for no cocaine use, for the 12-month periods before and after

treatment. By the time of treatment entry, intranasal use of cocaine was not

common in this group, and the level of use by this route remained low after

treatment (mean use level for the full 12-month periods was approximately

10 percent before and 5 percent after treatment). Before treatment entry,

approximately 45 to 65 percent of each month for the full 12-month period

was spent by the group smoking crack, whereas at followup, only 22 to 37

percent mean time was spent in this activity. Analysis of variance (ANOVA)

revealed a statistically significant change (P 0.05). Regarding severe use

of cocaine, an overall 65 to 75 percent mean time level was reported in the

period before treatment and 17 to 22 percent during the followup periods,

whereas the mean percent time not using cocaine increased from 5 to

20 percent before treatment to 58 to 69 percent during followup.

ANOVA also showed statistically significant changes observed in the use of

other drugs (P 0.05). The mean percent time using marijuana and excessive

alcohol declined, as figure 2 illustrates, with a statistically significant decrease

after treatment. Changes in narcotics and amphetamine use, although less

striking and not statistically significant, were also observed.

As figure 3 shows, social behavior in most cases changed relatively little

along the dimensions assessed in the study. Comparing before and after

treatment, the mean percent time spent working, engaged in stable

relationships, and in criminal activities did not change significantly. On

the other hand, ANOVA revealed a significant change in the percent of

242
KEY: TE=treatment entry

FIGURE 1. CTE total sample: months before and after index treatment—cocaine
KEY: TE=treatment entry

FIGURE 2. CTE total sample: months before and after index treatment—alcohol and other drugs
KEY:TE=treamententry

FIGURE 3. CTE total sample: months before and after index treatment—-social behavior
time involved in drug dealing, which decreased from 18 to 22 percent of

the time before treatment to 6 percent or less after treatment (p 0.05).

Effects of Treatment Combination

For the second phase of analysis, patients were categorized according to the

combination of treatments in which they participated within the followup year.

As indicated earlier, six different treatment combinations were identified. The

sociodemographic characteristics of the patients included in each of these

categories are presented in table 1. No statistically significant demographic

differences among the groups were detected.

The treatment combinations selected by the largest number of patients

(n=79) are shown in column C (one episode of inpatient followed by highintensity outpatient care and/or self-help) and column E (inpatient and lowintensity outpatient and/or self-help) (n=71). Combination (column) A (one

episode of inpatient care) was chosen by 61 patients, and (column) B

(multiple residential care programs) was chosen by 41 patients. The least

preferred combinations are shown in columns F (low-intensity outpatient and/

or self-help) and D (high-intensity outpatient and/or self-help), with 15 and

8 patients, respectively.

Table 2 presents data as levels of use of cocaine, alcohol, and other

drugs; involvement in antisocial behaviors such as drug dealing and criminal

activities; and constructive behaviors such as involvement in work and

interpersonal relationships before treatment (B column) and after treatment

(A column). These variables are expressed in terms of the mean percent

time engaged in each behavior. Column D expresses the difference between

A and B, indicating an increase (positive values) or decrease (negative

values) for each variable.

Following treatment, the mean percent time spent by patients abstinent from

cocaine increased in all groups, but this increase was significantly greater

in groups C (inpatient and high-intensity outpatient and/or self-help) and D

(high-intensity outpatient and/or self-help) than in any of the other groups.

Multiple analysis of variance showed a statistically significant difference

(p 0.05) for these two groups. The proportion of time reporting severe

use was also significantly reduced in group C. The proportion of time

spent smoking crack decreased in all groups regardless of the treatment

combination selected. Comparisons between the different treatment

combinations did not show statistically significant differences in terms

of this variable. Decreases, but without statistically significant differences

between treatment combinations, were also observed with regard to daily

use of marijuana. Use of narcotics, marijuana (less than daily), and

amphetamines decreased for some groups, remained stable for others,

246
TABLE 1. CTE sample by treatment combinations (n=275) and demographic characteristics (Percent*)

A B C D E

One IP

Multiple

Residential IP and OP/SH OP/SH IP and OP/SH

Admission Treatment

Characteristic (n=61)

High Intensity High Intensity Low Intensity

(n=41) (n=79) (n=8) (n=71)

F

OP/SH

Low Intensity

(n=15)

Age at interview (year)

21-29 17 17 18 14

53

29

59

13

30-39 42 63 58 64

40 30 29 25 25 24 21

Race†

Black 67 78 65 63 66 71

Hispanic 7 3 8 0 9 7

Anglo 27 20 25 38 24 21

Maritalstatus

Single 35 33 31 25 21 21

Married/common law 27 20 26 38 35 50

Separated 17 17 13 7

Divorced/widowed 21

23

25 26 25

16

28 21

Occupation

Unskilled 7

Semiskilled 40 33 36 38 51 64

Skilled

12 3

25 40

4 13 3

35 38 28 21

Sales/service/second level 25 26 25 13 18 7

executive/other

Never incarcerated 72 74 74 75 69 79

*Figures may not add to 100 percent because of rounding.

†Other races were 2 percent for group C and 1 percent for group E.

KEY: IP=inpatient; OP/SH=outpatient and/or self-help
TABLE 1. (continued)

Characteristic

A B C D E F

Mutiple

One IP Residential IP and OP/SH OP/SH IP and OP/SH OP/SH

Admission Treatment High Intensity High Intensity Low Intensity Low intensity

(n=81) (n=41) (n=79) (n=8) (n=71) (n=15)

Number of incarcerations

0

1

2-4

5

Number of convictions

0

1

2 4

5

38 38 32 75 30 38

22 31 22 0 25 14

27 13 30 25 28 29

15 25 18 0 17 21

Years of education

<12

12

>12

18

43

38

Homeless at admission 17

20 10 20 13 20 7

17 31 24 13 30 21

38 38 31 83 24 43

25 23 28 13 27 28

3

45

53

20

13

38

49

12

0

38

83

0

14

47

39

7

7

43

50

14

 *Figuree may not add to 100 percent because of rounding.

KEY: IP=inpatient; OP/SH=outpatient and/or setf-help
TABLE 2. CTE sample by treatment groups: difference between 12 months before and after treatment entry

(mean percent time*)
and increased slightly for others. Drug dealing and criminal activities

changed in a favorable direction for all treatment combinations, with group C

showing greater overall benefit than the others. Changes In work stability and

relationship patterns across the two periods were minor for most of the groups,

with two exceptions. The multiple residential patients (B) were less likely to

maintain involvement in both those activities, primarily because their choice of

treatment modality precluded such involvement. The high-intensity outpatient

and/or self-help group (D), although representing only a few patients, showed a

marked increase in relationship involvement. This result also can be attributed

to life circumstances that motivated their choice of treatment environment.

Comparisons of selected treatment combinations (those with a large enough

size) along individual variables clearly support the more favorable outcomes

for the C group. For example, figure 4 shows that the mean percent time using

cocaine at a severe level before treatment was similar for the four selected

groups.

After admission to the index treatment, severe use was lower in the C group

(inpatient and high-intensity outpatient and/or self-help) than in the inpatient

only, multiple residential treatment, or inpatient and low-intensity outpatient

and/or self-help groups (A, B, and E). Figure 5 compares the mean percent

time of cocaine abstinence between treatment combinations A, B, C,

and E. The performance of group C is the best following initial treatment.

However, combination B also improves through time, reaching the same

level as group C by the end of the first year after treatment.

In terms of excessive alcohol drinking, all four groups decreased similarly after

treatment (figure 6). Similar findings were observed regarding other drug use

and involvement in criminal activities and drug dealing. Although differences

were not significant, group C consistently showed more favorable changes.

Table 3 presents before- and after-treatment outcome data on the variables

just discussed, measured in terms of the percentage of patients from each

treatment combination group rather than mean percent time. The most striking

changes are again apparent in group C. For example, the proportion of

patients using cocaine severely decreased from 89 to 18 (net change -71).

The changes observed in the other treatment groups were less dramatic,

although all followed the same trend toward improvement.

Use of marijuana and alcohol reflected minor changes compared with

other variables (behaviors). The proportion of patients involved in criminal

activities and drug dealing also decreased in group C in comparison with

the other treatment groups, but there were only minor differences among

groups regarding work tenure and involvement in interpersonal relationships.

None of these differences were statistically significant.

250
KEY: TE=treatment entry; IP=inpatent; OP/SH=outpatient and/or self-help

NOTE: The letters A, B, C, and E within the box relate to column headings in table 2.

FIGURE 4. Severe cocaine use
KEY: TE=treatmententry; IP=inpatient; OP/SH=outpatient and/or self-help

NOTE: The letters A, B, C, and within the box relate to column headings in table 2.

FIGURE 5. No cocaine use
KEY: TE=treatment entry; IP=inpatient; OP/SH=outpatient and/or self-help

NOTE: The letters A, B, C, and E within the box relate to column headings in table 2.

FIGURE 6. Excessive alcohol use
TABLE 3. CTE sample by treatment groups: 12 months before and after treatment entry (percent people*)
SUMMARY AND DISCUSSION

This study investigated the clinical course of a cohort of patients who

requested treatment for cocaine dependence at the West Los Angeles

VA Hospital. Their behaviors were carefully assessed in two broad fields:

use of cocaine and other substances and social performance and deviance.

A significant decrease in intranasal cocaine use for the sample as a whole

was not apparent 1 year after entering index treatment. However, it should

be noted that although 68 percent reported lntranasal use as the preferred

route of administration at the time of initiation to cocaine, by 12 years later

(the average period from initiation to treatment entry), most patients had

shifted to crack smoking. At the time of entry into index treatment, only

32 percent were using by the intranasal route.

Crack use, the most common form of use during the year before entry into

treatment, decreased for the sample as a whole after treatment entry to

followup. Severe use of cocaine by any route also decreased substantially.

Use of other drugs also declined, although not uniformly: Marijuana and

excessive alcohol use decreased significantly, whereas the relatively low

rates of use of narcotics and amphetamines changed little.

Work activities, engagement in stable relationships, and criminal activities

did not show differences when comparing the year prior to treatment with the

year after treatment Only one specifically drug-related behavior, dealing,

did improve, and this change was statistically significant.

Most patients participated in other treatment modalities in addition to

the index treatment within the period of followup. The demographic

characteristics of the patients did not seem to influence the selection

process, as suggested by the fact that there were no statistically significant

differences in sociodemographic profile, regardless of the combination of

treatment selected.

When these patients were grouped according to the treatment experiences

reported within the followup year, interesting differences emerged. The

combination of inpatient and outpatient with self-help groups was the

most commonly selected and the one associated with more improvement.

Therefore, clinical outcome appeared to be more related to the treatment

combination chosen than to patient characteristics. Patients who selected

inpatient care followed by intense involvement in outpatient care with selfhelp groups reported the longest periods of abstinence from cocaine and the

lowest levels of cocaine use. This group was also significantly less involved

in criminal activities and drug dealing. On the other hand, this group, with

seemingly more favorable outcomes, did not show larger changes than other

255
groups in use of other drugs or alcohol, work stability, or maintenance of stable

interpersonal relationships. In these respects, patients who participated in

multiple residential programs did not display better outcomes for these

behaviors. Their drug use decreased substantially over time, but most

dimensions of social behavior showed less striking changes.

Overall, the results indicate a favorable response to the initiation of any

treatment process, with more favorable outcomes for patients able to be

engaged in frequent, longer term treatment participation. Further research

needs to be done on the issue of treatment self-selection and intensity of

self-selected treatment as influenced by motivational factors and other

variables as they may be related to the emotional state of the individuals.

Further research also needs to study the initial aspects or components of

the treatment experience that prompted continued treatment involvement,

either through increased retention or through a return to treatment if relapse

occurred.

ACKNOWLEDGMENT

This work was supported by grants DA-04268, DA-07699, and DA-00146 from

the National Institute on Drug Abuse.

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household population. In: Kozel, N.J., and Adams, E.H., eds. Cocaine Use in

America: Epidemiologic and Clinical Perspectives. National Institute on Drug

Abuse Research Monograph 61. DHHS Pub. No. (ADM)87-1414.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1985. pp. 35-49.

American Psychiatric Association, Diagnostic and Statistical Manual of Mental

Disorders (Third Edition, Revised). Washington, DC: American Psychiatric

Press, 1987.

Anglin, M.D.; Brecht, M.L.; Woodward, J.A.; and Bonett, D.G. An empirical

study of maturing out: Conditional factors. Int J Addict 21:233-246, 1986.

Anglin, M.D.; Hser, Y.; and Booth, M.W. Sex differences in addict careers. 4.

Treatment. Am J Drug Alcohol Abuse 13:253-280, 1987.

Anglin, M.D., and McGlothlin, W.H. Outcome of narcotic addict treatment in

California. In: Tims, F.M., and Ludford, J.P., eds. Drug Abuse Treatment

Evaluation: Strategies, Progress, and Prospects. National Institute on Drug

Abuse Research Monograph 51. DHHS Pub. No. (ADM)86-1329.

Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1984. pp, 106-128.

Anglin, M.D., and Speckart, G.R. Narcotics use, property crime, and dealing:

Structural dynamics across the addiction career. J Quant Crim 2(4):355-375,

1986.

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Brecht, M.L.; Anglin, M.D.; Woodward, J.A.; and Bonett, D.G. Conditional

factors of maturing out: Personal resources and preaddiction sociopathy.

Int J Addict 22(1):55-69, 1987,

Guydish, J.; Nemoto, T.; Chan, M.; Acampora, A.; and Werdegar, D.

Evaluation of drug abuse day treatment: Descriptive data. In: Harris L., ed.

Problems of Drug Dependence, 1992: Proceedings of the 54th Annual

Scientific Meeting, The College on Problems of Drug Dependence, Inc.

National Institute on Drug Abuse Research Monograph 132. NIH

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Hoffman, J.A.; Caudill, B.D.; and Koman, J.J. Ill. Craving for cocaine and

retention of crack addicts in cocaine abuse treatment. In: Harris, L., ed.

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Hser, Y.; Chou, C.-P.; and Anglin, M.D. The criminality of female narcotics

addicts: A causal modeling approach. J Quant Criminal 6(2):207-228, 1990.

Johanson, C.E., and Fischman, M.W. The pharmacology of cocaine related to

its abuse. Pharmacol Rev 41(1):3-52, 1989.

Kandel, D.B.; Murphy, D.; and Karus, D. Cocaine use in young adulthood:

Patterns of use and psychosocial correlates. In: Kozel, N.J., and Adams,

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Kang, S-Y.; Kleinman, P.H.; Woody, G.E.; Millman, R.B.; Todd, T.C.; Kemp,

J.; and Lipton, D.C. Outcomes for cocaine abusers after once-a-week

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Khalsa, H.; Paredes, A.; and Anglin, M.D. The role of alcohol in cocaine

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AUTHORS

M. Elena Khalsa, M.D., Ph.D.

Principal Investigator

M. Douglas Anglin, Ph.D.

Director

Penny Potepan, MS.

Programmer

Carolyn Potter, M.A.

Coder

Drug Abuse Research Center

Neuropsychiatric Institute

258
University of California, Los Angeles

Suite 763

1100 Glendon Avenue

Los Angeles, CA 90024

Alfonso Paredes, M.D.

Medical Coordinator

Residential Treatment Center

West Los Angeles VA Medical Center

11301 Wilshire Boulevard

Los Angeles, CA 90073

259
Treatment of Cocaine Abuse and

Dependence: Directions and

Recommendations

Carl G. Leukefeld and Frank M. Tims

INTRODUCTION

Although some degree of progress in understanding pharmacological

and psychosocial treatments that are generally effective has been made,

much more work remains to be done. Recommendations reported in this

monograph focus on understanding the client populations involved, existing

treatments and treatments under development, and research requirements.

Clearly, the number of problems addressed in a conference such as this

is limited and cannot address the complexity of integrating work at many

different levels. Nonetheless, an attempt was made to cover a broad range

of material. The recommendations are presented under several headings,

including consensus statements on research and practice needs.

RESEARCH ON CLIENT POPULATIONS

Research should address clients diagnosed as cocaine dependent,

using cocaine either alone or in combination with other drugs (including

alcohol). The foci of such studies should include social and demographic

characteristics, psychopathology, natural history, and treatment-seeking

behavior.

Studies should seek to increase understanding of client need and

availability for treatment as well as diagnostic subtypes that may indicate

differential response to available treatment.

The diversity of client populations should be a services research focus for

cocaine treatment. Given the differential access to treatment for these

populations, special attention should be given to the treatment needs of

pregnant women, mentally impaired chemical abusers, clients who are

human immunodeficiency virus (HIV) seropositive, and cultural minorities.

260
Attention should be given to clients with differing sets of natural

contingencies, such as employed clients and those with different kinds

of social networks that may be useful in understanding treatment

effectiveness.

Natural history studies are important to understand the context and

dynamics of cocaine treatment. Little is known about how individuals

recover from cocaine dependence over time and how key stages in

recovery lead to treatment seeking and cessation of use. Thus, longterm studies of outcomes are important, both for treated and untreated

cocaine abusers.

TREATMENT MODALITIES AND THERAPY RESEARCH

Despite the enormous resources that became available for cocaine

treatment research in the 1980s research related to cocaine treatment

interventions has produced only limited results. However, the many

studies under way should result in significant improvements in available

treatments.

Treatment studies should continue the present emphases on

(1) identifying and systematically testing pharmacological agents that

may be useful in achieving abstinence from cocaine and reducing the

likelihood of relapse; (2) characterizing and understanding the processes

and outcomes of existing treatments by using field studies with outcomes

studied over a 1-year posttreatment period and longer; and (3) testing the

efficacy of specific psychosocial interventions such as psychotherapies,

behavioral treatments, and relapse prevention strategies.

The need for theory-based treatment approaches should be recognized.

Promising pharmacotherapies also should be field tested in clinical

programs to understand issues related to compliance with medication

regimens.

The question of whether inpatient treatment has an inherent advantage

over outpatient treatment must be addressed. Although dropout rates

from outpatient programs are relatively high, it is not known whether

inpatient programs are more effective.

Studies should be designed and carried out to (1) improve retention in

treatment for outpatient programs and (2) rigorously test inpatient vs.

outpatient treatment for well-defined subgroups of clients.

261
Treatment approaches regarded as experimental or nontraditional

should be systematically investigated. For example, acupuncture is

widely used in detoxification, yet its status as a somatic treatment for

cocaine withdrawal remains to be scientifically established. Work by

such practitioners as Michael Smith, M.D., at New York City’s Lincoln

Hospital has been widely recognized, and his data are encouraging;

however, rigorous clinical trials of such interventions are difficult and

have been frustrated by methodological and operational problems.

Research in this area should continue to be encouraged.

Other widely used approaches that should be examined include 1 P-step

approaches, both as self-help programing and formal treatment.

To improve existing treatment, there should be a systematic effort to

integrate research and treatment. Studies should be undertaken to

increase understanding of the factors and mechanisms related to

client entry, engagement, retention, and compliance with treatment

expectations. Such knowledge is essential to the ability to design

effective treatments and improve existing treatments for cocainedependent clients.

Research should develop and test criteria for client-treatment matching

so that the most cost-effective treatments can be provided for cocainedependent clients.

Additional research should focus on better understanding motivation as

a factor for increasing the retention of cocaine users in treatment. This

focus would include use of motivational incentives to enter and remain

in treatment.

There is a need to better understand the role of self-help in treating

cocaine users.

The association between compulsive sexual behaviors and compulsive

use of cocaine needs to be better understood to strengthen relapse

prevention efforts.

The initial and high dropout rates from treatment during the first 60 days

by cocaine users should receive specific attention when future studies

are planned.

Treatment programs should not be content to reach only those who

present for treatment but also should seek to increase treatment entry

through outreach and to contact those reluctant to enter treatment to

262
provide information and services to them that will reduce the degree of

risk for HIV infection.

RESEARCH DESIGN ISSUES

A variety of study types and designs are necessary to understand cocaine

dependence and response to treatment and to develop more effective

treatments. Tightly controlled studies using randomized designs are

necessary if the relationship of targeted cocaine treatment and treatment

outcome is to be better understood. In such studies, inclusion and

exclusion criteria must be specified that take previous study findings into

consideration; treatments should be specified and be manual driven for

replication; treatment doses and levels should be specified and dropout rates

determined.

In treatment outcome studies, the training and experience of treatment

providers should be specified and documented.

Outcome measures should include both behavioral and intrapsychic

measures.

Outcome analyses should include survival rates.

Differences among study findings need to be better reconciled.

IMPLICATIONS FOR PRACTICE

Given that knowledge in the area of cocaine treatment is very preliminary,

recommendations for practice in this area must also include cautions.

Researchers are starting down a long road, because no specific protocols

for cocaine treatment have been empirically validated. Still, existing

treatment research findings and the experience of skilled practitioners

make possible a series of generalizations for practice.

Treatment

Although relatively little is known about what works for treatment of

cocaine users, cocaine treatment can have negative aspects.

Starting “where the client is” (e.g., history, comorbidity, legal status, what

the client has to lose) is important for cocaine treatment, given the high

dropout rates and low motivation.

263
Program flexibility, open attitudes, and attention to boundaries are

important to increase the retention of cocaine users, given their low

motivation, impulsivity, and low acceptance of self-help as well as high

staff burnout rates.

Treatment contracts and contingencies should be clearly stated and

agreed on at the outset of cocaine treatment.

It is important to remember that cocaine addicts are not just alcoholics

who have selected a different drug.

Initial data and anecdotal information indicate that programs are most

effective that include structure, intense and planned interventions,

frequent attendance, flexibility, definition of treatment stages, urine

testing, and targeted counseling.

Interventions to increase client motivation have been reported

anecdotally to be effective for some cocaine addicts when incorporated

with frequent group meetings, urine testing, educational lectures, and

individual counseling.

Cognitive behavioral approaches for cocaine treatment are seen as

appropriate, given that treatment for this group needs to be structured

and specific.

Pharmacotherapies for cocaine addicts are still undergoing testing, and

recommendations are limited to approved uses, such as treatment of

comorbidities. Practitioners are cautioned that some early trials of

medications thought to be promising have had disappointing results.

To the extent that efficacious medications become available, programs

should pay particular attention to medications dosage and compliance

issues.

Cocaine addicts are difficult to treat, which necessitates a balanced

approach for matching clients to treatment.

Practitioners should be open to participating in research and keeping

current with research findings.

Diagnosis

The provision of treatment service must take into consideration the

multiple problems associated with cocaine use, which include route of

264
administration (crack smoking, needle use), alcohol use, and compulsive

sexual behavior,

Psychiatric comorbidities are often present in cocaine users, including

Axis I (especially depression and anxiety disorders) and Axis II

diagnoses (American Psychiatric Association 1987). Although transient

depression and some psychotic states associated with stimulant use may

abate with entry into treatment, careful clinical evaluation of comorbidities

on a continuing basis is needed.

The implications of Axis II diagnoses, particularly antisocial personality

disorder, for treatment planning must be considered.

Drug Testing

Frequent and ongoing drug testing must be an integral part of treatment

protocols for cocaine users.

Legal Issues

Legal issues and legal involvement are important considerations when

cocaine users receive treatment.

HIV/AIDS

HIV/acquired immunodeficiency syndrome is a major risk associated with

compulsive cocaine use, particularly for intravenous drug users and for

women.

The issue of HIV risk reduction is an important aspect of cocaine

treatment.

Relapse

Relapse is an essential characteristic of cocaine addiction.

Cocaine addicts have high relapse rates as well as multiple relapses.

Tralnlng Issues

Cocaine treatment training modules are needed.

Counselors should be motivated to seek out research findings related

to cocaine treatment as a means to increase their effectiveness and

improve their practice.

265
Counselors and outreach workers should receive training related to

the specific characteristics of cocaine users and the implications for

treatment.

REFERENCE

American Psychiatric Association. Diagnostic and Statistical Manual of Mental

Disorders (Third Edition, Revised). Washington, DC: American Psychiatric

Press, 1987.

AUTHORS

Carl G. Leukefeld, D.S.W.

Director

Center on Drug and Alcohol Research

University of Kentucky

210 Medical Center Annex II

Lexington, KY 40536

Frank M. Tims, Ph.D.

Chief

Treatment Services Research Branch

Division of Clinical Research

National Institute on Drug Abuse

National Institutes of Health

Parklawn Building, Room 10A-30

5600 Fishers Lane

Rockville, MD 20857

266
While limited supplies last, single copies of the monographs can be obtained

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267
72 RELAPSE AND RECOVERY IN DRUG ABUSE. Frank M. Tims, Ph.D., and

Carl G. Leukefeld, D.S.W., eds.

NTIS PB #89-151963/AS $31

NCADI #M72

73 URINE TESTING FOR DRUGS OF ABUSE. Richard L. Hawks, Ph.D., and

C. Nora Chiang, Ph.D., eds.

NTIS PB #89-151971/AS $23

NCADI #M73

74 NEUROBIOLOGY OF BEHAVIORAL CONTROL IN DRUG ABUSE.

Stephen I. Szara, M.D., D.Sc., ed.

NTIS PB #89-151989/AS $23

NCADI #M74

78 THE ROLE OF NEUROPLASTICITY IN THE RESPONSE TO DRUGS.

David P. Friedman, Ph.D., and Doris H. Clouet, Ph.D., eds.

NTIS PB #88-245683/AS $31

NCADI #M78

79 STRUCTURE-ACTIVITY RELATIONSHIPS OF THE CANNABINOIDS.

Rao S. Rapaka, Ph.D., and Alexandros Makriyannis, Ph.D., eds.

NTIS PB #89-109201/AS $31

NCADI #M79

80 NEEDLE SHARING AMONG INTRAVENOUS DRUG ABUSERS:

NATIONAL AND INTERNATIONAL PERSPECTIVES. Robert J. Battjes, D.S.W.,

and Roy W. Pickens, Ph.D., eds.

NTIS PB #88-236136/AS $31

NCADI #M80

82 OPIOIDS IN THE HIPPOCAMPUS. Jacqueline F. McGinty, Ph.D., and

David P. Friedman, Ph.D., eds.

NTIS PB #88-245691/AS $23

NCADI #M82

83 HEALTH HAZARDS OF NITRITE INHALANTS. Harry W. Haverkos, M.D.,

and John A. Dougherty, Ph.D., eds.

NTIS PB #89-125496/AS $23

NCADI #M83

84 LEARNING FACTORS IN SUBSTANCE ABUSE. Barbara A. Ray, Ph.D., ed.

NTIS PB #89-125504/AS $31

NCADI #M84

268
85 EPIDEMIOLOGY OF INHALANT ABUSE: AN UPDATE. Raquel A. Crider,

Ph.D., and Beatrice A. Rouse, Ph.D., eds.

NTIS PB #89-123178/AS $31

NCADI #M85

87 OPIOID PEPTIDES: AN UPDATE. Rao S. Rapaka, Ph.D., and Bhola N.

Dhawan, M.D., eds.

NTIS PB #89-158430/AS $45

NCADI #M87

88 MECHANISMS OF COCAINE ABUSE AND TOXICITY. Doris Clouet,

Ph.D.; Khursheed Asghar, Ph.D.; and Roger Brown, Ph.D., eds.

NTIS PB #89-125512/AS $39

NCADI #M88

89 BIOLOGICAL VULNERABILITY TO DRUG ABUSE. Roy W. Pickens,

Ph.D., and Dace S. Svikis, B.A., eds.

NTIS PB #89-125520/AS $23

NCADI #M89

92 TESTING FOR ABUSE LIABILITY OF DRUGS IN HUMANS. Marian W.

Fischman, Ph.D., and Nancy K. Mello, Ph.D., eds.

NTIS PB #90-148933/AS $45

NCADI #M92

94 PHARMACOLOGY AND TOXICOLOGY OF AMPHETAMINE AND

RELATED DESIGNER DRUGS. Khursheed Asghar, Ph.D., and Errol De

Souza, Ph.D., eds.

NTIS PB #90-148958/AS $39

NCADI #M94

95 PROBLEMS OF DRUG DEPENDENCE 1969: PROCEEDINGS OF THE

51 ST ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS

OF DRUG DEPENDENCE, INC. Louis S. Harris, Ph.D., ed.

NTIS PB #90-237660/AS $67

NCADI #M95

96 DRUGS OF ABUSE: CHEMISTRY, PHARMACOLOGY, IMMUNOLOGY,

AND AIDS. Phuong Thi Kim Pham, Ph.D., and Kenner Rice, Ph.D., eds.

NTIS PB #90-237678/AS $31

NCADI #M96

269
97 NEUROBIOLOGY OF DRUG ABUSE: LEARNING AND MEMORY. Lynda

Erinoff, Ph.D., ed.

NTIS PB #90-237686/AS $31

NCADI #M97

96 THE COLLECTION AND INTERPRETATION OF DATA FROM HIDDEN

POPULATIONS. Elizabeth Y. Lambert, M.S., ed.

NTIS PB #90-237694/AS $23

NCADI #M98

99 RESEARCH FINDINGS ON SMOKING OF ABUSED SUBSTANCES. C.

Nora Chiang, Ph.D., and Richard L. Hawks, Ph.D., eds.

NTIS PB #91-141119/AS $23

NCADI #M99

100 DRUGS IN THE WORKPLACE: RESEARCH AND EVALUATION DATA.

VOLUME II. Steven W. Gust, Ph.D.; J. Michael Walsh, Ph.D.; Linda B. Thomas,

B.S.; and Dennis J. Crouch, M.B.A., eds.

GPO Stock #017-024-01458-3 $8 NCADI #M100

101 RESIDUAL EFFECTS OF ABUSED DRUGS ON BEHAVIOR. John W.

Spencer, Ph.D., and John J. Boren, Ph.D., eds.

GPO Stock #017-024-01426-7 $6 NTIS PB #91-172858/AS $31

NCADI #M101

102 ANABOLIC STEROID ABUSE. Geraline C. Lin, Ph.D., and Lynda Erinoff,

Ph.D., eds.

GPO Stock #017-024-01425-7 $8 NTIS PB #91-172866/AS $31

NCADI #Ml 02

103 DRUGS AND VIOLENCE: CAUSES, CORRELATES, AND

CONSEQUENCES. Mario De La Rosa, Ph.D.; Elizabeth Y. Lambert, M.S.;

and Bernard Gropper, Ph.D., eds.

GPO Stock #017-024-01427-3 $9 NTIS PB #91-172841/AS $31

NCADI #M103

104 PSYCHOTHERAPY AND COUNSELING IN THE TREATMENT OF DRUG

ABUSE. Lisa Simon Onken, Ph.D., and Jack D. Blaine, M.D., eds.

GPO Stock #017-024-01429-0 $4 NTIS PB #91-172874/AS $23

NCADI #M104

270
106 IMPROVING DRUG ABUSE TREATMENT. Roy W. Pickens, Ph.D.;

Carl G. Leukefeld, D.S.W.; and Charles R. Schuster, Ph.D., eds.

GPO Stock #017-024-01439-7 $12

Paperback $50 Microfiche $19

NCADI #M106

107 DRUG ABUSE PREVENTION INTERVENTION RESEARCH:

METHODOLOGICAL ISSUES. Carl G. Leukefeld, D.S.W., and William J.

Bukoski, Ph.D., eds.

GPO Stock #017-024-01441-9 $9 NTIS PB #92-160985

Paperback $35 Microfiche $17

NCADI #M107

108 CARDIOVASCULAR TOXICITY OF COCAINE: UNDERLYING

MECHANISMS. Pushpa Thadani, Ph.D., ed.

GPO Stock #017-024-01446-0 $7 NTIS PB #92-106608 P

Paperback $35 Microfiche $17

NCADI #M108

109 LONGITUDINAL STUDIES OF HIV INFECTION IN INTRAVENOUS DRUG

USERS: METHODOLOGICAL ISSUES IN NATURAL HISTORY RESEARCH.

Peter Harttsock, Dr.P.H., and Sander G. Genser, M.D., M.P.H., eds.

GPO Stock #017-024-01445-1 $4.50 NTIS PB #92-106616

Paperback $26 Microfiche $12.50

NCADI #M109

111 MOLECULAR APPROACHES TO DRUG ABUSE RESEARCH.

VOLUME I: RECEPTOR CLONING, NEUROTRANSMITTER EXPRESSION,

AND MOLECULAR GENETICS. Theresa N.H. Lee, Ph.D., ed.

NTIS PB #92-135743

Paperback $35 Microfiche $17

NCADI #M111

112 EMERGING TECHNOLOGIES AND NEW DIRECTIONS IN DRUG

ABUSE RESEARCH. Rao S. Rapaka, Ph.D.; Alexandros Makriyannis, Ph.D.;

and Michael J. Kuhar, Ph.D., eds.

GPO Stock #017-024-01455-9 $11 NTIS PB #92-155449

Paperback $44 Microfiche $17.50

NCADI #M112

271
113 ECONOMIC COSTS, COST-EFFECTIVENESS, FINANCING, AND

COMMUNITY-BASED DRUG TREATMENT. William S. Cartwright, Ph.D., and

James M. Kaple, Ph.D., eds.

NTIS PB #92-155795

Paperback $35 Microfiche $17

NCADI #M113

114 METHODOLOGICAL ISSUES IN CONTROLLED STUDIES ON EFFECTS

OF PRENATAL EXPOSURE TO DRUG ABUSE. M. Marlyne Kilbey, Ph.D., and

Khursheed Asghar, Ph.D., eds,

GPO Stock #017-024-01459-1 $12 NTIS PB #92-146216

Paperback $43 Microfiche $17

NCADI #M114

115 METHAMPHETAMINE ABUSE: EPIDEMIOLOGIC ISSUES AND

IMPLICATIONS. Marissa A. Miller, D.V.M., M.P.H., and Nicholas J. Kozel,

M.S., eds.

GPO Stock #017-024-01460-5 $4 NCADI #M115

116 DRUG DISCRIMINATION: APPLICATIONS TO DRUG ABUSE

RESEARCH. Richard A. Glennon, Ph.D.: Torbjorn U.C. Jorbe, Ph.D.; and

Jerry Frankenheim, Ph.D., eds.

GPO Stock #017-024-01470-2 $13 NCADI #M116

117 METHODOLOGICAL ISSUES IN EPIDEMIOLOGICAL, PREVENTION,

AND TREATMENT RESEARCH ON DRUG-EXPOSED WOMEN AND THEIR

CHILDREN. M. Marlyne Kilbey, Ph.D., and Khursheed Asghar, Ph.D., eds.

GPO Stock #017-024-01472-9 $12 NCADI #M117

118 DRUG ABUSE TREATMENT IN PRISONS AND JAILS. Carl G. Leukefeld,

D.S.W., and Frank M. Tims, Ph.D., eds.

GPO Stock #017-024-01473-7 $16 NCADI #M118

119 PROBLEMS OF DRUG DEPENDENCE 1991: PROCEEDING OFTHE

53RD ANNUAL SCIENTIFIC MEETING, THE COMMITTEE ON PROBLEMS

OF DRUG DEPENDENCE, INC. Louis Harris, Ph.D., ed.

GPO Stock #017-024-01474-5 $22 NCADI #M119

120 BIOAVAILABILITY OF DRUGS TO THE BRAIN AND THE BLOOD-BRAIN

BARRIER. Jerry Frankenheim, Ph.D., and Roger M. Brown, Ph.D., eds.

GPO Stock #017-024-01481-8 $10 NCADI #M120

121 BUPRENORPHINE: AN ALTERNATIVE TREATMENT FOR OPIOID

DEPENDENCE. Jack D. Blaine, Ph.D., ed.

GPO Stock #017-024-01482-6 $5 NCADI#M121

272
123 ACUTE COCAINE INTOXICATION: CURRENT METHODS OF

TREATMENT. Heinz Sorer, Ph.D., ed.

GPO #017-024-01501-6 $6.50 NCADI #M123

124 NEUROBIOLOGICAL APPROACHES TO BRAIN-BEHAVIOR

INTERACTION. Joseph Frascella, Ph.D., and Roger M. Brown, Ph.D., eds.

GPO Stock #017-024-01492-3 $9 NCADI #M124

125 ACTIVATION OF IMMEDIATE EARLY GENES BY DRUGS OF ABUSE.

Reinhard Grzanna, Ph.D., and Roger M. Brown, Ph.D., eds.

GPO #017-024-01503-2 $7.50 NCADI #M125

126 MOLECULAR APPROACHES TO DRUG ABUSE RESEARCH.

VOLUME II: STRUCTURE, FUNCTION, AND EXPRESSION. Theresa N.H.

Lee, Ph.D., ed.

NCADI #M126

127 PROGRESS AND ISSUES IN CASE MANAGEMENT. Rebecca Sager

Ashery, D.S.W., ed.

GPO Stock #017-024-01490-7 $14 NCADI #M127

128 STATISTICAL ISSUES IN CLINICAL TRIALS FOR TREATMENT OF

OPIATE DEPENDENCE. Ram B. Jain, Ph.D., ed.

GPO Stock #017-024-01491-5 $6.50 NCADI #M128

129 INHALANT ABUSE: A VOLATILE RESEARCH AGENDA. Charles W.

Sharp, Ph.D.; Fred Beauvais, Ph.D.; and Richard Spence, Ph.D., eds.

GPO Stock #017-024-01496-6 $12 NCADI #M129

130 DRUG ABUSE AMONG MINORITY YOUTH: ADVANCES IN RESEARCH

AND METHODOLOGY. Mario R. De La Rosa, Ph.D., and Juan-Luis Recio

Adrados, Ph.D., eds.

NCADI #M130

131 IMPACT OF PRESCRIPTION DRUG DIVERSION CONTROL SYSTEMS

ON MEDICAL PRACTICE AND PATIENT CARE. James R. Cooper, Ph.D.;

Dorynne J. Czechowicz, M.D.; Stephen P. Molinari, J.D., R.Ph.; and Robert C.

Peterson, Ph.D., eds.

NCADI #M131

132 PROBLEMS OF DRUG DEPENDENCE, 1992: PROCEEDING OF THE

54TH ANNUAL SCIENTIFIC MEETING, THE COLLEGE ON PROBLEMS OF

DRUG DEPENDENCE, INC. Louis Harris, Ph.D., ed.

GPO Stock #017-024-01502-4 $23 NCADI #M132

273
133 SIGMA, PCP, AND NMDA RECEPTORS. Errol B. De Souza, Ph.D.; Doris

Clouet, Ph.D.; and Edythe D. Condon, Ph.D., eds.

NCADI #M133

134 MEDICATIONS DEVELOPMENT: DRUG DISCOVERY, DATABASES,

AND COMPUTER-AIDED DRUG DESIGN. Rao S. Rapaka, Ph.D., and

Richard L. Hawks, Ph.D., eds.

NCADI #M134

*U.S. GOVERNMENT PRINTING OFFICE: 1993 342-283/80004

274
NIH Publication No. 93-3639

Printed 1993