Cocaine addiction has been associated with a variety of serious health consequences: cardiovascular and respiratory problems, psychiatric disorders, acquired immunodeficiency syndrome (AIDS), sexually transmitted diseases, early child development abnormalities, and death. Because cocaine use became epidemic in the early 1980s, research opportunities have been limited, and a standard cocaine treatment has not yet been found. Many substance abuse centers have provided cocaine users with the same treatment approaches provided to opiate and other drug users. But these treatments have not been as successful for cocaine users, who have demonstrated high relapse and dropout rates. The large-scale Treatment Outcome Prospective Study (TOPS) showed that about one-third of the clients who reported returning to cocaine use in the year after treatment began to do so as early as the first week following treatment termination. Another 25 percent began using the drug within 2 to 4 weeks following treatment termination, for a cumulative first-month relapse rate of 57 percent. Studies of crack cocaine users found that 47 percent dropped out of therapy between the initial clinic visit and the first session; three-quarters dropped out by the fifth session. Because of this lack of treatment success, in the late 1980s and early 1990s the federal government began playing a more active role in sponsoring cocaine-related treatment research, principally through NIDA and the Center for Substance Abuse Treatment (CSAT). NIDA is the largest federal sponsor of substance abuse-related research, conducting work in treatment and prevention research, epidemiology, neuroscience, behavioral research, health services research, and AIDS. Since 1991, NIDA has funded about 100 cocaine treatment grants and conducted in-house research through its laboratory facilities. CSAT’s mission includes developing treatment services, evaluating the effectiveness of these services, and providing technical assistance to providers and states. Since 1991, CSAT has funded approximately 65 substance abuse research projects with implications for cocaine addiction treatment. CSAT cocaine-related data were not yet available at the time this report was published. Results therefore derive from a literature review of studies published from 1991 through 1995 and ongoing NIDA-supported cocaine studies, for which some outcome data were available. During the 5-year period, two broad types of cocaine treatment approaches received research emphasis: cognitive/behavioral therapy and pharmacotherapy. Additionally, acupuncture has emerged as a potential therapy in the treatment of cocaine. Much of this research has been conducted in outpatient treatment settings, with a focus on “cocaine-dependent” clients—many of whom are considered to be “hardcore” drug users. Cognitive/behavioral therapies aim to modify the ways clients think, act, and relate to others, thereby facilitating initial abstinence and a continued drug-free lifestyle. These therapies include the psychotherapies, behavior therapies, skills training, and other counseling approaches. Three types of cognitive/behavioral therapies have received recent attention: relapse prevention, community reinforcement/contingency management, and neurobehavioral therapy. Relapse prevention focuses on helping clients to identify high-risk, or “trigger,” situations that contribute to drug relapse and to develop appropriate behaviors for avoiding, or better managing, these situations. For example, Yale University’s Substance Abuse Treatment Unit has three principal elements in its 12-week relapse prevention program. First, clients identify personal triggers by keeping a daily log of the situations in which they crave the drug. Second, they work with therapists to learn more effective ways of coping with and avoiding these and other commonly perceived triggers. And third, therapists help clients extinguish the drug-craving reactions to these triggers. Clients are taught that relapse is a process, that social pressures to use drugs can be formidable, and that lifestyle changes are necessary to discourage future substance abuse. Community reinforcement/contingency management aims to help the client achieve initial abstinence as well as an extended drug-free lifestyle. The therapy consists of several key community-oriented components, including the participation of a client’s significant other (family member or friend) in the treatment process; providing management incentives or rewards for drug abstinence; providing employment counseling when needed; and encouraging client participation in recreational activities as pleasurable, healthy alternatives to drug use. If clients remain abstinent, they receive vouchers from the program and earn the right to participate in desired activities with their significant other. If clients test positive for drug use, or do not submit to urine testing, negative sanctions are applied (for example, their vouchers are rescinded). In this manner, community reinforcement therapy teaches clients about the consequences of their actions and strengthens family and social ties. Neurobehavioral treatment is a comprehensive, 12-month outpatient treatment approach that includes individual therapy, drug education, client stabilization, and self-help groups. Relapse prevention techniques are included but constitute only a subset of neurobehavioral treatment.Five major stages of recovery are distinguished during the treatment process—withdrawal, “honeymoon,” “the wall,” adjustment, and resolution—with emphasis on addressing the client’s behavioral, emotional, cognitive, and relational problems at each stage of recovery. For example, in the withdrawal stage, depression, anxiety, self-doubt, and shame (emotional problems) and concentration difficulties, cocaine cravings, and short-term memory disruption (cognitive problems) are addressed. In the first 6 months, individual counseling is emphasized; in the second 6 months, weekly group counseling is provided, with optional individual and couple therapy sessions. Pharmacotherapy involves the use of medications to combat cocaine abuse and addiction. Recently, NIDA’s pharmacotherapy research has focused on two objectives: facilitating initial abstinence and supporting an extended, drug-free lifestyle. To facilitate initial abstinence, research has focused on medications that treat the withdrawal symptoms of cocaine addiction and block the euphoric high induced by the drug. To help maintain an extended drug-free lifestyle, research has focused on blocking the client’s craving for cocaine, treating the underlying psychopathologies, and treating the toxic effects of cocaine on the brain. The use of acupuncture in drug abuse treatment has not been limited to cocaine addiction. It has also been used during the past 20 years to treat addictions to opiates, tobacco, and alcohol. A Yale University acupuncture treatment program for cocaine abuse involved the insertion of needles into each ear at five strategic points, for a period of 50 minutes per session, over an 8-week period. Through the first 6 weeks, clients received the acupuncture therapy 5 days a week; in weeks 7 and 8, treatment was reduced to 3 days a week. Treatment was provided in a group context. The results from NIDA’s cocaine treatment grants are only now becoming available. Because cocaine therapies are still in their early stages of development, treatment outcome results cannot be generalized to all cocaine users. However, early results from a review of the literature and ongoing NIDA studies reveal the promise of three cognitive/behavioral approaches to treatment. Moreover, while a pharmacological treatment has not yet been consistently demonstrated, NIDA is continuing to actively pursue the biology of cocaine addiction. Further, few well-designed methodological studies of acupuncture exist, but the limited research in this area demonstrates at least some positive findings. Early research indicates relapse prevention, community reinforcement/contingency management, and neurobehavioral therapy are potentially promising cocaine-addiction treatment approaches for promoting extended periods of client abstinence and treatment retention in outpatient treatment settings. Table 1 provides an overview of cognitive/behavioral study methodologies and results. Clients who received relapse prevention treatment have demonstrated favorable abstinence rates not only during the period of treatment, but during follow-up periods as well. Client treatment retention results also appear to be favorable. For example, cocaine-dependent clients participating in a 12-week Yale University program focusing on relapse prevention were able to remain cocaine abstinent at least 70 percent of the time while in treatment. A year after treatment, gains were still evident: clients receiving relapse prevention treatment and a placebo medication were reported to have used cocaine on average fewer than 3 days in the past month. Positive outcome results were also found in two other programs: more than 60 percent of the primarily middle-class, cocaine-addicted clients attending a relapse prevention program at the Washton Institute in New York were abstinent from cocaine during the 6-to 24-month follow-up period. Similarly, in the Seattle area, cocaine-using clients cut their average number of days of cocaine use by 71 percent within 6 months. Among high-severity cocaine addicts participating in another Yale program, it was also found that 54 percent receiving relapse prevention therapy were able to attain at least 3 weeks of continuous abstinence, while only 9 percent of those receiving the interpersonal psychotherapy could remain abstinent for that period of time. Retention rates were also favorable: 67 percent of the relapse prevention clients completed the entire 12-week Yale program and more than 70 percent completed the Washton program. Community reinforcement/contingency management programs have also appeared promising in fostering abstinence and retaining clients in treatment. Almost one-half (46 percent) of the cocaine-dependent clients participating in a 12-week community reinforcement/contingency management program at the University of Vermont were able to remain continuously abstinent from cocaine through 2 months of treatment;when the program was extended to 24 weeks, 42 percent of the participating cocaine-dependent subjects were able to achieve 4 months of continuous abstinence. By comparison, only 5 percent of those in the control group receiving drug abuse counseling alone could remain continuously abstinent for the entire 4 months. A year after clients began treatment, community reinforcement/ contingency management treatment effects were still evident: 65 to 74 percent of those in the community reinforcement group reported 2 or fewer days of cocaine use in the past month. Only 45 percent of those in the counseling control group achieved such gains. Contingency management was also studied independently in an inner-city Baltimore program. Positive results were found when tying the 12-week voucher reward system to cocaine drug testing.