Psychological therapies and cocaine dependence

Evidence-based cognitive-behavioral and behavioral treatments for drug dependence

By: Tara M. Neavins, Caroline J. Easton, Janet Brotchie and Kathleen M. Carroll

Overview

The purpose of empirical validation of psychological therapies is to identify effective treatments that assist clinicians in delivering appropriate therapies (Chambless et al., 1996; Chambless et al., 1998). In general, this review focuses on interventions classified as ‘empirically validated’ or ‘likely to be efficacious’. To be considered empirically validated, it is necessary that a given treatment demonstrate efficacy in at least two randomized controlled trials (RCTs (McGovern & Carroll, 2003)). Included studies should be methodologically sound and incorporate features such as treatment manuals, random assignment to targeted and appropriate control and treatment conditions, and use validated measures. Moreover, a treatment’s efficacy should be confirmed by at least two independent investigation teams. In contrast, to be considered ‘probably efficacious’, a treatment’s efficacy must be confirmed by at least two positive randomized clinical trials with a waiting list control group, a small series of single case experiments, or one or more experiments meeting criteria for empirical validation but not by independent teams. Although this framework has generated considerable controversy, this model afforded a standard by which to compare treatments (McGovern & Carroll, 2003).

Psychological therapies and cocaine dependence

In contrast to the treatment of opioid dependence, where behavioral therapies have been most effective when combined with pharmacotherapies (especially agonist interventions, such as methadone maintenance), the cocaine literature is marked by strong evidence suggesting the effectiveness of purely behavioral treatments. Despite many clinical trials examining several pharmacologic agents, no pharmacotherapy currently is available for the general population of cocaine users (Carroll et al., 2000). In contrast, several investigations have shown that comparatively brief, purely behavioral approaches can be both sufficient and effective for the majority of patients.

Behavioral therapies in the context of cocaine dependence

Voucher-based contingency management and cocaine dependence Higgins et al.’s (1991, 1993, 2000; Budney & Higgins, 1998) Community Reinforcement Approach (Azrin, 1976) has paved the way toward the success of psychosocial treatments for cocaine dependence. Their treatment regime consists of the following elements: positive incentives for abstinence from cocaine, reciprocal relationship counseling, and disulfiram. This treatment has four essential guiding principles rooted in behavioral pharmacology:

(1) drug use and abstinence must be detected both quickly and accurately,

(2) abstinence is positively reinforced,

(3) drug use results in loss of reinforcement, and

(4) the development of competing reinforcers to drug use is emphasized (Higgins et al., 1993).

There are several other important features of the treatment program established by Higgins and colleagues (1991, 1993). In this program, urine samples are obtained thrice weekly. Abstinence, assessed through drug-free urine screens, is reinforced using a voucher system in which patients receive points redeemable for items consistent with a drug-free lifestyle, such as movie tickets, sporting events and similar items. In order to encourage longer periods of drug abstinence, the points earned by patients increase in value with each successive clean urine specimen. Moreover, the value of the points is reset back to its original level when patients produce a drug-positive urine screen or when patients fail to provide a urine screen.

In a series of well-controlled clinical trials, Higgins and colleagues reliably have demonstrated the following:

(1) high acceptance, retention, and rates of abstinence for patients involved with this approach (i.e. 85% completing 12 weeks of treatment and 65% achieving 6 or more weeks of abstinence) relative to standard substance abuse counseling (Higgins et al., 1991, 1993);

(2) rates of abstinence not declining substantially when less valuable incentives are substituted for the voucher system (Higgins et al., 1993);

(3) the value of the voucher system itself (as opposed to other program elements) in yielding good outcomes by comparing the behavioral system with and without the vouchers (Higgins et al., 1994); and,

(4) durable effects of the voucher system (Higgins et al., 2000).

The initial work with voucher-based contingency management conducted by Higgins and associated investigators now has been widely-replicated in a diverse array of settings and populations, including homeless substance abusers (Milby et al., 1996), freebase cocaine users (Kirby et al., 1998), alcohol-dependent individuals (Petry, 2000a), and cocaine-dependent individuals within methadone maintenance treatment programs (Peirce et al., 2006; Silverman et al., 1996a, 1996b; Rawson et al., 2002).

Low-cost contingency management of cocaine dependence

One of the more innovative, state-of-the-art, approaches to treatment of cocaine dependence, derived from work with alcohol-dependent patients, involves providing clients with prizes at variable intervals using the ‘fishbowl’ methodology (Petry, 2000a). This methodology is an inherently ‘low-cost’ alternative to traditional, fixed participant, financial reimbursement and is based on extensive demonstrations of the empirical validity of contingency management approaches (Higgins et al., 2000; Petry, 2000b; Petry & Martin, 2002; Petry et al., 2000, 2001, 2005). This technique affords clients the opportunity to choose a prize card from a bowl. Typically, prizes range from $1 to $100 (Petry et al., 2000). The success of this approach is rooted in utilizing this variable schedule of reinforcement, which has been associated with sustained behavioral change (Skinner, 1984). In addition, as only a small percentage of clients win the largest monetary amounts, researchers can minimize their study costs to a greater extent than they could were they to pay each participant the same, fixed amount (Petry et al., 2000).

Petry & Martin (2002) randomly assigned 42 methadone maintenance patients to 12 weeks of standard treatment or to 12 weeks of standard treatment plus contingency management (CM; fishbowl technique). In the CM condition, drawing from the fishbowl was contingent upon producing cocaine- and opioid-free urines. Individuals in the CM condition had significantly longer episodes of sustained abstinence from cocaine and opioids than individuals in the standard condition. Furthermore, these treatment gains were maintained over a 6-month interval. Petry et al. (2004) expanded the fishbowl technique by randomly assigning cocaine-using individuals to one of three conditions:

(1) standard care,

(2) standard care plus CM ($80), or

(3) standard care plus CM ($240).

Both CM conditions yielded similar rates of abstinence from cocaine for individuals whose urines were negative for drugs at intake. However, individuals who produced intake urines positive for drugs had significantly greater abstinence from cocaine when placed in the larger ($240) CM condition than those who only received standard care.

In their study of 120 cocaine-dependent individuals who participated in a methadone maintenance program, Rawson et al. (2002) directly compared CM and CBT. Participants were randomly assigned to one of four cells for the 16-week study period:

(1) CM (based on providing cocaine-negative urine samples),

(2) CBT,

(3) CM/CBT, or

(4) Methadone maintenance treatment program alone (3 weekly clinic visits; MMTP).

Three prominent findings emerged. First, during treatment, the CM condition yielded the best outcome in terms of within-treatment, cocaine free, urine specimens. In contrast, the CBT and MMTP conditions had similar, cocaine-positive, within-treatment urine specimens. Second, the CM, CBT, and CM/CBT conditions all revealed fewer self-reported days of cocaine use by the end of the study period than did the MMTP condition. Third, at both 26- and 52-week follow-up, the CBT condition showed a successful outcome and was indistinguishable from the CM and CM/CBT conditions when considering both cocaine-free urine specimens and self-reported cocaine use. Thus, although CM produced quicker results than were seen within treatment, CBT produced similar success at post-treatment and 6-month follow-up. Furthermore, combining CM and CBT did not lead to a more successful outcome than either condition alone. However, given the more immediate effects of CM and the more delayed effects of CBT in this study, the researchers wondered whether it might be useful to deliver CM initially and CBT later in the treatment process.

Like Rawson et al. (2002), Epstein et al. (2003) wished to examine whether a combination of CM and CBT might produce superior results for 193 cocaine-using patients (41% were cocaine-dependent) in a methadone maintenance treatment program who were randomized to 12 weeks of group treatment (CBT or a social support control group) and CM (based on providing cocaine-negative urines or based on being yoked to CM participants’ urine sample results). In all conditions, individuals received methadone maintenance. For the control condition, participants were unknowingly yoked to an individual in the CM condition, such that they would receive vouchers whenever this other individual received them regardless of their own behavior. Participants in the control condition were told that they would receive vouchers on ‘‘a totally unpredictable schedule’’ as long as they gave a urine sample (Epstein et al., 2003). These investigators discovered that initially, CBT hampered the very strong effects of CM on reducing cocaine use. However, when comparing the 12-month and 3-month post-treatment results, significant reductions in cocaine use were seen for the CBT/CM condition at 12 months post-treatment.

Other cognitive-behavioral therapies and cocaine dependence

Based on social learning theories pertaining to the acquisition and maintenance of substance use disorders (Marlatt & Gordon, 1985), cognitive-behavioral treatment (CBT) has demonstrated effectiveness in the treatment of cocaine-dependent individuals (Carroll, 1998). The goal of CBT (also frequently called relapse prevention or coping skills therapy) is to foster abstinence by teaching patients a set of individualized coping strategies as effective alternatives to substance use. Among the skills typically taught are the following:

(1) exploring the positive and negative outcomes of continued use as a means to promote motivation to stop cocaine and other substances;
(2) creating a functional analysis of substance use (i.e. understanding substance use in relation to its antecedents and consequences);

(3) developing strategies for coping with high-risk situations, including cocaine craving;

(4) preparing for emergencies and coping with a relapse to substance use; and

(5) identifying and confronting thoughts about substance use (Carroll, 1998).

A number of randomized clinical trials among several diverse cocaine-dependent populations have yielded several salient conclusions. First, compared with other popular psychological therapies for cocaine dependence, CBT appears to be especially more effective with individuals who have more severe cocaine problems or who also have comorbid disorders (Carroll et al., 1991a, 1994a, b; MaudeGriffin et al., 1998; McKay et al., 1997). Second, CBT is significantly more effective than less intensive approaches that have been considered control conditions (Carroll et al., 1998; Monti et al., 1997). Third, CBT is equivalent to or more effective than manualized disease-model approaches (Carroll et al., 1998; Maude-Griffin et al., 1998). Fourth, CBT appears to be a particularly durable treatment with several studies suggesting that patients who participated in CBT may continue to reduce their cocaine use even 1–2 years after leaving treatment (Carroll et al., 1994b, 2000; McKay et al., 1999). Finally, for individuals who have nondrug-abusing partners who are willing to participate in treatment, behavioral couples therapy has been shown to be more effective than individual therapy in terms of reducing within-treatment, cocaine-positive urine samples, for men in methadone maintenance treatment (Fals-Stewart et al., 2001) and for reducing self-reported cocaine use for both male and female outpatients enrolled in substance use treatment (Fals-Stewart et al., 1996; Winters et al., 2002).

Disease model approaches to cocaine dependence and other substances of abuse

The NIDA Collaborative Cocaine Treatment Study (CCTS), a multi-site randomized trial of psychotherapeutic treatments for cocaine dependence (Crits-Christoph et al., 1999), offered strong evidence of the effectiveness of a manualized treatment approach known as Individual Drug Counseling (Carroll, 2000; Mercer & Woody, 1992).

In this study, 487 cocaine-dependents were randomized to one of four manual-guided treatment conditions:

(1) Cognitive Therapy (Beck et al., 1993) plus Group Drug Counseling (Mercer et al., 1994);

(2) Supportive Expressive Therapy, a short-term psychodynamically oriented approach, which helps people feel comfortable discussing personal problems while learning ways to identify and work through interpersonal problems (Luborsky, 1984; Mark & Luborsky, 1992) plus Group Drug Counseling;

(3) Individual Drug Counseling, focused on abstinence from drugs and solving areas of impaired functioning (e.g. illegal activity, family issues, and unemployment), plus Group Drug Counseling; or,

(4) Group Drug Counseling alone.

The treatments offered were intensive (36 individual and 24 group sessions over 24 weeks – a total of 60 sessions) and were met with comparatively poor retention, with patients on average completing less than one-half of sessions offered, with higher rates of retention for subjects assigned to Cognitive Therapy or Supportive Expressive Therapy (Crits-Christoph et al., 1999).

Outcomes on the whole were good, with all groups significantly reducing their cocaine use from baseline; however, the best cocaine outcomes were seen for subjects who received Individual Drug Counseling (Carroll et al., 2000).

The findings from these studies offer compelling support for the efficacy of manual-guided disease-model approaches (Carroll, 2000). This result has important clinical implications, as these approaches are similar to the dominant model applied in most community treatment programs (Horgan and Levine, 1998), and thus may be more easily mastered by ‘‘real world’’ clinicians than approaches such as CM or CBT, treatments whose theoretical underpinnings may not be seen as highly compatible with disease model approaches (Carroll, 2000).

References

Peter Tyrer and Kenneth R. Silk, Cambridge Textbook of Effective Treatments in Psychiatry, Cambridge University Press 2008.

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