Cocaine disorders have proven to be refractory to both psychological and pharmacological treatment. Consequently, considerable energy has been directed toward developing and testing the efficacy of new psychotherapeutic approaches in the treatment of cocaine use disorders. Many of these therapies have been adapted from ones originally developed to treat alcoholism. One approach that has received attention is cognitive-behavioral relapse prevention (Marlatt & Gordon, 1985). Relapse prevention strives to teach the addict how to recognize high-risk situations and deal with these using cognitive strategies that have been well rehearsed. Relapse prevention recognizes that with a chronic disorder such as addiction, relapses and remissions are expected. When a relapse occurs, more intense treatment and cognitive restructuring are necessary to help prevent a "slip" from escalating. Reminding patients of their prior progress, focusing on making the "slip" an isolated event, and maximizing the learning value of this experience are constructive ways of handling the situation. The literature on efficacy of relapse prevention in the treatment of cocaine dependence is mixed. In a review of 24 randomized clinical trials of relapse prevention for drug abuse (including cocaine), Carroll (1996) concluded that relapse prevention is superior to no treatment, although superiority to other active therapies is less evident.
Cognitive behavioral therapy (CBT) is also an effective treatment for cocaine addiction, and improves comorbid psychosocial problems (Carroll, 2000). In addition, CBT has demonstrated higher retention rates and improved compliance compared to other forms of individual and group therapy (Crits-Christoph et al., 1999). However, recent findings indicate that patients with cognitive impairments are more likely to drop out of CBT (Aharonovich, Nunes, & Hasin, 2003).
A somewhat different approach has been taken by researchers studying the role of conditioned cues or "reminders" of cocaine use (O'Brien, Childress, Arndt, & McLellan, 1988); this approach attempts to extinguish conditioned responses to these cocaine cues, thereby reducing the chances for relapse. Desensitization training requires that patients be repeatedly exposed to drug stimuli, then given the opportunity to deal with them in real-life situations. Behavioral rehearsal is key to being prepared to deal with the drug-laden situations that exist outside the protection of the treatment center. In one study (O'Brien, Childress, McLellan, & Ehrman, 1990), 30 drug-free cocaine addicts were repeatedly exposed to cocaine cues within a controlled setting. Subjects reported experiencing strong physiological arousal, including cocaine craving, highs, and withdrawal in response to exposure. However, by the sixth hour of extinction (repeated nonreinforced exposure to cocaine cues), highs and withdrawal were no longer reported and, by the 15th hour, craving was no longer experienced. Despite the strong extinction of arousal, these effects diminished over time, unless they were reinforced with repeated cue exposure sessions.
Voucher-based reinforcement strategies have also shown considerable promise (Higgins, Budney, Bickel, & Foerg, 1994; Higgins et al., 1995, 2000). Higgins and colleagues (1994) demonstrated that voucher incentives (in combination with comprehensive behavioral intervention) enhanced retention in the 24-week-long treatment program both for patients receiving interventions (75%) and those receiving behavioral therapy only (40%). In addition, those in the voucher group had greater continuous abstinence and evidenced greater improvements on the Addiction Severity Index (ASI) Drug and Psychiatric scales than those not receiving vouchers. Subsequent follow-up assessments indicated that these gains were maintained 6 months after treatment (Higgins et al., 1995), and as much as 15 months after treatment (Higgins et al., 2000). Other studies of contingent vouchers have yielded similarly positive outcomes in cocaine-dependent outpatients (Kirby, Marlowe, Festinger, Lamb, & Platt, 1998; Silverman et al., 1996). In addition, a study by Rawson and colleagues (2002) compared contingency management (vouchers), CBT, a combination of the two, and a "no-cocaine-treatment condition," which consisted of metha-done maintenance for heroin addiction only in patients with heroin and cocaine dependence. They found that contingency management was associated with significantly higher levels of cocaine abstinence than were the CBT or control interventions. However, the CBT group showed improvement at the 6-and 12-month follow-up points that was congruent with the contingency management group.
Unfortunately, not all substance abusers are motivated to change their drug use behavior; this is particularly true of patients with comorbid psychiatric disorders, who may be overwhelmed by their multiple problems and prior treatment failures (Martino, McCance-Katz, Workman, & Boozang, 1995; Ziedonis & Fischer, 1996). Motivational enhancement therapy (MET), or motivational interviewing (MI), a nonconfrontational approach developed by Miller and Rollnick (1991), was originally designed for working with problem drinkers. In numerous trials, the principles of MI have been shown to be effective, sometimes after only one or two sessions (Bien, Miker, & Tonigan, 1993; Brown & Miller, 1993). Because of promising results with alcoholics, MET/MI is currently being adapted for use with drug abusers, including those with cocaine dependence and psychiatric comorbidity. MET/MI works in tandem with the stages-of-change model of Prochaska, DiClemente, and Norcross (1992). The model postulates five distinct stages: precontemplation, contemplation, action, maintenance, and relapse. These stages can be assessed via paper-and-pencil instruments, such as the University of Rhode Island Change Assessment (URICA). Different therapeutic strategies are employed, based on the patient's designated stage of change. MET/MI represents a clear departure from traditional drug abuse counseling strategies. Because acceptance of the addict iden tity is considered unimportant, patients are less likely to manifest overt resistance. Rather than emphasize powerlessness, this approach assumes that people have within themselves the capacity to change. Although the efficacy of MET/ MI for cocaine abusers has yet to be proven, it would appear that its unique focus on readiness should, at minimum, help patients to engage in other forms of therapy. In addition, a few studies have begun to support the use of MET/MI for treatment of cocaine abuse and dependence. In a small study examining 27 female workers with concurrent cocaine or heroin dependence, MI significantly reduced the women's cocaine use (Yahne, Miller, Irvin-Vitela, & Tonigan, 2002). Similarly, compared to patients who only underwent a detoxification program, patients who also received MI were more likely to be abstinent from cocaine following detoxification and demonstrated higher abstinence rates throughout the following relapse prevention treatment. In addition, MI was more effective for those patients with lower initial motivation (Stotts, Schmitz, Rhoades, & Grabowski, 2001). Finally, Brown and colleagues (1998) showed that, compared to patients who received meditation/relaxation, patients who received MI had better retention in treatment, though no differences were found in overall cocaine use. The researchers also found that MI patients who initially reported less motivation for change had higher rates of abstinence at follow-up than did MI patients reporting more motivation for change at baseline. These findings suggest that MET/MI strategies may be most effective for patients who come into drug treatment with low motivation.
The approaches described (i.e., relapse prevention, cue exposure/desensiti-zation, contingency management, and motivational interviewing) are somewhat technical and require specific training and supervision. Research-based interventions such as these appear to be the wave of the future, and most can be adapted for use in community-based programs. Frequently, treatment of cocaine dependence takes place within the context of a comprehensive drug treatment program. Although therapeutic modalities may be the same as for other drug abusers (e.g., education, and individual and group therapy), the intensity of treatment must be greater. Emphasis must be placed on the acquisition of skills that will enable the cocaine abuser to have more internal control, greater self-efficacy, and reduced likelihood of relapse. This means that treatment must have multiple "practical" components.
The first goal of treatment is to interrupt recurrent binges or daily use of cocaine and overcome drug craving. For patients who do not have serious psychiatric comorbidity, a structured outpatient program can be attempted prior to physically removing the person from the drug-using environment for treatment in a residential setting. While attempting to initiate abstinence, treatment should include daily or multiple weekly contacts and urine monitoring, with as many external controls as possible. Explicit practical measures to limit exposure to stimulants and high-risk situations should be individualized but might include monitoring and support by drug-free "significant others," discarding drug supplies and paraphernalia, breaking off relationships with dealers and drug-using comrades, limiting finances, changing one's telephone number and/ or geographic location, and structuring one's time during all waking hours. Instead of simply replacing cocaine's central role in one's existence, emphasizing lifestyle changes such as stress reduction, wellness, exercise, and leisure activities is important. This may be more difficult for persons of lower socioeconomic groups and/or those with an earlier onset of addiction. These persons lack the knowledge, experience, and resources to make these changes. Such patients may need linkage to other social services and habilitation, in addition to the rehabilitation just discussed. The involvement of significant others in the treatment of cocaine use disorders can have a positive impact. For instance, Higgins, Budney, Bickel, and Badger (1994) recently showed that patients who had family involvement were 20 times more likely to complete treatment. Finally, supportive therapies, including self-help groups, may provide positive role models, group spirituality, and the backing needed to assist in change. Special Cocaine Anonymous (CA) groups may be beneficial in addressing issues pertinent to cocaine's strong reinforcing properties and associated lifestyle. On the other hand, CA meetings may have detrimental effects by continuing to foster a sense of cocaine separatism.
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