Cocaine Use: Recommendations in Treatment and Rehabilitation

6. Other Influences On Treatment Effectiveness

6.1 Client Characteristics

Studies have found that there are many impediments to the treatment of cocaine-related problems (Gorelick, 1992). First, a very large percentage of people who use/abuse cocaine also use/abuse other substances, including alcohol, THC and heroin. This poly drug use is associated with more frequent psychopathology, discontinuation of treatment programs and relapse (Brady, et al., 1995; Brown, Serganian and Tremblay, 1993, 1994; Condelli, Fairbank, Dennis and Rachal, 1991). There is evidence that these groups are particularly resistant to treatment (Leal, Ziedonis and Kostien, 1994). Also, a large number of people either discontinue treatment

or continue to use substances during treatment (Agosti, Nunes and Ocepeck-Welikson, 1996). Agosti et al. (1996) have reported that approximately 55% of people drop out of treatment programs. Those who do discontinue treatment are more likely to be younger, less well-educated, to have begun using substances at an earlier age, and to be from minority groups. In addition, Hoffman et al. (1996) found that those who used cocaine regularly during the 12 months post-treatment were more likely to have attended fewer treatments, to be female, to be less educated, and to have been regular cocaine users prior to entering treatment. The latter, showing that those who used cocaine on a regular basis before treatment were more likely to relapse or discontinue treatment, is supported by a recent study comparing people who had or had not participated in self-help programs prior to seeking treatment. Weiss et al. (1996) reported that a significantly larger proportion of those who had attended self-help programs prior to treatment became abstinent within one month of treatment when compared to those not previously in self-help groups.

There is also evidence that there may be different types of cocaine users. Ball et al. (1995), using two different cluster analytic procedures, identified two subgroups of cocaine users. The Type B cocaine users, which constituted one third of their sample, compared to Type A users, had higher risk factors (e.g. family history and childhood behaviour problems), more antisocial behaviour and more psychiatric problems. These factors may play an important role for the assessment, treatment and prevention of cocaine use.

The above observations highlight the importance of individualized treatment planning and programming.

Table 6 Enhanced Treatment Programs

Study	Medicine	Subj- ects	Ret- en. 1	Red. Coc. 2	Red. Urg-es 3	Med/ Psy-ch Imp- rov. 4	Comments
Lam et al., 1995	Residential vs. Normal Community	Cocaine					Homeless participants.
Schneider et al., 1996	Day vs. Inpatient	Cocaine	-	?			Day treatment participants relapsed faster
Richard et al., 1995	Cognitive-Behavioural & Adjunct Therapy	Cocaine		-			Adjunct therapies included acupuncture, medication or biofeedback.
Schumacher et al., 1995	Enhanced vs.Usual Day Care	Cocaine		?			Homeless participants. Group therapy was the primary treatment. Enhanced group met more often halfway house used social learning approach.
Hoffman et al., 1996	Intensive vs.Regular group therapy	Cocaine		?			Intensive group met more often and could include individual and family therapy.
Wells et al., 1994	Relapse prevention vs. 12 step	Cocaine	-	-			Both groups improved.
Rosenblum et al., 1999	High intensity vs. Low intensity CBT	Cocaine		-			High severity users did better in high intensity treatment.
Note: 1. Increased Retention in Program 2. Reduced Cocaine Usage 3. Reduced Cocaine Craving 4. Medical/Psychological Improvement = treatment group improved compared to control group = no differences between groups ? = could not determine if differences occurred

6.2 Treatment Exposure

The issue of treatment exposure has been examined in a number of studies. The studies reported in Table 6 generally compare a regular program with an enhanced program. The enhanced programs included more frequent contact, e.g. daily rather than once or twice a week and/or a greater variety of treatment components, e.g. individual counselling and family counselling. The study results generally show that clients participating in an "enhanced program" versus the regular program had greater reductions in cocaine use than did the controls. (Richard et al., 1995; Hoffman et al., 1996; Lam et al., 1995; Schumacher et al., 1995; Schneider et al., 1996)

Schumacher and his colleagues (1995) compared an enhanced day-program (state of the art day-treatment model) versus a "usual care" program (twice weekly individual and group counselling with medical evaluation and referral). At the 12 months follow-up, they found that significant reductions in cocaine and other substance use and homelessness occurred in clients who attended an average of 4.1 days a week versus those who attended an average of less than one day a week. Schumacher et al. note that: "... greater attendance and consequently better outcome is more likely to occur in a program that requires more participation than a program that requires less" (Schumacher et al., 1995).

In a similar study, Hoffman et al. (1996) randomly assigned a sample of cocaine users of (primarily) crack cocaine to one of six different four month treatment conditions: standard group therapy twice a week or group counselling for five days a week using a cognitive behavioural approach with an emphasis on relapse prevention, and, within these two group treatment conditions, the provision of either no additional services, or individual psychotherapy, or individual psychotherapy plus family therapy. Greater treatment exposure was associated with less likelihood of regular use of cocaine, other substances or engaging in criminal behaviour at the 12 month follow-up. However, the study did not find outcome differences based on different treatment approaches.

Richard et al. (1995) compared a standard outpatient neurobehavioural group receiving individual treatment only, with a neurobehavioural group that was also receiving an adjunctive treatment involving one of either acupuncture, anti craving medication or biofeedback (brainwave therapy) for cocaine-dependent clients. At the nine month follow-up, it was found that clients receiving adjunct therapy stayed in treatment almost 60 days longer than those in the control group, and they also attended more days of the core neurobehavioural program. Further, retention in treatment significantly improved drug-use outcome as measured by cocaine-specific urinalysis, but the study did not demonstrate additional effects for adjunctive therapies beyond their role in treatment retention.

A very recent study, Rosenblum et al. (1999), found that, in a six month randomized trial of low-intensity versus high-intensity treatment, both groups showed declines in cocaine use, but subjects with more severe levels of cocaine use did better in high-intensity treatment.

Best Practice Guideline #3: Enhanced treatment (greater frequency of contact, more treatment components) is associated with reduced cocaine use at follow-up.

6.3 Treatment Setting

Studies that have compared the efficacy of inpatient/residential versus outpatient treatment programs have produced mixed results (Alterman, O'Brien and Droba, 1996; Hitchcock, Stainback and Roque, 1995; Khalsa et al.,1996; Lam et al., 1995; Schneider, Mittelmeier and Gadish, 1996; Schumacher et al., 1995). Khalsa et al. (1996), for example, found that inpatients who had long-term follow-up improved more than those in other programs. Lam et al. (1995) compared the efficacy of a sheltered residential program with stages of privileges to a community-based treatment program for homeless cocaine-abusing men. Their results showed that, although both groups improved, the residential program produced much higher reductions in cocaine use at the 6, 9 and 21 months follow-ups and greater residential stability at 6 and 9 months in comparison with the control group.

A study by Alterman et al. (1996) found equivalent effects for inpatient and day-patient programs. Similarly, in a comparison of day versus inpatient treatment for cocaine-dependent patients following an initial brief inpatient detox, Schneider et al. (1996), found that there were significant differences in rates of total abstinence in favour of the inpatient group at three months, but these differences had disappeared by six months. The authors conclude that the study results support the use of day treatment as a viable and cost-effective alternative to inpatient treatment for this group. However, it should be noted that the day-treatment group had a higher treatment drop-out rate.

Schneider et al. (1996), in an especially well-designed program, found that, at three months follow-up, the inpatient group had a significantly higher rate of abstinence (63%) compared to those in the day-treatment program (38%).

Finally, it is worth noting the findings from the recent U.S. Drug Abuse Treatment Outcome Study (DATOS) (NIDA , 1998). When four different types of treatment programs were compared (outpatient methadone programs, long-term residential programs, outpatient drug-free programs and short-term inpatient programs), there were substantial reductions in drug use among clients in all types of programs. The primary drug of abuse in these programs was cocaine, and, even in the outpatient methadone programs, 42% of clients abused cocaine. The percentages of clients reporting weekly or more frequent cocaine use prior to treatment was higher in both residential settings (66% and 67%) versus 42% in the outpatient settings. Thus reduction to approximately 20% across all four settings in reported weekly or more frequent cocaine use was more significant for the residential settings than for the outpatient settings.

Best Practice Guideline #4: Consistent with other literature in the substance treatment and rehabilitation field, research continues to support the cost-effectiveness of outpatient/day-treatment versus inpatient treatment. However, some cocaine-dependent clients may require the additional support provided by residential care or inpatient treatment, e.g. clients who are homeless.

6.4 Individual Versus Group Treatment

Many of the effective interventions discussed above have been delivered in an individual counselling format. However, Smokowski and Wodarski (1998) in a recent article on cognitive behavioural treatment for cocaine addiction, identify the group format as an important component of substance-abuse treatment. They note that, apart from the support and reinforcement provided by group members, the group format can also provide group-reward structures for programs that use contingency management.

In conclusion, unlike the conclusions arising from much of the research on using medications to treat cocaine addictions, it appears that behavioural methods are effective. This is especially true for behavioural procedures that provide incentives for cocaine-free urine samples and include cognitive behavioural treatment.

Multicomponent programs, that address cocaine use, family and financial issues, and relapse prevention, appear to retain people in programs longer, reduce cocaine usage, and reduce the use of other substances. Finally, provision of continuing care may improve outcome.