An enhanced positive reinforcement model for the severely impaired cocaine abuser

A treatment model for craving identification and management

This article presents an addiction treatment model based on craving identification and management (CIM). Craving is broadly defined as the desire to use alcohol or other drugs; it increases the likelihood of use of these substances. In the CIM Model treatment interventions are referenced to craving, i.e., helping clients to identify their craving level and equipping them with strategies to avoid use. Four causes of craving are identified: (1) environmental cues (triggers): exposure to people, places, and things associated with prior drug-using experiences may cause immediate and overwhelming craving; (2) stress: addicted persons experience stress as craving; (3) mental illness; and (4) drug withdrawal: symptoms of both mental illness and withdrawal lead to craving if clients associate use with relief of these symptoms. The CIM Model incorporates four service delivery elements: Relapse Prevention Workshop, individual counseling, medical/psychiatric services, and screening for ongoing drug use. At its core, the CIM Model asks clients to be aware of craving, analyze its causes, and, based on those causes, implement specific strategies to prevent and manage craving. The CIM Model combines several treatment components, including control of exposure to environmental cues, establishment of a daily schedule, the use of behaviors that dissipate craving (tools), and treatment (with medications when appropriate) of mental health and withdrawal symptoms. The CIM Model is a client-derived approach to achieving and maintaining sobriety based on a process of analyzing craving and managing it with an individualized program of recovery activities.

Motivationally enhanced group counseling for substance users in a soup kitchen: a randomized clinical trial

Soup kitchens tend to serve residentially unstable adults characterized by a high prevalence of substance abuse. In this study, 289 soup kitchen guests who reported drug or alcohol problems were randomly assigned to information and referral (I&R) plus peer advocacy (peers encouraging subjects to participate in other services) (N = 139) or to an experimental 12-session motivational group (three sessions per week for 4 weeks) followed by a 36-session cognitive-behavioral group (three sessions per week for 12 weeks), plus I&R and peer advocacy. Mean age was 42; 82% male; 68% African-American; 81% unstable residence; 14% HIV+. Experimentals were significantly more likely than the controls to have increased their participation in some type of substance abuse intervention during the follow-up period. In addition, experimentals were significantly more likely than controls to have reduced both drinking and heavy drinking at follow-up (there was no difference between groups in reduction of cocaine use). Interaction analysis indicated that the experimental intervention was more effective for participants with higher rather than lower substance abuse severity at baseline. These results support the concept that motivationally enhanced group counseling, provided as a low-threshold outreach intervention, can help to increase participation in formal treatment and 12-step groups and to reduce substance abuse, particularly for those starting with high severity of use.

Treatment responsivity of cocaine-dependent patients with antisocial personality disorder to cognitive-behavioral and contingency management interventions

This study compared the efficacy of 2 approaches for the treatment of cocaine dependence among methadone-maintained patients with and without antisocial personality disorder (ASPD). Patients were randomly assigned to 4 study conditions: cognitive-behavioral treatment (CBT), contingency management (CM), CBT with CM, or methadone maintenance. The Structural Clinical Interview for Mental Disorders-IV was administered to 108 patients to assess ASPD. A 2-way analysis of variance showed that patients with ASPD were more likely to abstain from cocaine use during treatment than patients without ASPD. The strong treatment effect for ASPD patients was primarily due to the CM condition. Regression analyses showed that ASPD remained significantly related to CM treatment responsivity while controlling for other factors.

Improving treatment engagement and outcomes for cocaine-using methadone patients

A task-based behavioral contingency-the "treatment reinforcement plan" (TRP)-was implemented with cocaine-using methadone patients to increase treatment engagement and retention. Subjects (N = 57) were rewarded up to $15 per week in travel/food/entertainment vouchers for the completion of tasks related to their individual treatment needs. Eighteen types of tasks were contracted and completed with varying frequency. The largest categories of tasks were related to therapy attendance (N = 272; 58% completed), obtaining public entitlements (N = 165; 61% completed), medical/psychiatric appointments (N = 155; 70% completed), and obtaining Medicaid (N = 96; 54% completed). The highest proportion of tasks completed were related to human immunodeficiency virus (HIV) testing/education (N = 19; 100% completed), managing money (N = 17, 94% completed), and legal matters (N = 16, 88% completed). Successful TRP involvement during months 1-2 predicted longer retention in methadone treatment, greater therapy attendance during months 3-6, and lower proportion of cocaine-positive urines at 6-month follow-up. This research supports recent findings that early treatment engagement is associated with improved therapeutic relationships, increased retention, and reduced cocaine use. Behavioral counseling techniques may be especially helpful in addressing the complex needs of high-risk methadone patients, which in turn may facilitate treatment process and positive outcomes.

Evaluation of an alternative program for MMTP drop-outs: impact on treatment re-entry

INTRODUCTION

Retention in a Methadone Maintenance Treatment Program (MMTP) is predictive of abstaining from heroin and has other benefits. Many individuals leave treatment before they experience these positive outcomes.

OBJECTIVE

This research project targeted MMTP drop-outs with an intervention designed to assist them in returning to drug treatment.

METHODS

Subjects who had left MMTP within the prior 12 months were randomly assigned to intervention or comparison groups. The 3-month long intervention consisted of street outreach, cognitive behavioral groups, and individual counseling. Data were analyzed for 175 subjects who were out of treatment at baseline and who returned for a 6-month follow-up interview (Intervention group, N=111; Comparison group, N=64).

RESULTS

A total of 87% of subjects assigned to the intervention condition participated in at least one component. Intervention subjects who attended two or more cognitive behavioral group sessions were more likely than those who attended 0-1 sessions or those in the comparison group to have returned to treatment during the 6 month follow up time period (72 vs. 53 vs. 50%, respectively, P<0.05, chi square test).

CONCLUSION

MMTP drop-outs need not be lost to the drug treatment system if special efforts are made to engage them in interventions developed to encourage treatment re-entry.

Treating cocaine-using methadone patients: predictors of outcomes in a psychosocial clinical trial

Cocaine-using methadone patients in two clinics were assigned to 8 months of enhanced methadone treatment-primarily cognitive-behavioral therapy (CBT) for cocaine use-while similar patients in two "sibling" clinics were assigned to standard methadone treatment during 1995-1998. Cocaine use declined significantly from baseline to 4- and 12-month follow-ups. Patients receiving CBT rated the quality of their counseling relationship higher and obtained more supportive services than those receiving standard treatment. However, study treatment condition itself was not associated with outcome. Baseline measures associated with poorer outcomes across both treatment conditions were: currently enrolled in methadone treatment (in contrast to being newly enrolled), higher cocaine use frequency, greater cocaine use associated problem recognition, and an ambivalent attitude toward methadone. The results are consistent with some previous clinical trials showing that psychosocial treatments of different intensities result in similar declines in cocaine use. The findings indicate that methadone maintenance treatment can help dually-addicted patients reduce their cocaine use.

Engaging hospitalized heroin-dependent patients into substance abuse treatment

The purpose of this study was to evaluate a 6-month outpatient program developed to improve abstinence and other health and social problems of heroin-addicted persons hospitalized in an urban academic medical center's medical or surgical unit and referred from the Substance Abuse Consult Service. Treatment intervention consisted of methadone therapy, daily group therapy, individual case management, medical and psychiatric consultation, and social services. The first 67 patients referred were followed for 6 months. Outcome measures were retention in treatment, urine drug screens, and health and social indicators. Patients averaged 19 weeks in treatment, with 52% of patients completing the 6-month program. Urine toxicology screens showed a reduction of illicit drug use. Patients improved deficits in health and social indicators by obtaining medical coverage, keeping outpatient medical appointments, and improving their housing conditions. Findings suggest that this combination of intensive psychosocial treatment with opioid substitution following an acute illness substantially impacts treatment outcomes. Implications for service delivery and health-care economics are discussed.

Enhanced treatment outcomes for cocaine-using methadone patients

Cocaine dependent methadone patients were randomly assigned to 6 months of high intensity cognitive-behavioral therapy or low intensity therapy. A repeated measures ANOVA was conducted with patients stratified on severity of cocaine use at baseline. Both treatment groups showed significant and equivalent reductions in cocaine use during the post-treatment period. Completing either therapy and lower cocaine severity at baseline were associated with lower proportion of cocaine-positive urines across a 48-week post-treatment period. Examination of the treatment x cocaine severity interaction provided some evidence that high-severity patients improved more if exposed to high intensity treatment than to low intensity treatment. Positive outcomes for therapy completers relative to non-completers increased over time. The results are consistent with several clinical trials showing that: (1) participation in treatment is associated with reductions in cocaine use; and (2) the relationship between treatment intensity and outcome is not linear and may better be explained by an interaction between patient and treatment factors.

Getting off the fence: procedures to engage treatment-resistant drinkers

Historically there have been few options for individuals seeking help for treatment-resistant loved ones with substance abuse problems. This article describes a program with empirical backing called Community Reinforcement and Family Training (CRAFT). This cognitive-behavioral treatment teaches the concerned significant other how to use behavioral principles to reduce the loved one's drinking and to encourage the drinker to seek treatment. Additionally it assists the concerned significant other in alleviating other types of stress and in introducing meaningful reinforcers into his or her own life.

Follow-up of inpatient cocaine withdrawal for cocaine-using methadone patients

Significant proportions of opiate-dependent persons entering methadone treatment are also addicted to cocaine and continue to use cocaine during treatment. One standard response to cocaine use has been inpatient detoxification. This study examined the effectiveness of this procedure by comparing pre- and posttreatment urine toxicologies for methadone patients who had been hospitalized for cocaine withdrawal. The results showed a negligible effect on cocaine abstinence (less than 1 out of 10 patients abstinent 12 weeks after detox) and a modest reduction in the frequency of cocaine use (one-quarter decline in urine tests positive after 12 weeks). These findings raise serious doubts about the cost-effectiveness of inpatient cocaine detoxification. Better strategies need to be implemented to enhance the chances of remaining abstinent once detoxified.

Video techniques with chemically-dependent patients

This paper describes the use of videotaping as an adjunctive intervention in the treatment of substance-dependent patients. In the context of a cognitive-behavioral treatment extensively modified to work with inner-city, methadone-maintained cocaine users, videotaping in both individual and group formats is described. Video sessions create an opportunity for patients to reflect on their experience, enhance their self-esteem, aid in teaching social skills, and help hard-to-engage patients begin to participate in treatment. In order to compete with both the powerfully reinforcing qualities of cocaine and the extreme degree of avoidance exhibited by this population, therapy has to provide intense capturing experiences at the outset of treatment. Patient's reactions indicate that the experience they have is captivating and stimulating more than most other early therapy experiences. It is additionally concluded that the use of video can be instrumental in addressing the severe psychological deficits of this population that otherwise impede treatment efforts. While the role of video was not independently evaluated for its contribution to patient retention, 62% of patients were retained through completion of an intensive 6-month protocol.

Patients' perspective on the process of change in substance abuse treatment

Understanding how methadone patients view treatment for their cocaine dependence and the process of recovery from cocaine addiction, is important in helping to design treatment strategies that will effectively motivate and engage these patients. There has been little development or testing of treatment approaches for cocaine-dependent, methadone-maintained patients and research on the effectiveness of outpatient cocaine treatment has excluded the perspectives of patients. This article presents the patient's view, using ethnographic interviews with 17 patients enrolled in a relapse prevention treatment program for cocaine dependence, that was set up in an inner-city methadone maintenance clinic. Findings suggest that despite initial ambivalence or resistance, patients became highly engaged by the positively reinforcing treatment intervention. In addition, patients found the highly structured nature of the program and the cognitive behavioral techniques critical in reducing their cocaine use. Finally, patients responded positively to the psychodynamic issues addressed within a cognitive behavioral format, and reported improvements in certain areas of psychological functioning.

Treatment intensity and reduction in drug use for cocaine-dependent methadone patients: a dose-response relationship

This study examined the impact of treatment intensity on cocaine use. Seventy-seven cocaine-using methadone patients were enrolled in a six-month, structured, manual-driven, cognitive-behavioral treatment program. Sessions consisted of five individual and/or group sessions per week. At intake subjects showed extensive polydrug abuse, psychiatric comorbidity, criminal histories, and HIV risk behaviors. Treatment intensity was measured by dividing number of sessions attended into quartiles. Paired comparisons, within treatment quartiles, were made between subjects' intake and six-month self-reports of cocaine use. Subjects in quartiles two through four showed significant reductions in frequency of cocaine use at follow-up, with subjects who received the most treatment showing the greatest reductions in cocaine use. Bivariate and multivariate analyses showed that treatment sessions attended remained a strong predictor of reduction in cocaine use at follow-up, even after controlling for drug use at intake and background variables. The results indicate that there is a substantial treatment dose-response relationship.