Title: A National Evaluation of Treatment Outcomes for Cocaine Dependence
Authors: D. Dwayne Simpson, PhD, George W. Joe, EdD, Bennett W. Fletcher, PhD,
Robert L. Hubbard, PhD, M. Douglas Anglin, PhD
Journal: Archives of General Psychiatry 1999 Vol 56:507-514
Background: Although the epidemic proportion of cocaine use seen in the 1980's and early
1990's has decreased, cocaine still presents a major problem of illicit drug use. Without any
proven pharmacotherapies for cocaine use, psychosocial interventions are the main approach to
treatment. Many of these treatments are based on psychosocial learning principles such as
contingency management programs that offer rewards or incentives for positive behavior
changes. In addition, there are cognitive behavior programs for promoting conceptual
restructuring and training in cognitive coping techniques in high risk situations, as well as
adaptations of supportive expressive psychodynamic therapy that are available for treatment of
cocaine. Despite the existence of manualized therapeutic treatments using various specific
approaches, most treatment settings rely on very eclectic approaches that combine individual and
group counseling with the involvement of 12-step and other self-help programs. Therefore, it is
necessary to study programs in the community and determine whether treatments as currently
being delivered are efficacious.
Objective: To evaluate post treatment outcomes of community treatments of cocaine
Type of Article: Study
Design Naturalistic nonexperimental evaluation design
Patients: 1605 cocaine dependent patients from 11 cities located in the United States who
were admitted from November 1991 to December 1993 to 95 community based treatment
programs in the National Drug Abuse Treatment Outcomes Study. 542 patients were admitted to
19 long term residential programs, 258 patients were admitted to 24 outpatient drug free
programs and 605 patients were admitted to short term inpatient programs.
Outcome Measured: Time to relapse to weekly and more frequent cocaine in the first year after
discharge was examined in relation to patient problem severity at admission to the treatment
program and length of stay.
1) Of 1605 patients, 377 (23.5%) reported weekly cocaine use in the year following treatment.
2) This is a significant reduction from baseline where 73.1% reported weekly cocaine use in the
year before admission.
3) 18% have returned to another treatment program.
4) Higher severity of patient problems of program intake and shorter stays in treatment are in
less than 90 days are related to higher cocaine relapse rates.
Conclusions: Patients with the most severe problems were more likely to enter long term
residential programs and better outcomes were reported for those who have treatment stays of 90
days or longer. Cocaine relapse for patients with few problems of program intake were most
favorable across all treatment condition, but better outcomes for patients with medium to high
level problems were dependent on longer treatment stays.
Commentary: This large naturalistic treatment study demonstrates that patients who enter
treatment for cocaine dependence can have significant reductions in the use of cocaine in the
year following treatment. It is also important to recognize that patients with psychiatric
comorbidity should have longer treatment stays in residential treatment is more beneficial for
these patients. Internists should recognize that referring cocaine dependent patients to treatment
can improve their functioning and significantly reduce their cocaine use. Continued support of
these patients through their treatment and post treatment will help in maintaining positive
outcome for the treatment.
Title: Psychosocial Treatments for Cocaine Dependence
National Institute on Drug Abuse collaborative Cocaine Treatment Study
Authors: Paul Crits-Christoph, PhD, Lynne Sequeland, PhD, Jack Blaine, MD, Arlene
Frank, PhD, Lester Luborsky, PhD, Lisa S. Onken, PhD, Larry r. Muenz, PhD, Michael E.
Thase, MD, Roger D. Weiss, MD, David R. Gastfriend, MD, George E. Woody, MD, Jacques
P. Barber, PhD, Stephen F. Butler, PhD, Dennis Daley, MSW, Ihsan Salloum, MD, Sarah
Bishop, MA, Lisa M. Najavits, PhD, Judy Lis, MSN, Delinda Mercer, PhD, Margaret L.
Griffin, PhD, Karla Moras, PhD, Aaron T. Beck, MD
Journal: Archives of General Psychiatry 1999 Vol 56:493-501
Background: Opioid dependence is the only area in which pharmacotherapy has been
determined to be efficacious. Since there are no efficacious pharmacotherapies for the treatment
of cocaine dependence, the primary mode of treatment is based on psychosocial therapies.
Psychotherapy has been proven to be a useful addition to the standard drug treatment
approaches, especially for patients with high levels of concurrent psychiatric problems. Some
studies have demonstrated the need to match patients with the appropriate treatment based on the
presence of psychiatric pathology. In an attempt to determine the efficacy of various
psychosocial approaches to treatment of cocaine dependence for manualized approaches to
treatment were studied. All of these have demonstrated some efficacy in previous studies.
Objective: To study the efficacy of 4 psychosocial treatments for cocaine dependent patients.
Type of Article: Study
Design Randomized controlled clinical trial
Setting: Outpatient treatment programs of cocaine dependence patients, 287
patients from the DSM-IV criteria for cocaine dependence were randomized for study
Interventions: All interventions were manually guided treatments. Included: 1)
individual drug counseling plus group drug counseling 2) cognitive therapy plus group drug
counseling 3) supportive expressive therapy plus group drug counseling 4) drug counseling
alone. Treatment included up to 36 possible individual sessions and 24 group sessions over 6
months. Subjects were assessed monthly during active treatment and at 9 and 12 months after
Outcome Measured: Primary outcome measures were the Addiction Severity Index -Drug Use
Composites score and the number of days of cocaine use in the past month prior to assessment.
1) Individual group drug counseling plus group drug counseling showed the greatest
improvement on the addiction severity index drug use composite score. It was also superior to
the other therapies and the number of days of cocaine use in the past month.
2) Cognitive therapy plus group drug counseling and supportive expressive therapy plus group
drug counseling were not superior on patients with antisocial personality traits.
3) All the treatments showed significant improvements from baseline in cocaine use in the past
4) There was no evidence that therapists or counselors in recovery from addiction had better
outcomes for their patients.
Conclusions: Compared with professional psychotherapy a manual guided combination of
intensive individual drug counseling and group drug counseling has promise for the treatment of
Commentary and Impact on Internal Medicine and Limitations: This study demonstrates
that there is efficacy in the use of intensive psychosocial treatments in the treatment of cocaine
dependence. All of the therapies described had improvement in cocaine use when compared to
baseline. However, limitations to this study are based on the fact that these are all manually
guided treatments that require significant training for the treatments to be appropriately delivered
by the therapist. It would be very difficult for internists to provide this type of treatment in the
office setting. However, it should encourage internists to refer patients with cocaine dependence
to programs offering intensive psychosocial treatments.
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