Chapter 3Approaches to Treatment

Aslargenumbersofpeoplewithsubstanceusedisordersbegantoseektreatmentintheearlyandmid1980s,"treatment"forstimulant
abuseanddependencewasinvented.Thetreatmentsystemthatrespondedmostquicklywasthe28dayMinnesotaModelhospitalindustry.
Thenumberofthese28day,forprofittreatmentunitsgrewatanastonishingrate.Tensofthousandsofcocaineusersweretreatedin
theseprogramswithstrategiesadaptedfromthetreatmentofalcoholics.Today,thereislittleempiricalevidencetoassesstheefficacyof
theseefforts.

Duringthissameperiod,allsortsofunconventionalremedies,includinghealthfoods,aminoacids,hottubs,electronicbraintuners,and
other"NewAge"treatmentsemergedanddisappeared.Researcheffortstodevelopscientificallybasedtreatmentsbeganduringthis
periodwithbehavioraltechniqueslikecontingencycontracting(AnkerandCrowley,1982)andmedicationevaluationsincludingtheuseof
desipramine(Norpramine)(TennantandRawson,1983GawinandKleber,1984).Overthe15yearperiodsincetheseearlyefforts,an
entirestimulantusedisordertreatmentliteraturehasdeveloped.

Thischapterreviewsthecurrentstateofknowledgeonthetreatmentofstimulantusedisorders,beginningwiththeapproachesthathave
themostrigorousempiricalsupport.Otherapproacheswithlesssupportinthescientificliteraturearepresentedlaterinthechapter.At
theendofthechapterisareviewofthecurrentstateofmedicationsresearchinthetreatmentofstimulantusedisorders.Althoughatthe
timeofthiswritingtherewerenomedicationswithdemonstratedclinicalefficacy,theongoingprogramofresearchsponsoredbythe
NationalInstituteonDrugAbuse(NIDA)holdsgreatpromiseforimportanttreatmentadvances.Forthisreason,thecurrentstateofthis
researcheffortwillbereviewed.

Documented Treatment Approaches

How To Measure Effectiveness

Thischapterreviewswhatisscientificallyknownabouteffectivetreatmentsforstimulantusedisorders.Tobejudgedeffective,a
treatmentmusthavebeentestedanddemonstratedtobeeffectiveinarandomizedclinicaltrial.Manypsychosocialandpharmacological
treatmentshavebeeninvestigatedinsuchtrials.Severalpsychosocialtreatmentsforstimulantabuseanddependencehavebeenfoundto
beeffective,buttodate,noreliablyeffectivepharmacologicaltreatmentshavebeenfound.Whathasbeenlearnedsofarabouttheuseof
psychosocialandpharmacologicaltreatmentsforstimulantuseissummarizedbelow.Almostalloftheinformationhasbeengleanedfrom
studiesconductedwithcocaineusers.Similarstudieswithmethamphetamine(MA)usershavenotbeenreported.However,evidence
fromatleastonestudyindicatesthatcocaineandMAusersrespondsimilarlytopsychosocialinterventions,suggestingthatwhathasbeen
learnedfromcocaineusersmaybeapplicabletoMAusers(Huberetal.,1997).

Randomizedclinicaltrialsarethebestavailablemethodfordeterminingwhetheraninterventionimproveshealth.Arandomizedclinical
trialisaprospectivestudycomparingtheeffectofsomeinterventionagainstacontrolinterventioningroupsofclientswhoareassigned
randomlytotherespectivetreatmentgroups(seeFriedmanetal.,1983).Insuchtrials,clientsfromaparticularpopulationsample(e.g.,
alladmissionstoclinicXduring1998meetingaparticularlistofinclusionandexclusioncriteria)arerandomlyassignedtothe
interventionunderstudyortoacontrolcondition.Randomassignmentensuresagainstpossiblebiasinassigningparticularkindsofclients
totherespectivegroupsandhelpstodistributeevenlybetweenthegroupsanysubjectcharacteristicsthatmightinfluenceoutcomes.

Prospectivemeansthatclientsinthegroupsarestudiedfromthestartoftheinterventionasopposedtoretrospectivelycompilingthe
informationaftertheinterventioniscompleted.Retrospectiveobservationstendtobelessaccuratebecauseofrelevantinformationnot
beingcollected,gettinglost,orbeingdistortedthroughrelianceonpeople'srecall.Havingacomparisonorcontrolgroupisessential
becausemostproblemshavesomelevelofvariability(i.e.,theywaxandwaneovertime)andbecausemanyhealthproblemsresolveover
timewithoutanyformaltreatment.Themosteffectivewaytodeterminewhetheranyobservedchangesareduetothetreatmentbeing
investigatedratherthannaturalvariabilityisbycomparingagainstasimilargroupofclientswhoeitherreceivednotreatmentorreceived
astandardtreatment.

Someofthealternativestorandomizedclinicaltrialscommoninthesubstanceusedisordertreatmentfieldcanprovideusefulinformation
buthaveseriouslimitationsthatmustberecognized.Forexample,followingagroupofclientswhoreceivedaparticulartreatmentinthe
absenceofacomparisongroupcanbeinformativeintermsofcharacterizingwhathashappenedtothem(e.g.,percentagerelapsed,
percentagewhoreceivedadditionaltreatment,amountofchangefrompretoposttreatment),butsuchobservationsdonotpermitany
scientificallyvalidinferencesregardingtheroleofthetreatmentprovidedtoanyofthechangesobservedduringfollowup.Forthat
purpose,acomparisongroupisnecessary.Anychangesobservedmighthaveoccurredintheabsenceoftreatment.Withoutacomparison
grouptheresimplyisnowaytoruleoutthatpossibility.Similarly,whenclientsthemselvesselectgroupmembership,asopposedtobeing
assignedbytheresearcher,onecannotmakevalidinferencesabouttheroleoftreatmenttooutcome.Forexample,comparingtreatment
completerstodropoutsiscommonandmaybeinformativeintermsofcharacterizinghowthegroupsfared,butitisnotscientificallyvalid
toinferthatanydifferencesobservedbetweenthemwereduetothedifferentamountsoftreatmentreceived.Itverywellcouldbethat
someotherfactor(e.g.,differencesintheamountofotherdemandsontheirtime)wasresponsiblebothforthedifferentialretentionrates
andforthesubsequentdifferencesobservedatfollowup.

Psychosocial Treatment Approaches

Thepsychosocialinterventionsdemonstratedthusfartobeefficaciousinrandomizedclinicaltrialswithstimulantusersshareacommon
featureofincorporatingwellestablishedpsychologicalprinciplesoflearning.

Itisimpossibletoquantifyallaspectsofpsychosocialtreatment.Oftentherapistsworkinginthesameclinicandusingthesametreatment
approachdiffergreatlyintermsoftheprogresstheirclientsmake.Putsimply,sometherapistsappeartobeveryeffectiveandothers
relativelyineffective.Theuseofcarefullypreparedtreatmentmanualsreducessuchbetweentherapistdifferences.Treatmentmanuals
increasethelikelihoodthattherapistswilldeliverauniformsetofservicestotheirclients.Thatdoesnotcomeatthecostofeliminating
therapists'clinicaljudgmentorflexibility.Acarefullypreparedmanualrecognizestheimportanceofclinicaljudgmentandflexibilityin
addressingtheindividualneedsofclientsandincorporatesthosefeaturesintothemanual.Consideringthateffectivetreatmentsand
associatedmanualsareavailable,usingthemisprudentandwillhelpensurethatclientsreceivetheservicesthatresearchhasshowntobe
effective.

Community-Reinforcement-Plus-Vouchers Approach
Communityreinforcementisanindividualizedtreatmentdesignedtopromotelifestylechangesinseveralkeyareasthatareconduciveto
successfulrecovery(seeMeyersandSmith,1995SissonandAzrin,1989).First,clientswithspouseswhoarenotthemselvesusersare
offeredmaritaltherapytoimprovethequalityoftheirrelationshipsinareciprocalandrewardingmanner.Second,clientswhoare
unemployed,employedinjobsthatarehighriskforsubstanceabuse,orneedvocationalassistanceforsomeotherreasonreceivehelpin
thatdomain.Third,clientsarecounseledandassistedindevelopingnewsocialnetworksandrecreationalpracticesthatpromoteand
supportrecovery.Selfhelpparticipationisnotmandatorybutisoftenusedasaneffectivemeansofdevelopinganewsocialnetwork.
Fourth,varioustypesofskillstrainingareprovideddependingonindividualizedclientneeds,includingsubstancerefusalandassociated
skills,socialskills,timemanagement,andmoodregulationtraining.Finally,clientswithalcoholusedisordersandnomedical
contraindicationsareofferedaprogramofdisulfiram(Antabuse)therapycoupledwithstrategiestosupportmedicationcompliance.

Voucherbasedincentiveprogramsaredesignedtofacilitateretentionintreatmentandtopromoteinitialabstinencefromstimulants.Such
incentiveprogramsareknownascontingencymanagementinterventions,whicharediscussedfurtherbelow.Inthistreatment,clients
earnvouchersthatareexchangeableforretailitemscontingentonstimulantfreeurinalysisresultsduringtheinitial12weeksofthe24
weektreatment.Urinalysismonitoringisconductedthriceweeklyduringthatperiod.Thevouchersystemusedinstudiesevaluatingthis
treatmentincludedincentivesworthamaximumofapproximately$980acrossthecourseoftreatment.Sincethosestudieswere
completed,othershavereportedeffectivevoucherprogramsusinglowercostincentives(Tuseletal.,1995)anotherprogramobtainedall
itsincentivesviadonationsfromcommunitybusinesses(Amass,1997),althoughtheefficacyofthisprogramwasnotevaluated.How
valuabletheincentivesmustbetosignificantlyimproveoutcomeshasnotyetbeenevaluated.

Theefficacyofthecommunityreinforcementplusvouchersapproach,deliveredasacomprehensive,standalonetreatment,issupported
bythreerandomizedclinicaltrials(Higginsetal.,1993b,1994b,1997),withseveraladditionaltrialssupportingtheefficacyofparticular
componentsofthatapproach(e.g.,Silvermanetal.,1996).Thefirsttrialexaminedtheefficacyofthistreatmentcomparedwithstandard
outpatientcounseling(Higginsetal.,1993b).Treatmentwas24weeksindurationwith6monthsofadditionalfollowup.Thecommunity
reinforcementplusvoucherstreatmentretainedclientssignificantlylongeranddocumentedsignificantlylongerperiodsofcontinuous
stimulantabstinencethandidstandardcounseling.Forexample,58percentofclientsassignedtothecommunityreinforcementplus
voucherstreatmentcompleted24weeksoftreatmentcomparedwith11percentofthoseassignedtostandardcounseling.Furthermore,of
theclientsinthecommunityreinforcementplusvouchersgroup,68percentweredocumentedtohaveachieved8weeksofcontinuous
cocaineabstinence,and42percenthad16weeksofcontinuousabstinence.Oftheclientsinthestandardcounselinggroup,only11percent
weredocumentedtohaveachieved8weeksofcontinuouscocaineabstinence,andonly5percenthadachieved16weeksofcontinuous
abstinence.Followupassessmentsrevealedanotherimportantdifference:Greatercocaineabstinencewasdocumentedat6,9,and12
monthsaftertreatmententryinthegroupthatreceivedcommunityreinforcementplusvoucherstreatmentthaninthosewhoreceived
standardcounseling(Higginsetal.,1995).

Adetailedmanual(BudneyandHiggins,1998)thatwasdesignedspecificallytoguidecliniciansinthedaytodayimplementationofthis
approachwaspublishedrecentlybyNIDAandisavailableatnocostviatheNIDAClearinghouse(18007296686)orcanbe
downloadedfromthewebsitehttp://www.nida.nih.gov/TXManuals/CRA/CRA1.html

Contingency Management
Thevouchersystemmentionedaboveisacontingencymanagementintervention(alsoreferredtoascontingencycontracting).
Contingencymanagementisawellknownbehavioralinterventionthatisdesignedtoincreaseordecreasedesiredbehaviorsbyproviding
immediatereinforcingorpunishingconsequenceswhenthetargetbehavioroccurs.Contingencymanagementhasbeenusedwith
considerableeffectivenessinthetreatmentofavarietyoftypesofsubstanceusedisordersandisveryusefulfortreatmentplanning
becauseitsetsconcreteshorttermandlongtermgoalsandemphasizespositivebehavioralchanges(StitzerandHiggins,1995).
However,relyingexclusivelyonpunitiveconsequencesincontingencymanagementinterventionsisnotrecommendedbecausedoingso
canpromoteearlytreatmentdropout(Stitzeretal.,1986).

Thevoucherprogramhasbeendemonstratedtobeefficaciouswhendeliveredapartfromthecommunityreinforcementtreatment.
Silvermanandcolleagues,forexample,demonstratedthatvoucherscontingentoncocainenegativeurinalysisresultsincreasecocaine
abstinenceinmethadonemaintenanceclientswhoabusecocaine(Silvermanetal.,1996).Tuselandcolleaguesdemonstratedreductionsin
allillicitsubstanceabusewithcontingentvouchers(Tuseletal.,1995).

Althoughvouchersareawellsupportedcontingencymanagementinterventionforincreasingabstinenceinstimulantusers,othermethods
arealsoeffective.Examplesamongmethadonemaintenanceclientsaretakehomemethadonedoses(whicheliminatetheneedfor
methadoneclientstovisittheclinicdailytoconsumetheirmedicationunderstaffsupervision)(Stitzeretal.,1992),continuanceof
methadonemaintenancetreatmentcontingentonabstinencefromcocaine(KidorfandStitzer,1993),andevenasimplesystemwherein
publiclydisplayedgoldstarsandinexpensivegifts(e.g.,coffeecups,gasolinecoupons)areearnedforsubstanceabstinenceand
counselingattendance(RowanSzaletal.,1994).

Contingentmethadonetakehomedoseshavebeenusedeffectivelywhencoupledwithothertreatmentservices.Anexcellentexampleof
thiswasprovidedbyMcLellanandcolleagues(McLellanetal.,1993).Methadonemaintenanceclientswererandomlyassignedtooneof
threeconditionsthatprovidedincreasinglevelsofservices.Twoofthethreegroupsreceivedmethadonetakehomedosescontingenton
negativeurinalysisresultsandproofofcurrentemployment.Thesegroupsalsoreceivedadditionalservicesnotprovidedtotheminimal
servicegroup.Thetwogroupsgiventheopportunitytoearncontingenttakehomemethadonedosesachievedhigherratesofcocaineand
opiateabstinencethandidclientsreceivingnoncontingenttakehomedoses.

Iguchiandcolleaguesinvestigatedwhethercocaineabstinencecouldbeincreasedthroughcontingentreinforcementofcompliancewith
individualizedtreatmentplansratherthannegativeurinalysisresults(Iguchietal.,1997).Newlyadmittedmethadonemaintenanceclients
wereassignedtooneofthreegroups:(1)acontrolgroupreceivingstandardtreatmentatthemethadoneclinic(thestandardgroup)(2)a
groupreceivingstandardtreatmentplusmonetaryvoucherscontingentonthesubmissionofsubstancefreeurinespecimens(urinalysis
contingentgroup),or(3)agroupreceivingstandardtreatmentplusthesamemonetaryvouchersbutcontingentoncompletingtreatment
plantasks(treatmentplangroup).Thethirdgroupdemonstratedsignificantlygreaterreductionsinillicitsubstanceusethandidtheother
twogroups.
Contingencymanagementcanbeeffectivewithmoredifficulttotreatsubgroupsofstimulantusers.Forexample,acontingency
managementapproachthatwasefficaciousinhomelessstimulantuserscombinednonhospitaldaytreatmentwithaccesstoworktherapy
andhousingcontingentonsubstanceabstinence(Milbyetal.,1996).Nearlythreefourthsofthesubjectsinthisstudywereprimarily
crackcocaineusers.Theywererandomlyassignedtoreceiveeitherenhancedorusualcare.Enhancedcareconsistedof2monthsof
clinicattendancefor5.5hourseachweekday,transportationtoandfromtheclinic,lunch,psychoeducationalgroups,andindividualized
counseling.

Duringthelast4monthsofthetrial,theintensityofdaytreatmentwasreducedtoallowsubjectstoparticipateinaworktherapyprogram
refurbishingcondemnedhousesinwhichtheycouldliveforamodestrentalfee.Participationintheworkprogramandhousingwere
contingentontheprovisionofweeklyrandomurinalysistesting.Drugpositiveresultsprecludedsubjectsfromworkingintheprogramand
requiredthemtovacatethehousingwithin2weeks.Theworkandlivingarrangementscouldberesumedonsubmissionoftwo
consecutivesubstancefreeurinespecimens.Usualcareconsistedoftwiceweekly,12Steporientedgroupandindividualcounseling,
medicalevaluationandtreatmentorreferral,andreferralstocommunityagenciesforhousingandvocationalservices.Enhancedcare
increasedcocaineabstinencesignificantlyatthe2monthassessment,althoughnotatthe6or12monthassessments.Enhancedcarealso
producedgreaterreductionsinalcoholuseateachassessmentandsignificantlyfewerdayshomelessatthe6and12monthassessments.

Pregnantwomenareanotherimportantsubgroupwithwhomcontingencymanagementhasbeenevaluated,althoughonlyintheformof
preliminarystudies.Intwopilotstudies,pregnantwomenwereofferedincentivesforattendanceatprenatalclinicsand/ormaintaining
cocaineabstinence(Elk,inpress).Monetaryvouchersofincreasingvaluewereawardedforeachsuccessivesubstancefreeurine
specimenandforincreasedorconsistentattendanceatprenatalandsubstanceusedisordertreatmentclinics.Abstinence,retentionrates,
andcompliancewithprenatalcarevisitsweregenerallyhigherinthecontingencygroups.Inanotherstudy,pregnantclientswere
randomlyassignedtoreceivestandardorenhancedmethadonemaintenancetreatment(Carrolletal.,1995a).Standardtreatmentconsisted
ofdailymethadone,weeklygroupcounseling,andthriceweeklyurinetesting.Enhancedtreatmentconsistedofweeklyprenatalcare,
weeklyrelapsepreventiongroups,andmonetaryvouchersforeverythreeconsecutivesubstancefreeurinesamples.Treatmentretention
wassimilarinthetwogroups,andtherewerenosignificantdifferencesinthepercentageofcocainepositiveurinesamplesprovidedby
thetwogroups.

Thistreatmentapproachwithpregnantwomenwithstimulantusedisordersisverypreliminaryandneedsmorethoroughevaluation.
However,theseeffortsfurtherillustratethepotentialutilityofcontingencymanagementforaddressingsomeofthemoredauntingclinical
challengesintreatingstimulantabuse.Otherimportantexamplesarerecentpilotstudies(Rolletal.,1998Shaneretal.,1997)suggesting
thatcontingentmonetaryreinforcementcanreducecigaretteandcocaineuseinadultschizophrenicclientsandprovidingevidencethat
contingentmonetaryreinforcementcanbeusedtoincreasemedicationcomplianceintuberculosisinfectedstimulantusers(Elk,inpress).

Whenconsideredasagroup,contingencymanagementinterventionshavebyfarthegreatestamountofempiricalsupportfortheir
efficacyinpromotingtherapeuticbehavioralchangeamongstimulantusers.Stimulantusersaresensitivetosystematicallyapplied
contingencymanagementinterventions.Presently,thereisnoothertreatmentstrategyaboutwhichonecanmakeanequallystrong
positivestatement.

Relapse Prevention
Relapseprevention(RP)systematicallyteachesclients(1)howtocopewithsubstancecraving,(2)substancerefusalandassertiveness
skills,(3)howseeminglyirrelevantdecisionscanaffecttheprobabilityoflatersubstanceuse,(4)generalcopingandproblemsolving
skills,and(5)howtoapplystrategiestopreventafullblownrelapseshouldanepisodeofsubstanceuseoccur(MarlattandGordon,
1985).

Carrollandcolleagueshaveadaptedanddemonstratedtheefficacyofthistreatmentapproachwithcocaineusers(Carrolletal.,1991a,
1991b,1994a,1994b).Inaninitialstudy,RPwascomparedwithinterpersonalpsychotherapy(IP),whichteachesstrategiesforimproving
socialandinterpersonalproblems(Carrolletal.,1991a).RetentionwasbetterwithRPthanIP,andtrendssuggestedcocaineabstinence
mayhavebeenaswell,butthatdifferencewasnotsignificant.

AsubsequentstudycomparedRPandcasemanagement(Carrolletal.,1994a)theclientsinthisstudyalsoreceivedeitherdesipramineor
placebo.Atotalof139clientswererandomizedtooneoffourtreatmentgroups.Casemanagementwasdesignedtoprovideanonspecific
therapeuticrelationshipandanopportunitytomonitorclients'clinicalstatus.Bothtreatmentsweredeliveredinweeklytherapysessions
during12weeksoftreatment.Allclientsalsoreceivedweeklyurinalysistestingandotherclinicalmonitoring.Alltreatmentgroups
improvedfrompretoposttreatmentonmeasuresofcocaineuseandtheAddictionSeverityIndex(ASI)drug,alcohol,family/social,and
psychiatriccompositescales,buttherewerenosignificantmaineffectsforpsychosocial(RPvs.casemanagement)ordrugtreatment
(desipraminevs.placebo).At1yearfollowup,thoseclientswhoreceivedRPreportedsignificantlyhigherlevelsofcocaineabstinence
thandidclientswhoreceivedcasemanagement(Carrolletal.,1994b).ConsideringRP'sfocusonteachingskillstopreventalapsefrom
becomingafullblownrelapse,thesedelayedeffectsmightbeexpected.Indeed,similardelayedeffectsofRPhavebeenreportedin
studiesontreatmentofothertypesofsubstanceusedisorders(seeCarroll,1996).

NotallstudieswithRPhavebeenpositive.Forexample,WellsandcolleaguesreportednegativeresultsinacomparisonofRPand12
Stepbasedcounseling(Wellsetal.,1994).Nosignificantdifferencesbetweenthetwogroupswerediscernedinretentionorcocaineuse
duringthe24weekoutpatienttrialorata6monthfollowupevaluation.

Treatment Approaches With Supportive Research

The Matrix Model

TheMatrixmodel(originallyreferredtoastheneurobehavioralmodel)isanoutpatienttreatmentapproachthatwasdevelopedduringthe
mid1980sforthetreatmentofindividualswithcocaineandMAusedisorders(Rawsonetal.,1990).Themodelintegratestreatment
elementsfromanumberofspecificstrategies,includingrelapseprevention,motivationalinterviewing,psychoeducation,familytherapy,
and12Stepprograminvolvement.Thebasicelementsoftheapproachconsistofacollectionofgroupsessions(earlyrecoveryskills,
relapseprevention,familyeducation,andsocialsupport)and20individualsessions,alongwithencouragementtoparticipatein12Step
activities,deliveredovera24weekintensivetreatmentperiod(Rawsonetal.,1989).

ThistreatmentmodelservesastheprimarytreatmentprotocolforanetworkofoutpatienttreatmentofficesinSouthernCalifornia
(MatrixCenter).Inthisnetworkofclinics,morethan8,000peoplewithcocaineandMAusedisordershavebeentreatedwiththis
approachsince1985.TheclientpopulationrangesfromprofessionalsandexecutivestoinnercitycrackusersandindigentruralMA
users.Inordertoadapttothefinancialrealitiesimposedbytheemergenceofmanagedcare,2monthand4monthversionsofthemodel
havebeendevelopedandarecurrentlybeingevaluated.Asthemodelwasdevelopedandrefined,anextensivesetofdataonthevalueof
thetreatmentapproachwascollected.Theresearchstudiesevaluatingthistreatmentapproachdonotincludearandomizedclinicaltrial.
However,insevenresearchprojectsevaluatingthetreatmentmodel,applicationofthemodelhasbeenshowntobeassociatedwith
significantreductionsincocaine,MA,andothersubstanceuse(Rawsonetal.,1993,1996Shoptawetal.,1994).Inaprojectcomparing
thetreatmentoutcomeof224cocaineand500MAuserstotheMatrixapproach,allindicatorssuggestedacomparabletreatmentresponse
(Rawsonetal.,1996Huberetal.,1997).Alongwithareductionofstimulantandothersubstanceuse,treatmentparticipationinthe
MatrixmodelhasbeendemonstratedtobeassociatedwithasignificantreductioninHIVriskysexualbehavior(Shoptawetal.,1997).
SeeFigure31foranevaluationofMatrixCenterprotocolsforthetreatmentofMAabuseanddependence.

Box
Figure31:EvaluatingtheMatrixModel.TheCenterforSubstanceAbuseTreatmenthasrecentlysolicitedapplications
toreplicateandevaluatetheMatrix8and16weekprotocolsforthetreatmentofMAusedisorders.Thisprojectwill
represent(more...)

Behavioral Family/Couples Therapy

Peoplewithsubstanceusedisordersoftenhaveextensivemarital,relationship,andfamilyproblems.Stablemaritalandfamilyadjustment
isassociatedwithbettertreatmentoutcomes.Inclusionoffamilymembersintreatmentisbasedontheviewthattheycanprovide
importantsupportfortheclient'seffortstochangeandprovideadditionalinformationabouttheclient'ssubstanceuseandotherbehavior.
Interventionsdirectedatimprovingmaritalandfamilyadjustmenthavethereforebeenjudgedtohavethepotentialtoimprovetreatment
outcome.Studieswithalcoholicshavesupportedthishypothesis,atleastinpart.Fewstudieshavebeenattemptedwithstimulantusers,
however.

Onerandomizedtrialconductedwithaheterogeneousgroupofsubstanceusers,manyofwhomwerecocaineusers,supported
marital/familytherapyasameanstoimprovetreatmentoutcome(FalsStewartetal.,1996).Subjectsweremalesubstanceusersunder
currentcriminaljusticesupervision,whowerelivingwithaspouseduringthepastyear,andwhoexpressedacommitmenttosustained
substanceabstinence.Theseindividualswererandomlyassignedtotwotreatmentgroupsthatreceivedanequalnumberoftherapy
sessionsacross24weeksoftreatment.Foronegroup,thosesessionsfocusedexclusivelyoncopingskills.Fortheothergroup,sessions
consistedofcopingskillstrainingplusbehavioralmaritaltherapy.Thegroupthatreceivedmaritaltherapyhadbetterrelationship
outcomes(intermsofmorepositivedyadicadjustmentandlesstimeseparated)thandidthecomparisongroup,andreportedfewerdaysof
substanceuse,longerperiodsofabstinence,fewersubstancerelatedarrests,andfewerhospitalizationsduringtheyearaftertreatment.
Asmightbeexpected,someofthosedifferencesdissipatedoverthecourseofthefollowupperiod,butthisstudyillustratesanimportant
roleforbehavioralmaritaltherapyforstimulantuserswhohavearelativelystableromanticrelationshipandwhoexpressacommitment
tosubstanceabstinenceattheinitiationoftreatment.

Other Interventions With Supportive Research

Someadditionalinterventionsmeritmention.Permittingwomenenteringresidentialtreatmenttobeaccompaniedbysomeoralloftheir
childrenappearstoimproveretention.Inapublishedcontrolledstudyonthistopic(Hughesetal.,1995),womenenteringresidential
treatmentforcocaineusewhowerepermittedtohaveoneortwooftheirchildrenresidewiththemwereretainedsignificantlylonger
thanwomenwhosechildrenwereplacedwiththebestavailablecaretaker(300.4vs.101.9meandaysofretention).Noothermeasuresof
outcomewerereported.

Anotherstudydescribedproceduresforimprovingtreatmentparticipation(Halletal.,1994).Clientswerecocainedependentmale
veterans.Allclientsbegantreatmentasinpatients,typicallyfor2weeks,andwerethenencouragedtocontinuetherapyintheoutpatient
centerofthesamemedicalcomplex.Therapyconsistedofindividualandgrouptherapysessions.Participationintheoutpatientregimen
beganeitherduringtheinpatientstay,inwhichcaseclientskeptthesameindividualandgrouptherapiststhroughouttheinpatientand
outpatientphases,oritbeganaftertheinpatientstayandsubjectswereassignednewindividualandgrouptherapistsonenteringthe
outpatientphase.Havingparticipationinoutpatientcarebeginduringtheinpatientstayresultedinsomewhatbetterparticipationafter
hospitaldischarge,andsignificantlybetterinitial(3weeks)butnotlatercocaineabstinence.

Woodyandcolleaguesreportedthatsupportiveexpressivepsychotherapymayhelpthesubsetofclientsinterestedinreceivingsuch
therapytoreducetheircocaineuse(Woodyetal.,1995).Theystudiedasubsetofnewlyadmittedmethadoneclientswhoindicatedan
interestinreceivingpsychotherapyandwerecompliantwithattendingcounselingsessions(lessthanhalftheclientsadmitted).These
individualswererandomizedtoreceivesupportiveexpressivepsychotherapyplussubstanceusecounselingoronlysubstanceuse
counseling.Supportiveexpressivepsychotherapyfocusedonexploringtherolethatsubstancesplayedinrelationshipproblems,troubling
feelings,andotherproblems.Thosewhoreceivedpsychotherapyusedsignificantlylesscocaineduringthe24weekstudythanthosewho
receivedonlysubstanceusecounseling.

Finally,aninterventioncalled"nodelinkmapping"maybehelpfulinreducingcocaineabuse(Czuchryetal.,1995Dansereauetal.,
1995Joeetal.,1994).Thisinterventionusesflowchartsandothermethodstodiagramrelationshipsbetweenclients'thoughts,actions,
feelings,andsubstanceuse.Clientswereindividualsenrolledinmethadonetreatmentwhowererandomizedtoreceivestandard
counselingornodelinkenhancedcounseling.Thosewhoreceivedthenodelinkmappingappearedtoreducetheircocaineusemore
during6monthsoftreatmentthanthosewhoreceivedstandardcare,buttheeffectwasnotcompelling.Thenodelinkmappinggroupwas
usingmorecocaineatthestartoftreatment.Althoughthenodelinkmappinggroupshowedagreaterreductionfromthestarttotheend
oftreatmentthandidthestandardgroup,theabsoluteamountofcocaineuseattheendoftreatmentwasnotsignificantlydifferent.
Furtherstudiesareneededinwhichtheseresultsarereplicatedingroupsthatstarttreatmentwiththesamelevelofcocaineuseorfinish
treatmentwiththenodelinkmappinggroupusingsignificantlylesscocaine.

Other Models of Psychosocial Treatment

Anumberofotherpsychosocialmodelsandapproacheshavebeendescribed,andsomeusedquitewidely,forthetreatmentofstimulant
usedisorders.

Network Therapy
Networktherapyisbasedontherationalethatpeoplecanrecoverfromsubstanceusedisordersiftheyhaveastablesocialnetworkto
supporttheminpsychotherapeutictreatment.Inthismodel,clientsreceivingindividualpsychotherapydevelopanetworkofstable,
nonsubstanceusingsupportpersons,suchasfamily,partners,andclosefriends.Thesesupportpersonslearnstrategiesfromthetherapist
tosupportthetherapeuticprocessfortheindividualbeingtreated.Theymayinteractregularlywiththetherapist,participateintreatment
sessionswiththeclient,andbeinvolvedinsettinguptreatmentplansfortheclient.

Empiricalevidencefornetworkpsychotherapyisscarce.Controlledtrialsofnetworktherapyforcocaineorothersubstanceusehavenot
yetbeenpublished.

Acupuncture
AcupunctureisanancientChinesetherapyinwhichthinneedlesareinsertedsubcutaneouslyatvariouspointsonthebody.Thetechnique
isbasedonthebeliefthatthebody'snormalfunctioningdependsonabalanceoftwooppositepolarenergiesthatflowalonglinesofthe
bodycalledmeridians.Approximately1,000acupuncturepointsarealignedalongthesemeridians,andtheirstimulationbythethinneedles
isbelievedtocorrectenergyimbalancesandenhancethebody'snaturalcapacitytohealitself.Nocontrolledoutcomestudieshavebeen
reportedsupportingtheefficacyofacupunctureforthetreatmentofcocaineorotherstimulantusedisorders(TIP10,Assessmentand
TreatmentofCocaineAbusingMethadoneMaintainedPatients[CSAT,1994b]).

Inpatient Treatment
Inpatienttreatmenthastraditionallyconsistedofa28daystayinahospitalorresidentialtreatmentfacility,duringwhichdailyactivities
suchasselfhelpgroups,grouppsychotherapy,andrelaxationtechniqueswereprovidedinastructuredformat.Generallysupportiveand
sometimesconfrontationalinnature,inpatienttreatmentwasaimedatcombatingclients'denialandinitiatingparticipationinthe12steps
ofrecoveryoriginallydelineatedbyAlcoholicsAnonymous(AA).Themajorgoalsofmostinpatienttreatmentprogramsare
detoxificationfromtheinfluenceofchronicsubstanceuseandbeginningtheprocessofengagingwithselfhelpprogramssuchasAAand
NarcoticsAnonymous(NA).Treatmentcomponentsincludedidacticlearningabouttheprocessesofaddictionandrecoveryaswellas
experientialtechniques.Oftentheclient'sfamilyisinvolvedinspecial"FamilyDays"toacquaintthemwiththeseissues.

Originallydevelopedforthetreatmentofalcoholism,the28daystandardhospitaltreatmentregimenwasusedespeciallyintheearly
1980s,whenthenumbersofclientsseekingtreatmentforcocaineusedisordersbegantorisedramatically.Thistrendpeakedinthemid
1980s,whenmorethanhalfofclientsinmanyprivateprogramswerebeingtreatedforcocaineabuseanddependence(Rawson,1986).
Mostoftheseinpatientprogramswereadaptedtotreatcocaineuserswithfewornomodificationsfromthealcoholregimens.Inthemid
1980s,whencocaineuseamongmiddleclassAmericansreachedepidemicproportions,thestandard28dayinpatienttreatmentprogram
wasthemostwidelyusedtreatmentmodalityforthispopulation(Rawsonetal.,1991a).

Severalhospital/residentialtreatmentorganizationsdidattempttoevaluatetheeffectivenessoftheirtreatmentprogrammingforcocaine
users.Forexample,SierraTucson,inTucson,Arizona,conductedaprogramofoutcomeresearchduringthe1980sdesignedtoevaluate
andimprovetheefficacyofitstreatmenteffortsforcocaineusers.TheHazeldentreatmentorganizationcompiledanextensivedatabase
ontheeffectivenessofitstreatmentserviceswithcocaineandothersubstanceusers.TheCarrierorganizationhaspublishedaseriesof
studiesdesignedtoevaluatetheeffectivenessoftheirtreatmentprograms(Pettinati,1991).Althoughtheevaluationswerenotrandomized
clinicaltrials,theinformationcollectedinthereportssupportedthevalueofthetreatmentservices.

Thetraditional28dayinpatienttreatmentregimenwasdevelopedwithlittleinputfromempiricallybasedresearch.Inthepastseveral
years,theuseofsuchinpatientprogramshasbeencalledintoquestionbyinsuranceproviders,andsubsequentlytheirusehasbeensteadily
declining.Asinsurancecoverageforinpatienttreatmentlikewisebegantodwindle,theseprogramsbecamevariableinlength.Many
programsclosed,andotherswereforcedtoscalebackontheservicestheyprovided.Currently,inmanycasesclientsarecoveredfor
briefinpatientstays(upto7days)fordetoxificationpurposesonly,andpsychosocialserviceshavebeenlimited.Inpatienttreatment
programsarewidelyvariableinthecredentialingoftheirstaff,butnearlyallemploysomestaffmemberswhoarethemselvesin
recovery.

Long-Term Residential Treatment

Longtermresidentialtreatmentisusedforsubstanceuserswhoaredeemedtobeinneedofastructuredsupportsystemforasustained
period.Thestructureprovidedbylongtermresidentialtreatmentisdesignedtoallowpositivechangesandstabilizationintheclient's
attitudesandlifestyle.Thedurationsofresidentialtreatmentprogramsvaryatonetime,mostprogramswereatleast1yearinduration,
buttodaymostareabout6months,orevenonly90days.Mostresidentialprograms,bothlongtermandhalfwayhouses,arestaffedat
leastinpartbypeoplewhoarethemselvesinrecovery.

Therapeuticcommunities(TCs),themostcommontypeoflongtermresidentialtreatment,areresidentialtreatmentprogramsthatusually
usegroupactivitiesdirectedtowardeffectingsignificantchangesintheresidents'lifestyles,attitudes,andvalues.Theyemphasize
prosocialbehaviorandtheassumptionofresponsibilityforone'sactions.ManyreferralstoTCstakeplacethroughthecourtsystem.In
fact,TCsoriginallyweredesignedforheroinaddictedclientswithdeprivedsocioeconomicbackgroundsandlongtermhistoriesof
criminalinvolvement.

Halfwayhousesareresidentialtreatmentprogramsprovidingtransitionalsupportforindividualswhoareusuallyprogressingfromamore
restrictiveenvironment,suchasaTC,butwhoarenotyetreadytofunctionindependentlyinthecommunity.Theseindividualsmaynot
needtheintensivestructuredenvironmentofaTCbutmaynotyetbereadyforindependentliving.Requirementsofhalfwayhouse
programsusuallyincludespecifiedcommunityinvolvement,suchasemploymentorenrollmentinschool,andabstinencefrommood
alteringsubstances.Eveninggroupactivitiesarestructuredaroundresidents'workschedules.

Althoughrelativelylittleempiricalevidenceexistssupportingtheefficacyoflongtermresidentialtreatmentforstimulantusedisorders,
thereisatleastsomereasontobelievethatitcanbeeffective(Gersteinetal.,1994MuellerandWyman,1997).Althoughclinical
experiencesuggeststhatTCsareeffectivewithasubsetofcocaineusers,totheConsensusPanel'sknowledgenocontrolledclinicaltrials
havebeenpublishedsupportingtheirefficacyinthetreatmentofcocainedependentindividuals.

Pharmacological Treatments for Stimulant Abuse and Dependence

Thereisnotyetaneffectivepharmacotherapyforcocaineusedisorders,butthistopicisbeingresearchedintensively.Becauseof
differencesintheneurochemistryofcocaineandMA,thereissoundreasontobelievethatdifferentpharmacotherapiesmaybeneededto
treatthosetwoformsofstimulantuse(LingandShoptaw,1997).However,becausebothdrugsproducesimilareffectsonthebrain's
dopaminelevels,promisingmedicationsforthetreatmentofcocaineusedisordersarealsobeingexaminedforthetreatmentof
methamphetamineuse.

ClinicalresearchonpharmacotherapiesforMAusedisordersisjustgettingunderway.Medicationsarebeingsoughttoaddressarange
ofindications.Thereisinterestindevelopingagentsthatcanalleviatethemedical/psychiatricsymptomscausedbyMAintoxicationand
withdrawal.Forexample,antidepressantmedicationshavebeenfoundusefulinthetreatmentofindividualswhohavediscontinuedtheir
useofMA(NIDA,1998c).Also,thereisinterestindevelopingmedicationstotreatMAabuseanddependence.Ongoingtrialsare
currentlyassessingdopaminergic(i.e.,dopaminemediated),serotonergic(i.e.,serotoninmediated),andothercompounds(CSAT,1997).

Pharmacotherapyresearchforcocaineusedisorderswasspurredinitiallybyanopenlabeltrialfollowedbyadoubleblind,randomized
trialsupportingtheefficacyofdesipramine,atricyclicantidepressant,inproducingshorttermreductionsincocaineuseandcravingin
outpatients(GawinandKleber,1984Gawinetal.,1989).Intherandomizedtrial,59percentofcocainedependentclientstreatedfor6
weekswithdesipramineachieved3ormoreweeksofcontinuouscocaineabstinencecomparedwith25percentofthosetreatedwith
lithiumand17percentofthosewhoreceivedplacebo(Gawinetal.,1989).Unfortunately,thosepromisingresultshavenotbeen
replicatedinsubsequentcontrolledtrialswithdesipramine(e.g.,Carrolletal.,1994aWeddingtonetal.,1991)orimipramine(Janimine),
anothertricyclicantidepressant(Nunesetal.,1995).Evidencethatclientswithlessseverecocainedependencemaybenefitfrom
treatmentwithdesipramineandimipraminewaspresentedinatleasttworeportsandmeritsfurtherstudy(Carrolletal.,1994aNuneset
al.,1995).
Otherantidepressantsthathavebeeninvestigatedinprimarycocaineusersincludefluoxetine(Prozac)(Grabowskietal.,1995),
maprotiline(Ludiomil)(Brotmanetal.,1988),andgepirone(Jenkinsetal.,1992).Studiesarestillinprogresswithsomeofthese
compounds,butnonehasdemonstratedreliableefficacyinreducingcocainecravingoruseincontrolledtrials.Becauseofcocaine'svery
pronouncedeffectsinthedopaminesystem,avarietyofdifferentdopaminergiccompoundshasbeeninvestigated,includingamantadine,
bromocriptine,bupropion,flupenthixol,carbidopaldopa,mazindol,methylphenidate,andtyrosine(seereviewsbyGorelick,1994
Kleber,1995MendelsonandMello,1996).Opentrialdatahavesometimeslookedpromising,butnoreliablepositiveeffectshavebeen
observedwithanyofthesecompoundsinrandomizedtrials.Thesameistruefortheanticonvulsantcarbamazepine(Kranzleretal.,
1995).

Buprenorphineisanopioiddrugthatiscurrentlybeingevaluatedasatreatmentforopiatedependenceinthesamemannerasmethadone
isused.Inthecourseofthiswork,observationsbyseveralresearcherssuggestedthatbuprenorphinemightbeaneffectivetreatmentfor
cocaineusedisordersinthepopulationthatusesbothopiatesandcocaine(e.g.,Kostenetal.,1992Schottenfeldetal.,1993).However,
othermorerigorousclinicalstudieshavefailedtofindthatbuprenorphinehasefficacyinsuppressingcocaineabuse(e.g.,Johnsonetal.,
1995).Researchcontinuesonthistopic.Currently,thereisnoconvincingevidenceshowingthatbuprenorphinecausesdecreasesin
cocaineuseorisassociatedwithgreaterreductionsincocaineusethanwhenmethadoneisusedtotreatclientswhoabuseopiatesand
cocaine(seeSilvermanetal.,1998).

Useofdisulfiramtherapyforclientswhousebothcocaineandalcohollookspromising.Themajorityofstimulantusersmeetmedical
criteriaforalcoholdependence,andmorethan90percentarecurrentalcoholusers(GrantandHarford,1990Higginsetal.,1994a).
Disulfiramtherapywithsocialmonitoringtoensuremedicationcompliancewasusedasastandardcomponentinthecommunity
reinforcementplusvoucherstreatmentapproachdescribedabove.Achartreviewwasconductedon16cocainedependentindividuals
whoreceivedthattreatment(Higginsetal.,1993a).Carrollandcolleaguesreportedresultsconsistentwiththesefindingsinapilot
randomizedtrial(Carrolletal.,1993b).Inthatstudy,disulfiramtherapywascomparedwithnaltrexonetherapyinapopulationof18
outpatientswhoabusedcocaineandalcohol.Disulfiramtherapyresultedinsignificantlygreaterreductionsindrinkingandcocaineuse
thannaltrexonetherapy.Finally,alargerrandomizedtrialontheefficacyofdisulfiramtherapywascompletedrecently,andagain
cocaineusewassignificantlyreducedbydisulfiramtherapy(Carroll,1996).Adetailedprotocolforuseofdisulfiramtherapywith
cocaineusersisprovidedintheNIDAmanualoncommunityreinforcementplusvouchersmentionedabove(BudneyandHiggins,1998).

Finally,anexcitingareaofresearchcurrentlybeingpursuedinthebasicsciencelaboratoryusingnonhumansubjectsfocusesonthe
developmentofpotentialvaccinesagainst

cocaineusedisordersintheformofenzymesorcatalyticantibodies.Thesenovelapproachesmayholdgreaterpromisethanmore
conventionalapproaches(LingandShoptaw,1997).

Publication Details

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Publisher

Substance Abuse and Mental Health Services Administration (US), Rockville (MD)

NLM Citation

Center for Substance Abuse Treatment. Treatment for Stimulant Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US);
1999. (Treatment Improvement Protocol (TIP) Series, No. 33.) Chapter 3Approaches to Treatment.