NIDA's research into treatments for cocaine abuse has identified a variety of effective treatments ranging from group drug counseling to individualized psychotherapies. In a NIDA-funded clinical trial investigating the efficacy of four types of treatment, patients who received group drug counseling combined with individual drug counseling were more likely to reduce their drug use than were patients who received group drug counseling alone or in combination with psychotherapies that are used to treat addictions.
Patients who received combined individual and group drug counseling used less cocaine than did patients who received other forms of treatment.
The NIDA Collaborative Cocaine Treatment Study involved 487 patients with relatively low levels of psychiatric severity whose principal diagnosis was cocaine dependence as defined by the Diagnostic and Statistical Manual of Mental Disorders. The drug counseling therapies evaluated in the multisite study are specifically designed to treat drug use; the psychotherapies-supportive-expressive therapy and cognitive therapy-are less focused on drug use.
The study involved patients recruited at five sites-the University of Pennsylvania in Philadelphia; the Western Psychiatric Institute and Clinic at the University of Pittsburgh; Massachusetts General Hospital in Boston; McLean Hospital in Belmont, Massachusetts; and Brookside Hospital in Nashua, New Hampshire. Each research center provided four treatments: group drug counseling alone, group drug counseling combined with individual drug counseling, group drug counseling combined with cognitive therapy, or group drug counseling combined with supportive-expressive therapy. Each of the 487 patients was randomly assigned to one of the therapies. Treatment results were evaluated through patient self-reporting, weekly observed urine testing, and the Addiction Severity Index-an interview-based assessment used to measure treatment outcome.
During each of the 6 months of treatment, and at 3 months and 6 months after treatment ended, patients who received combined individual and group drug counseling used less cocaine and drugs overall than did patients who received other forms of treatment. A higher percentage of combined drug counseling patients were able to achieve abstinences of 1, 2, and 3 months than were patients in the other study groups. During the 6 months after treatment ended, 38 percent of patients who completed combined counseling treatment maintained drug-free periods of 3 consecutive months compared with 27 percent of patients treated with group counseling alone, 23 percent of patients treated with cognitive therapy plus group counseling, and 18 percent of patients receiving supportive-expressive therapy plus group counseling. In addition, patients who received combined drug counseling showed more improvement in Addiction Severity Index ratings than did patients receiving other treatments. "These results underline the valuable role of well-designed drug counseling in treating drug abuse. More specifically, this study demonstrates the effectiveness that combined counseling therapies can have in treating cocaine addiction," notes Dr. Jack Blaine of NIDA's Division of Treatment Research and Development.
"The success of combined drug counseling treatment compared with the psychotherapies may be due to the fact that drug counseling delivers a message that is simple and strong-stay away from the situations where you use drugs and the people you use drugs with. The counselors at all sites involved in our study were able to deliver that message effectively," says Dr. Paul Crits-Christoph of the University of Pennsylvania, who coordinated the multicenter study.
Criteria for Success
"The success of combined drug counseling compared with other treatments is the result of the nature, intensity, and quality of counseling," Dr. Crits-Christoph says. "We paid a great deal of attention to selecting and training counselors, all of whom had extensive previous experience treating patients with substance abuse disorders." The counselors and psychotherapists received more than a year of training in standardized therapy using published manuals, and were evaluated during training and certified prior to participation in the collaborative treatment study.
Group drug counseling, given to all study participants, consisted of weekly sessions for the full 6 months of the study and individual meetings with the group counselor once per month during a 3-month "booster" phase following the 6 months of active treatment. Patients in individual drug counseling and psychotherapy treatments participated in twice-weekly sessions during the first 3 months, weekly sessions during the second 3 months, and monthly meetings during the booster phase.
Group drug counseling treatment involved an initial 3-month phase during which patients were educated about the concepts in recovery from addiction, and a second 3-month phase that involved open group discussions focusing on patients helping each other solve problems encountered in recovery. Individual drug counseling focused on helping patients achieve and maintain abstinence through behavioral changes such as avoiding situations that trigger drug use. Group drug counseling and individual drug counseling encouraged patient involvement in self-help and support groups such as Cocaine Anonymous outside of scheduled treatment sessions.
Cognitive therapy involved identifying the underlying beliefs related to a patient's drug use. Therapists worked with patients to evaluate the advantages and disadvantages of their beliefs. They also employed role-playing, behavioral experiments, and scheduling and monitoring activities. Supportive-expressive therapy involved identifying interpersonal conflicts that relate to a patient's drug use. Therapists helped patients interpret the role that these conflicts play in drug use and problems encountered in stopping drug use.
Because treatment and training were based on published manuals, it may be possible for other treatment programs to achieve similar results, Dr. Crits-Christoph notes. "If other programs can apply these tools with the intensity that characterized this study, their outcomes should be similarly successful."
Crits-Christoph, P., et al. The National Institute on Drug Abuse collaborative cocaine treatment study: Rationale and methods. Archives of General Psychiatry 54(8):721-726, 1997.
Crits-Christoph, P., et al. Psychosocial treatments for cocaine dependence: Results of the National Institute on Drug Abuse collaborative cocaine treatment study. Archives of General Psychiatry 56(6):493-502, 1999.
Crits-Christoph, P., et al. Training in cognitive, supportive-expressive, and drug counseling therapies for cocaine dependence. Journal of Consulting and Clinical Psychology 66(3):484- 492, 1998.