Relapse Prevention

Relapse prevention (RP) systematically teaches clients (1) how to cope with substance craving, (2) substance refusal and assertiveness skills, (3) how seemingly irrelevant decisions can affect the probability of later substance use, (4) general coping and problem solving skills, and (5) how to apply strategies to prevent a full-blown relapse should an episode of substance use occur (Marlatt and Gordon, 1985).

Carroll and colleagues have adapted and demonstrated the efficacy of this treatment approach with cocaine users (Carroll et al., 1991a, 1991b, 1994a, 1994b). In an initial study, RP was compared with interpersonal psychotherapy (IP), which teaches strategies for improving social and interpersonal problems (Carroll et al., 1991a). Retention was better with RP than IP, and trends suggested cocaine abstinence may have been as well, but that difference was not significant.

A subsequent study compared RP and case management (Carroll et al., 1994a); the clients in this study also received either desipramine or placebo. A total of 139 clients were randomized to one of four treatment groups. Case management was designed to provide a nonspecific therapeutic relationship and an opportunity to monitor clients' clinical status.

Both treatments were delivered in weekly therapy sessions during 12 weeks of treatment. All clients also received weekly urinalysis testing and other clinical monitoring. All treatment groups improved from pre- to posttreatment on measures of cocaine use and the addiction Severity Index (ASI) drug, alcohol, family/social, and psychiatric composite scales, but there were no significant main effects for psychosocial (RP vs. case management) or drug treatment (desipramine vs. placebo).

At 1-year followup, those clients who received RP reported significantly higher levels of cocaine abstinence than did clients who received case management (Carroll et al., 1994b). Considering RP's focus on teaching skills to prevent a lapse from becoming a full-blown relapse, these delayed effects might be expected. Indeed, similar delayed effects of RP have been reported in studies on treatment of other types of substance use disorders (see Carroll, 1996).

Not all studies with RP have been positive. For example, Wells and colleagues reported negative results in a comparison of RP and 12-Step-based counseling (Wells et al., 1994). No significant differences between the two groups were discerned in retention or cocaine use during the 24-week outpatient trial or at a 6-month followup evaluation.

Treatment Approaches With Supportive Research

The Matrix Model

The Matrix model (originally referred to as the neurobehavioral model) is an outpatient treatment approach that was developed during the mid-1980s for the treatment of individuals with cocaine and MA use disorders (Rawson et al., 1990). The model integrates treatment elements from a number of specific strategies, including relapse prevention, motivational interviewing, psychoeducation, family therapy, and 12-Step program involvement.

The basic elements of the approach consist of a collection of group sessions (early recovery skills, relapse prevention, family education, and social support) and 20 individual sessions, along with encouragement to participate in 12-Step activities, delivered over a 24-week intensive treatment period (Rawson et al., 1989).

This treatment model serves as the primary treatment protocol for a network of outpatient treatment offices in Southern California (Matrix Center). In this network of clinics, more than 8,000 people with cocaine and MA use disorders have been treated with this approach since 1985.

The client population ranges from professionals and executives to inner-city crack users and indigent rural MA users. In order to adapt to the financial realities imposed by the emergence of managed care, 2-month and 4-month versions of the model have been developed and are currently being evaluated. As the model was developed and refined, an extensive set of data on the value of the treatment approach was collected.

The research studies evaluating this treatment approach do not include a randomized clinical trial. However, in seven research projects evaluating the treatment model, application of the model has been shown to be associated with significant reductions in cocaine, MA, and other substance use (Rawson et al., 1993, 1996; Shoptaw et al., 1994).

In a project comparing the treatment outcome of 224 cocaine and 500 MA users to the Matrix approach, all indicators suggested a comparable treatment response (Rawson et al., 1996; Huber et al., 1997). Along with a reduction of stimulant and other substance use, treatment participation in the Matrix model has been demonstrated to be associated with a significant reduction in HIV-risky sexual behavior (Shoptaw et al., 1997). See Figure 3-1 for an evaluation of Matrix Center protocols for the treatment of MA abuse and dependence.

Behavioral Family/Couples Therapy

People with substance use disorders often have extensive marital, relationship, and family problems. Stable marital and family adjustment is associated with better treatment outcomes. Inclusion of family members in treatment is based on the view that they can provide important support for the client's efforts to change and provide additional information about the client's substance use and other behavior. Interventions directed at improving marital and family adjustment have therefore been judged to have the potential to improve treatment outcome. Studies with alcoholics have supported this hypothesis, at least in part. Few studies have been attempted with stimulant users, however.

One randomized trial conducted with a heterogeneous group of substance users, many of whom were cocaine users, supported marital/family therapy as a means to improve treatment outcome (Fals-Stewart et al., 1996). Subjects were male substance users under current criminal justice supervision, who were living with a spouse during the past year, and who expressed a commitment to sustained substance abstinence.

These individuals were randomly assigned to two treatment groups that received an equal number of therapy sessions across 24 weeks of treatment. For one group, those sessions focused exclusively on coping skills. For the other group, sessions consisted of coping-skills training plus behavioral marital therapy. The group that received marital therapy had better relationship outcomes (in terms of more positive dyadic adjustment and less time separated) than did the comparison group, and reported fewer days of substance use, longer periods of abstinence, fewer substance-related arrests, and fewer hospitalizations during the year after treatment.

As might be expected, some of those differences dissipated over the course of the followup period, but this study illustrates an important role for behavioral marital therapy for stimulant users who have a relatively stable romantic relationship and who express a commitment to substance abstinence at the initiation of treatment.

Other Interventions With Supportive Research

Some additional interventions merit mention. Permitting women entering residential treatment to be accompanied by some or all of their children appears to improve retention. In a published controlled study on this topic (Hughes et al., 1995), women entering residential treatment for cocaine use who were permitted to have one or two of their children reside with them were retained significantly longer than women whose children were placed with the best available caretaker (300.4 vs. 101.9 mean days of retention). No other measures of outcome were reported.

Another study described procedures for improving treatment participation (Hall et al., 1994). Clients were cocaine-dependent male veterans. All clients began treatment as inpatients, typically for 2 weeks, and were then encouraged to continue therapy in the outpatient center of the same medical complex. Therapy consisted of individual and group therapy sessions.

Participation in the outpatient regimen began either during the inpatient stay, in which case clients kept the same individual and group therapists throughout the inpatient and outpatient phases, or it began after the inpatient stay and subjects were assigned new individual and group therapists on entering the outpatient phase. Having participation in outpatient care begin during the inpatient stay resulted in somewhat better participation after hospital discharge, and significantly better initial (3 weeks) but not later cocaine abstinence.

Woody and colleagues reported that supportive-expressive psychotherapy may help the subset of clients interested in receiving such therapy to reduce their cocaine use (Woody et al., 1995). They studied a subset of newly admitted methadone clients who indicated an interest in receiving psychotherapy and were compliant with attending counseling sessions (less than half the clients admitted).

These individuals were randomized to receive supportive-expressive psychotherapy plus substance use counseling or only substance use counseling. Supportive-expressive psychotherapy focused on exploring the role that substances played in relationship problems, troubling feelings, and other problems. Those who received psychotherapy used significantly less cocaine during the 24-week study than those who received only substance use counseling.

Finally, an intervention called "node-link mapping" may be helpful in reducing cocaine abuse (Czuchry et al., 1995; Dansereau et al., 1995; Joe et al., 1994).

This intervention uses flowcharts and other methods to diagram relationships between clients' thoughts, actions, feelings, and substance use. Clients were individuals enrolled in methadone treatment who were randomized to receive standard counseling or node-link enhanced counseling.

Those who received the node-link mapping appeared to reduce their cocaine use more during 6 months of treatment than those who received standard care, but the effect was not compelling. The node-link-mapping group was using more cocaine at the start of treatment. Although the node-link-mapping group showed a greater reduction from the start to the end of treatment than did the standard group, the absolute amount of cocaine use at the end of treatment was not significantly different.

Further studies are needed in which these results are replicated in groups that start treatment with the same level of cocaine use or finish treatment with the node-link-mapping group using significantly less cocaine.