Other Models of Psychosocial Treatment

A number of other psychosocial models and approaches have been described, and some used quite widely, for the treatment of stimulant use disorders.

Network Therapy

Network therapy is based on the rationale that people can recover from substance use disorders if they have a stable social network to support them in psychotherapeutic treatment. In this model, clients receiving individual psychotherapy develop a network of stable, nonsubstance-using support persons, such as family, partners, and close friends.

These support persons learn strategies from the therapist to support the therapeutic process for the individual being treated. They may interact regularly with the therapist, participate in treatment sessions with the client, and be involved in setting up treatment plans for the client.

Empirical evidence for network psychotherapy is scarce. Controlled trials of network therapy for cocaine or other substance use have not yet been published.

Acupuncture

Acupuncture is an ancient Chinese therapy in which thin needles are inserted subcutaneously at various points on the body. The technique is based on the belief that the body's normal functioning depends on a balance of two opposite polar energies that flow along lines of the body called meridians. Approximately 1,000 acupuncture points are aligned along these meridians, and their stimulation by the thin needles is believed to correct energy imbalances and enhance the body's natural capacity to heal itself.

No controlled outcome studies have been reported supporting the efficacy of acupuncture for the treatment of cocaine or other stimulant use disorders (TIP 10, Assessment and Treatment of Cocaine-Abusing Methadone-Maintained Patients[CSAT, 1994b]).

Inpatient Treatment

Inpatient treatment has traditionally consisted of a 28-day stay in a hospital or residential treatment facility, during which daily activities such as self-help groups, group psychotherapy, and relaxation techniques were provided in a structured format. Generally supportive and sometimes confrontational in nature, inpatient treatment was aimed at combating clients' denial and initiating participation in the 12 steps of recovery originally delineated by Alcoholics Anonymous (AA).

The major goals of most inpatient treatment programs are detoxification from the influence of chronic substance use and beginning the process of engaging with self-help programs such as AA and Narcotics Anonymous (NA). Treatment components include didactic learning about the processes of addiction and recovery as well as experiential techniques. Often the client's family is involved in special "Family Days" to acquaint them with these issues.

Originally developed for the treatment of alcoholism, the 28-day standard hospital treatment regimen was used especially in the early 1980s, when the numbers of clients seeking treatment for cocaine use disorders began to rise dramatically. This trend peaked in the mid-1980s, when more than half of clients in many private programs were being treated for cocaine abuse and dependence (Rawson, 1986).

Most of these inpatient programs were adapted to treat cocaine users with few or no modifications from the alcohol regimens. In the mid-1980s, when cocaine use among middle-class Americans reached epidemic proportions, the standard 28-day inpatient treatment program was the most widely used treatment modality for this population (Rawson et al., 1991a).

Several hospital/residential treatment organizations did attempt to evaluate the effectiveness of their treatment programming for cocaine users. For example, Sierra Tucson, in Tucson, Arizona, conducted a program of outcome research during the 1980s designed to evaluate and improve the efficacy of its treatment efforts for cocaine users.

The Hazelden treatment organization compiled an extensive database on the effectiveness of its treatment services with cocaine and other substance users. The Carrier organization has published a series of studies designed to evaluate the effectiveness of their treatment programs (Pettinati, 1991). Although the evaluations were not randomized clinical trials, the information collected in the reports supported the value of the treatment services.

The traditional 28-day inpatient treatment regimen was developed with little input from empirically based research. In the past several years, the use of such inpatient programs has been called into question by insurance providers, and subsequently their use has been steadily declining. As insurance coverage for inpatient treatment likewise began to dwindle, these programs became variable in length.

Many programs closed, and others were forced to scale back on the services they provided. Currently, in many cases clients are covered for brief inpatient stays (up to 7 days) for detoxification purposes only, and psychosocial services have been limited. Inpatient treatment programs are widely variable in the credentialing of their staff, but nearly all employ some staff members who are themselves in recovery.

Long-Term Residential Treatment

Long-term residential treatment is used for substance users who are deemed to be in need of a structured support system for a sustained period. The structure provided by long-term residential treatment is designed to allow positive changes and stabilization in the client's attitudes and lifestyle. The durations of residential treatment programs vary; at one time, most programs were at least 1 year in duration, but today most are about 6 months, or even only 90 days. Most residential programs, both long-term and halfway houses, are staffed at least in part by people who are themselves in recovery.

Therapeutic communities (TCs), the most common type of long-term residential treatment, are residential treatment programs that usually use group activities directed toward effecting significant changes in the residents' lifestyles, attitudes, and values. They emphasize prosocial behavior and the assumption of responsibility for one's actions. Many referrals to TCs take place through the court system. In fact, TCs originally were designed for heroin-addicted clients with deprived socioeconomic backgrounds and long-term histories of criminal involvement.

Halfway houses are residential treatment programs providing transitional support for individuals who are usually progressing from a more restrictive environment, such as a TC, but who are not yet ready to function independently in the community. These individuals may not need the intensive structured environment of a TC but may not yet be ready for independent living. Requirements of halfway-house programs usually include specified community involvement, such as employment or enrollment in school, and abstinence from mood-altering substances. Evening group activities are structured around residents' work schedules.

Although relatively little empirical evidence exists supporting the efficacy of long-term residential treatment for stimulant use disorders, there is at least some reason to believe that it can be effective (Gerstein et al., 1994; Mueller and Wyman, 1997). Although clinical experience suggests that TCs are effective with a subset of cocaine users, to the Consensus Panel's knowledge no controlled clinical trials have been published supporting their efficacy in the treatment of cocaine-dependent individuals.

Pharmacological Treatments for Stimulant Abuse and Dependence

There is not yet an effective pharmacotherapy for cocaine use disorders, but this topic is being researched intensively. Because of differences in the neurochemistry of cocaine and MA, there is sound reason to believe that different pharmacotherapies may be needed to treat those two forms of stimulant use (Ling and Shoptaw, 1997). However, because both drugs produce similar effects on the brain's dopamine levels, promising medications for the treatment of cocaine use disorders are also being examined for the treatment of methamphetamine use.

Clinical research on pharmacotherapies for MA use disorders is just getting under way. Medications are being sought to address a range of indications. There is interest in developing agents that can alleviate the medical/psychiatric symptoms caused by MA intoxication and withdrawal. For example, antidepressant medications have been found useful in the treatment of individuals who have discontinued their use of MA (NIDA, 1998c). Also, there is interest in developing medications to treat MA abuse and dependence. Ongoing trials are currently assessing dopaminergic (i.e., dopamine-mediated), serotonergic (i.e., serotonin-mediated), and other compounds (CSAT, 1997).

Pharmacotherapy research for cocaine use disorders was spurred initially by an open-label trial followed by a double-blind, randomized trial supporting the efficacy of desipramine, a tricyclic antidepressant, in producing short-term reductions in cocaine use and craving in outpatients (Gawin and Kleber, 1984; Gawin et al., 1989).

In the randomized trial, 59 percent of cocaine-dependent clients treated for 6 weeks with desipramine achieved 3 or more weeks of continuous cocaine abstinence compared with 25 percent of those treated with lithium and 17 percent of those who received placebo (Gawin et al., 1989).

Unfortunately, those promising results have not been replicated in subsequent controlled trials with desipramine (e.g., Carroll et al., 1994a; Weddington et al., 1991) or imipramine (Janimine), another tricyclic antidepressant (Nunes et al., 1995). Evidence that clients with less severe cocaine dependence may benefit from treatment with desipramine and imipramine was presented in at least two reports and merits further study (Carroll et al., 1994a; Nunes et al., 1995).

Other antidepressants that have been investigated in primary cocaine users include fluoxetine (Prozac) (Grabowski et al., 1995), maprotiline (Ludiomil) (Brotman et al., 1988), and gepirone (Jenkins et al., 1992). Studies are still in progress with some of these compounds, but none has demonstrated reliable efficacy in reducing cocaine craving or use in controlled trials.

Because of cocaine's very pronounced effects in the dopamine system, a variety of different dopaminergic compounds has been investigated, including amantadine, bromocriptine, bupropion, flupenthixol, carbidopa-l-dopa, mazindol, methylphenidate, and tyrosine (see reviews by Gorelick, 1994; Kleber, 1995; Mendelson and Mello, 1996).

Open-trial data have sometimes looked promising, but no reliable positive effects have been observed with any of these compounds in randomized trials. The same is true for the anticonvulsant carbamazepine (Kranzler et al., 1995).

Buprenorphine is an opioid drug that is currently being evaluated as a treatment for opiate dependence in the same manner as methadone is used. In the course of this work, observations by several researchers suggested that buprenorphine might be an effective treatment for cocaine use disorders in the population that uses both opiates and cocaine (e.g., Kosten et al., 1992; Schottenfeld et al., 1993).
However, other more rigorous clinical studies have failed to find that buprenorphine has efficacy in suppressing cocaine abuse (e.g., Johnson et al., 1995). Research continues on this topic. Currently, there is no convincing evidence showing that buprenorphine causes decreases in cocaine use or is associated with greater reductions in cocaine use than when methadone is used to treat clients who abuse opiates and cocaine (see Silverman et al., 1998).

Use of disulfiram therapy for clients who use both cocaine and alcohol looks promising. The majority of stimulant users meet medical criteria for alcohol dependence, and more than 90 percent are current alcohol users (Grant and Harford, 1990; Higgins et al., 1994a). Disulfiram therapy with social monitoring to ensure medication compliance was used as a standard component in the community-reinforcement-plus-vouchers treatment approach described above. A chart review was conducted on 16 cocaine-dependent individuals who received that treatment (Higgins et al., 1993a).

Carroll and colleagues reported results consistent with these findings in a pilot randomized trial (Carroll et al., 1993b). In that study, disulfiram therapy was compared with naltrexone therapy in a population of 18 outpatients who abused cocaine and alcohol. Disulfiram therapy resulted in significantly greater reductions in drinking and cocaine use than naltrexone therapy. Finally, a larger randomized trial on the efficacy of disulfiram therapy was completed recently, and again cocaine use was significantly reduced by disulfiram therapy (Carroll, 1996). A detailed protocol for use of disulfiram therapy with cocaine users is provided in the NIDA manual on community reinforcement plus vouchers mentioned above (Budney and Higgins, 1998).

Finally, an exciting area of research currently being pursued in the basic-science laboratory using nonhuman subjects focuses on the development of potential vaccines against cocaine use disorders in the form of enzymes or catalytic antibodies. These novel approaches may hold greater promise than more conventional approaches (Ling and Shoptaw, 1997).

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For additional material:
Chapter 4—Practical Application of Treatment Strategies
Chapter 5—Medical Aspects of Stimulant Use Disorders
Chapter 6—Treatment Issues for Special Groups and Settings
Appendices    Figures

see source: SAMHSA/CSAT Treatment Improvement Protocols
TIP 33: Treatment for Stimulant Use Disorders
http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat5.chapter.57310