Cocaine Treatment: Behavioral Approaches

In the medical community, there is no general agreement as to the best way to treat cocaine dependence. This is alarming given that in 2000, an estimated 1.2 million Americans were current cocaine users. One form of treatment takes a behavioral approach towards cocaine dependence. Behavioral therapy works to change how a person thinks, feels, and behaves. Behavioral therapy uses a number of different approaches to work on breaking an individual of his or her drug use. The behavioral approach uses various methods depending on the doctor's own preferences and the needs of the patient. Many consider it particularly useful because it can be combined with other treatments, such as medication. However, the effectiveness of behavioral treatment is in the early stages of being tested.

Outpatient versus Inpatient Treatment

People dependent on drugs can get treatment as an outpatient—meaning the person lives at home but visits a hospital or other treatment center regularly—or as an inpatient—meaning the person lives at the treatment center. Inpatient treatment is not usually recommended for people dependent on cocaine. This is because, in general, recovering from cocaine dependence requires that the patient learn to cope with circumstances in his or her environment that have led to cocaine abuse. The best chance for accomplishing this task lies outside the hospital. However, inpatient treatment is necessary if the patient (1) fails to make progress or worsens during outpatient treatment; (2) has severe medical or psychiatric problems; (3) is physically dependent on other drugs; or (4) has a history of criminal activity.

Inpatient treatment takes place in a therapeutic community. The patient lives in this community for a period of time determined in advance, from six to twelve months. One study has shown that patients who stayed for longer periods at treatment centers were less likely to relapse, or return to drug use, after treatment. Inpatient treatment focuses on helping the individual readjust to living and functioning in

society without taking drugs. In addition to support services, the individual may receive rehabilitation through working at a particular trade.

Cocaine Anonymous

Cocaine Anonymous (CA) is a community-based organization that offers self-help to cocaine users. CA takes Alcoholics Anonymous (AA) as its model and applies the same basic principles. The goal for members is to stop using cocaine and remain drug-free by following the Twelve Steps of CA (which are based on the original Twelve Steps of AA).

See Organizations of Interest at the back of Volume 1 for address, telephone, and URL.

CA is available to anyone who expresses a desire to stop using cocaine and other drugs. All that is necessary to become a group member is to attend meetings. Meetings vary from large, open sessions that anyone can attend to small, closed discussions reserved for specific groups. For example, young people, professionals, or women might organize their own groups to address their specific concerns. At most meetings, members share their experiences and offer advice and support to each other. In addition, CA offers sponsors, or members who have been in recovery for a substantial period of time, to provide support and guidance to a person attempting to recover. Many treatment professionals recommend CA for people with cocaine problems.

Group Therapy

Many professionals suggest that group therapy is an essential part of cocaine-abuse treatment. These groups are led by a therapist and include people of different backgrounds and at different stages of recovery from cocaine dependence. Group therapy aims (1) to help individuals overcome the feeling that they are suffering alone with their drug problem; (2) to provide positive role models for those in the early stage of treatment; and (3) to encourage hope for success. Doctors who recommend group therapy believe that peer pressure and support are necessary to persuade individuals that stopping cocaine use is the right thing to do.

People in group therapy may discuss their feelings of guilt, problems in their personal relationships, or how cocaine has changed their lives. The therapist points out the negative effects of cocaine. Group therapy occurs in outpatient or inpatient settings. It is sometimes used as the sole source of treatment or combined with individual counseling and other forms of treatment. Group therapy has some drawbacks, including the individual's loss of confidentiality and the possibility that some peers in the group may have a negative influence on the other participants. Research continues on the effectiveness of group therapy as compared to individual therapy alone or a combination of both approaches.

Psychotherapy

Inpatient and outpatient treatment for cocaine dependence usually includes individual therapy with a psychotherapist. Psychotherapy tries to discover the underlying personality disturbances that bring about cocaine abuse. These disturbances include painful emotional states, such as depression. Psychotherapists believe that the individual's emotional and psychological problems must be solved before he or she can become abstinent from cocaine.

Supportive Psychotherapy. Supportive or supportive-expressive psychotherapy is often used for cocaine dependence. In this type of therapy, the patient must acknowledge the negative consequences of cocaine use, accept the need to stop using the drug, and learn to control the impulses that lead to cocaine use. The therapist and the patient explore ways to stay away from other users and environments where drug use is common. The focus of treatment then shifts to exploration of the underlying reasons for the cocaine abuse. The patient tries to gain insight into his or her personality and understand why he or she has turned to cocaine. However, a study from the 1990s has led some researchers to conclude that psychotherapy of this type was ineffective with the majority of their subjects.

Interpersonal Psychotherapy. Interpersonal psychotherapy (IPT) is based on the idea that drug abuse is one way in which an individual attempts to cope with problems in interpersonal relationships. In this therapy, the therapist and patient discuss the negative effects cocaine has had on the patient's functioning. They then compare those effects with any supposed benefits the patient might have believed he or she was getting from cocaine use. After the patient stops using cocaine, the therapy then addresses difficulties in relationships, including the role of drug use in these relationships.

IPT patients must recognize that drug use cannot help them achieve the goal of satisfying relationships or a rewarding social life. For example, the cocaine abuser may be using the drug to meet new people or to feel relaxed in a social situation. IPT tries to offer patients different and better ways to achieve their social goals.

Behavioral Therapy

Like all drugs, cocaine produces particular effects on the brain. In the view of some drug-abuse therapists, dependence on cocaine is a behavior that begins and continues because of those biological effects. Cocaine produces a reaction in the brain that increases the likelihood that a person will take the drug again.

Environmental factors also determine whether a person will become dependent on cocaine. These factors include (1) the person's peers, (2) a desire for acceptance by others, and (3) the person's belief that drug use will have no negative consequences. In addition, research has clearly demonstrated that cocaine users try to obtain and use the drug at certain times of day, in response to certain events, and in response to certain of their own emotional states. The goal, then, of behavioral therapy is to change these "using" conditions and creating new conditions that encourage abstinence from cocaine.

Behavioral therapy for cocaine dependence is often conducted through group therapy. The idea behind the therapy is to make drug use less attractive and to create alternatives to drug use. Patients learn how to change their external environments and their own internal responses. They also learn to recognize situations in which they are most likely to use cocaine, to avoid these situations when they can, and to cope more effectively with problems and problematic behaviors associated with drug abuse. For example, individuals learn how to cope with boredom, anger, frustration, and depression, and how to handle social pressure to use drugs. Sometimes individuals act out social situations in therapy sessions so that they can better handle such situations in real life. Individuals are also urged to give up other drugs, especially alcohol, because drinking makes a person more likely to use cocaine and weakens his or her resolve to avoid cocaine.

Behavioral therapy acknowledges that people will sometimes have a lapse and use cocaine while under treatment. A typical group therapy session might address why temporary lapses occur and try to help individuals work to prevent total relapse. Family and friends are also encouraged to join therapy groups, as many researchers believe that such support is one of the most effective ways to encourage abstinence.

Reward System. Some behavioral therapy uses a system in which the patient receives a reward for staying in treatment and remaining cocaine-free (proven through drug-free urine tests). The patients earn points that can be exchanged for items that encourage healthy living, such as joining a gym or going to a movie and dinner. This reward system has shown positive results among many cocaine users.

Negative Incentive System. In another behavioral treatment method that sometimes works, the cocaine addict writes a letter admitting to cocaine use. The addict then agrees that the letter can be made public if a urine test turns out positive for cocaine. This system uses a negative incentive. The patient avoids the drug in order to avoid a negative consequence rather than to win a positive reward. Researchers believe that a negative incentive works for some cocaine users who have something to lose, such as a good job.

Environmental Factors. Another behavioral approach focuses on people, places, and things in a person's environment that produce a craving for cocaine. These might include drug-using friends, drug paraphernalia , white powder, and places where cocaine is used. In therapy, the person is exposed repeatedly to those aspects of his or her environment. The difference is that, in the controlled conditions of therapy, cocaine is not available. As a result, the events or places that used to produce a craving gradually lose their ability to do so. Once the person breaks the connection between cocaine and certain places or certain things, he or she is less likely to use cocaine when in those places or exposed to those things.

Relapse Prevention Treatment. Relapse prevention treatment (RPT) focuses on ensuring that brief lapses to cocaine use do not become full relapses. In this approach, the therapist communicates to the patient that a lapse is not uncommon in recovery and that it does not negate the progress the patient has made. The first test of RPT's effectiveness at treating cocaine dependence showed that relapse prevention helped individuals stay in treatment and did help them to become abstinent.

Motivational Therapy

Most studies of drug treatment show that a large number of patients drop out of their treatment programs. Studies also show that most individuals who do remain in treatment succeed in breaking the habit. As a result of these findings, researchers believe that a cocaine user's commitment to stop taking drugs is the most important factor affecting chances for success. Motivational therapy focuses on the person's motivation to change and aims to strengthen his or her desire to quit.

The Best Treatment Method

No single treatment for cocaine abuse has proven more effective than any other. The treatment of cocaine addiction is complex and must address a variety of problems. Like any good treatment plan, cocaine treatment strategies must match the needs of particular patients. Programs that combine several treatment methods may prove the most effective. In general, researchers believe that recovery from cocaine addiction will be difficult unless the individual has something to lose and unless the individual believes that he or she has the power to change and make positive choices.

see also Cocaine Treatment: Medications; Risk Factors for Substance Abuse.

THE BIOLOGICAL MYSTERY OF COCAINE ADDICTION

For a long time, the human brain has remained clouded in mystery including the mystery of why some drugs, such as cocaine, lead to such intense cravings that users will destroy marriages, careers, and families in order to get their fix. Recently scientists who study the human brain have begun testing more than 500 chemicals in order to locate an anticocaine, or a medication that will eliminate these cravings without causing negative side effects.

While such a discovery will never substitute for an addict's desire for recovery, a chemical breakthrough could make relapses rarer and greatly help individuals who are struggling to quit their cocaine use.