|
|||||||
|
|
|
|||||
|
|
|||||||
|
Chemical Dependency Research Working Group |
Stephen Magura, Ph.D. is Principal Investigator for this research project conducted by National Development and Research, Inc. (NDRI), New York, NY, and was assisted by Andrew Rosenblum, Ph.D. and Meg Lovejoy, B.A. Jeffrey Foote, Ph.D. and Leonard Handelsman, M.D. carried out the clinical work at the Narcotics Rehabilitation Center of the Mount Sinai Medical Center, New York, NY.
The use of methadone as a pharmacologic treatment for heroin dependency has well-documented results of reducing or eliminating heroin use (Bale et al, 1980; Newman and Whitehill, 1979; Ball and Ross, 1991; Hubbard et al, 1989). A significant problem within methadone treatment, however, is the prevalence of secondary substance abuse, particularly cocaine injection and crack-cocaine use (Kolar et al, 1990; Condelli et al, 1991; Magura et al, 1991a). Current estimates of cocaine use among methadone patients range from 16% to 66% (Hartel et al, 1989; Kolar et al, 1990; GAO, 1990; Magura et al, 1991b; BIMC, 1993). A secondary dependence on cocaine carries with it serious detrimental consequences, including deterioration of social and psychological functioning (Kosten et al, 1987), substantially increased health risks (e.g. HIV exposure) (Chaisson et al, 1989), criminal activity (Hunt et al, 1986), and disruption of engagement in methadone and other treatment services (Kolar et al, 1990).
Similar to other drug rehabilitation centers, methadone clinics have been ill-equipped to respond to the cocaine epidemic. Although there is some evidence that cocaine use declines once dually-addicted patients enter methadone treatment (Dunteman et al, 1992; Magura et al, 1991b), methadone has no pharmacological effect upon cocaine use and methadone counselors typically are not trained in the treatment of cocaine abuse (Kolar et al, 1990).
The initial pool of subjects was selected by the methadone counselors and by reviewing the clinic's toxicology records for cocaine use. Methadone patients identified as cocaine users were contacted and, if they expressed interest, underwent an informed consent procedure. Ninety-six percent of the patients contacted agreed to participate and were randomly assigned to either the intensive treatment condition or control group. Subjects were considered to have entered treatment if they attended at least one session. For a more complete description of the methodology see Magura et al (in press, a).
The core of our treatment for these cocaine-dependent methadone patients was developed by Rawson and colleagues (1990) at the Matrix Institute in Los Angeles. The highly structured, manual-driven, outpatient therapy is 6 months in duration, and includes two individual and three group sessions per week, followed by a 3 month aftercare component consisting of a once weekly group. The Matrix model was developed specifically for cocaine users, incorporating the idea that there are stages of recovery from cocaine dependence. Such stages, also noted elsewhere in the literature (Gawin and Kleber, 1986), are thought to be correlated with the neurophysiologic changes that follow cessation of cocaine use. The Matrix model describes these stages as (1) Withdrawal (0-15 days post cocaine use); (2) Honeymoon (16-45 days post cocaine use); (3) the Wall (46-120 days post cocaine use); (4) Adjustment (121-180 days post cocaine use; and (5) Resolution (181= days post cocaine use). Each stage presents with different issues and problems. Progression through these stages is contingent upon achieving abstinence.
Program materials consist of very concrete cognitive-behavioral nd relapse prevention techniques addressing specific problems of drug cessation and recovery. The model makes no assumptions about underlying psychopathology, addressing the most commonly observed symptoms presented by cocaine dependent patients, including behavioral, emotional, cognitive and interpersonal issues. Core topics include: assessing external and internal triggers to relapse; establishing structure in daily life, issues of relapse prevention; re-establishing trust and learning to be truthful; developing a "recovery-oriented" lifestyle; and dealing with alcohol and other drugs (Rawson et al, 1990). The Matrix group, working with a non-methadone, essentially middle class population in Los Angeles, has reported positive results with this approach (Rawson et al, 1993), which has been described as "state of the art" treatment for primary cocaine abusers (Wallace, 1991).
The Matrix model was modified by the study to better address the needs of an impoverished, psychologically fragile population with little or no experience in psychotherapy. While this population is characterized by massive psychiatric, social and economic impoverishment, we have focussed our modification efforts on the pervasive psychological deficits which produce a tremendous barrier to engagement in treatment. These deficits include four areas of symptoms presentation: regulation of affect (problems in recognizing, modulating and tolerating emotion); interpersonal relations (problems in negotiating and managing casual or intimate relationships); "self" deficits (poor self-esteem, problems in self-care, poor self-efficacy, high levels of shame), and use of externalizing defenses or behavior (denial, projection, manipulation, avoidance). It has been our experience that these areas of psychological vulnerability and their resultant symptoms impede or destroy treatment efforts if left unaddressed. Symptoms of these deficits have frequently been viewed as issues of patient "readiness" to work on recovery, requiring a change in patient "attitude" before treatment can progress. Based on clinical evidence, we take the position that this is deficit-driven behavior which needs to be appropriately addressed within the treatment setting.
Two general types of modifications have been made in the Matrix model. First, we have written new curricula to identify and predict potentially disorganizing and destructive issues to which patients are vulnerable in these areas of deficit, to destigmatize the issues of the shame and fear that patients often experience; and to problem-solve in these areas, usually with a behavioral or cognitive action plan.
Second, we have developed an "enhanced positive reinforcement" model. This has entailed: (1) providing as many concrete positive reinforcements as possible; (2) stressing the use of interpersonal reinforcers, particularly therapist positive regard, respect, praise and attention; and 3) breaking down goal behaviors into units as small as necessary for successful accomplishment. These steps were designed to provide opportunities for patients to succeed, thereby increasing feelings of self-efficacy and esteem, while simultaneously creating an environment where patients could experience interpersonal engagement as rewarding, not aversive or punishing. The use of positive reinforcement techniques is in distinct contrast to the more widely used approach in drug-dependency treatment of either a punishment/aversion paradigm or a negative reinforcement paradigm.
Data collection included personal interviews, psychological scales, and weekly clinic urine toxicology results. Subjects received an incentive of $30 at baseline and at follow-up for completion of the interview protocol. Baseline research interviews were conducted prior to study treatment entry, and follow-up interviews were conducted six months after subjects entered study treatment. Interviews consisted of closed and open-ended items in domains which included sociodemographics, drug/alcohol use, AIDS risk behavior, crime and psychological functioning. Affect was measured with the Profile of Moods Scale (POMS) (McNair et al, 1971) and psychological symptoms were measured with the Brief Symptom Inventory (BSI) (Derogatis & Spencer, 1982). At baseline the Structured Clinical Interview Schedule for DSM-III-R (SCID) (Spitzer et al, 1990) was used to screen subjects with psychotic disorders and to diagnose all non-psychotic Axis I psychiatric disorders and on Axis II disorders, anti-social personality. Weekly cocaine toxicology results were used to validate self-reports of cocaine abstinence at six month follow-up. One subject, who reported no cocaine use at follow-up but who had a positive toxicology for cocaine, was excluded from the analysis.
Demographics. Intake characteristics of the sample include the following: 47% of the sample were women; the majority of the sample were either Hispanic (64%) or African-American (31%); mean age was 36.
Social and Psychological Deficits. The sample population presents a number of psychosocial deficits. The majority never graduated from high school (61%) and are currently not employed (83%). The main source of income reported is public assistance (79%). Seventy-nine percent report having been arrested, 71% have been incarcerated in either a jail or prison, and 47% report criminal activities, other then drug possession, within the past 30 days. SCID diagnoses showed that 70% had an Axis I psychiatric disorder other than cocaine dependence. Subjects also exhibited elevated levels of psychological disturbance on the POMS and the BSI.
Drug Use at Intake. In addition to 100% of the subjects qualifying as cocaine dependent, 81% of the sample report using other drugs in addition to cocaine. Heroin, alcohol (four or more drinks a day), marijuana and diazepam are used by more than 25% of the sample. For subjects who use these drugs, the mean number of days used in the past 30 is 8 days for heroin, alcohol and injection; 12 days for marijuana; and 9 days for benzodiazepines and other tranquilizers.
Sessions Attended. 61% of the subjects completed the six month cocaine treatment regimen. Patients attend 55% of all scheduled sessions, with the highest attendance being individual sessions (63%).
Drug Use. At 6 month follow-up subjects reported significant declines in cocaine, heroin, alcohol and benzodiazepine use. Frequency of drug injection declined by 39%. Frequency of cocaine use declined by 33%, dropping from 18 days to 12 days, and percent of subjects achieving abstinence from cocaine during the 30 day interview period (confirmed by toxicology) increased from 0% to 21% (for more details, see Magura et al, 1994).
Treatment Intensity. The study examined the relationship between cocaine use frequency at follow-up and number of sessions attended (our measure of treatment intensity). There was an inverse association between session attendance and cocaine use. That is, the more sessions attended, the less cocaine used at follow-up. However, baseline frequency of cocaine use was associated with cocaine use at follow-up, regardless of initial baseline levels. The 25% of subjects who attended the most sessions during the 6 month treatment showed a 60% reduction in cocaine use.
Those patients attending the most sessions showed the greatest reduction in cocaine use at follow-up, and patients attending the fewest sessions showed no change at follow-up. The data suggest that a certain minimum number of sessions may be required for the cognitive-behavioral treatment to be effective. Although many of these patients present psychiatric co-morbidity (typically major depression or anxiety disorders) and elevation on measures of psychological disturbance, neither of these psychiatric factors predicted outcome or treatment attendance. Our results support the view that treatment factors may be the strongest predictors of treatment efficacy. Of particular importance is that treatment intensity, measured on a continuum, was associated with reduction in cocaine use, even after controlling for patient intake characteristics.
Finally, the results of this study have implications for the treatment of cocaine-using methadone patients. These patients present severe psychiatric and interpersonal deficits and have been though to be resistant to psychotherapy. However, our study suggests that innovative psychotherapy which is structured, intensive, coherent and emphasizes positive reinforcement can engage, retain and treat many such problematic patients. Motivating patients can be understood as a two-step process: 1) establishing an easily understood and rewarding external focus to initially engage the patient, and 2) using interpersonal reinforcement to facilitate the transition from external motivation to internal motivation. The use of tangible incentives early on represents the externalized end of the motivation spectrum, and is critical for early engagement. As treatment proceeds, interpersonal reinforcement moves the patient toward a growing reliance on acceptance and attachment. Unlike tangible external reinforcers, these interpersonal processes can be internalized by the patient, and can then serve as more lasting reinforcers. In this way, in-treatment gains may result in longer term change, as internalized reinforcers begin to take precedence over external ones. The use of this richer, "enhanced positive reinforcement" paradigm offers the opportunity to engage the "unmotivated" patient, and promote both intrapsychic and behavioral changes.
In order to test the generalizability of our enhanced behavioral treatment model we have submitted a competing continuation proposal to NIDA to integrate the model into methadone clinic practice at two separate programs (one Mount Sinai MMTP clinic and two Beth Israel MMTP clinics). This will involve: a) recruiting cocaine-dependent patients into enhanced cognitive-behavioral treatment at admission to the clinics, (b) training methadone counselors and supervisors in cognitive-behavioral treatment principles and techniques, (c) implementing and monitoring delivery of cognitive-behavioral treatment by clinic staff, and (d) instituting a system of treatment phases for patients, from highest to lowest intensity, in order to allocate treatment resources with greatest efficiency. Our proposal also includes a comprehensive process and outcome evaluation.
This study was funded by Grant No. 5 R18 DA06959-04 from the National Institute on Drug Abuse.
Bales, R.N.; Stone, W.W.V.; Kuldau, J.M.; Engelsing, T.M.J.; Elashoff, R.M.; Zarcone, V.P. Therapeutic communities vs. methadone maintenance. Archives of General Psychiatry 1980 37.
Ball. J.C.; Ross, A. The Effectiveness of Methadone Maintenance Treatment. New York: Springer-Verlag, 1991.
Beth Israel Medical Center (BIMC), Methadone Maintenance Treatment Program. Patient Status Report. New York: Internal Report, 1993.
Chaisson, R.E.; Bacchetti, P.; Osmond, D.; Bradie, B.; Sande, M.A.; Moss, A.R. Cocaine use and HIV infection in intravenous drug users in San Francisco. Journal of the American Medical Association 1989 261: 561-565.
Condelti, W.S.; Fairbank, J.A.; Dennis, M.L.; Rachal, J.V. Cocaine use by clients in methadone programs: Significance, scope, and behavioral interventions. Journal of Substance Abuse Treatment 1991 8: 203-212.
Derogatis, L.R.; Spencer, P.M. The Brief Symptom Inventory. Baltimore: Clinical Psychometric Research, 1982.
Dunteman, G.H.; Condelti, W.S.; Fairbank, J.A. Predicting cocaine use among methadone patients. Analysis of findings from a national study. Hospital and Community Psychiatry 1992 43: 608-611.
Gawin, F.H.; Kleber, H.D. Abstinence symptomatology and psychiatric diagnosis in cocaine abusers. Archives of General Psychiatry 1986 43: 107-113.
Hartel, D.; Schoenbaum, E.E.; Selwyn, P.A.; Drucker, E.; Friedland, G.H. Temporal patterns of cocaine use and AIDS in intravenous drug users in methadone maintenance [abstract]. Presented at the V International Conference on AIDS. Montreal: June, 1989.
Hunt, D.; Spunt, B.; Lipton, D.; Goldsmith, G.; Strug, D. The costly bonus: Cocaine related crime among methadone treatment clients. Advances in Alcohol and Substance Abuse 1986 6: 97-122.
Kolar, A.F.; Brown, B.S.; Weddington, W.W.; Ball, J.C. A treatment crisis: Cocaine use by clients in methadone maintenance programs. Journal of Substance Abuse Treatment 1990 7: 101-107.
Kosten, T.R.; Rounsaville, B.J.; Kleber, H.D. A 2-5 year follow-up of cocaine use among treated opioid addicts. Archives of General Psychiatry 1987 44.
Magura, S.; Rosenblum, A.; Lovejoy, M.; Handelsman, L.; Foote, J.; Stimmel, B. Neurobehavioral treatment for cocaine-using methadone patients. A preliminary report. Journal of Addictive Diseases (in press)
Magura, S.; Siddqi, Q.; Freeman, R.; Lipton, D.S. Cocaine use and help-seeking among methadone patients. Journal of Drug Issues 1991a 21(3): 629-645.
Magura, S.; Siddqi, Q.; Freeman, R.; Lipton, D.S. Changes in cocaine use after entry to methadone treatment. Journal of Addictive Diseases 1991b 10(4): 31-45.
McNair, D.M.; Lorr, M.; Droppleman, J.F. Profile of Mood States. San Diego: Educational and Industrial Testing Service, 1971.
Newman, R.G.; Whitehall, W.B. Double-blind comparison of methadone and placebo maintenance treatments of narcotic addicts in Hong Kong. Lancet 1979: 485-488.
Rawson, R.A.; Obert, J.L.; McCann, M.J.; Ling, W. Neurobehavioral treatment for cocaine dependency: A preliminary evaluation. In: Tims, F.M. and Leukefeld, C.G. (eds), Cocaine Treatment: Research and Clinical Perspectives. NIDA Research Monograph Series, #135. Rockville: NIDA Research Monograph Series, 1993.
Rawson, R.A.; Obert, J.L.; McCann, M.J.; Smith, D.P.; Ling, W. Neurobehavioral treatment for cocaine dependency. Journal of Psychoactive Drugs 1990 22(2).
Spitzer, R.L.; Williams, J.B.W.; Gibbons, M.; First, M.B. Structured Clinical Interview for DSM-III-R (With Psychotic Screen). Washington, DC: American Psychiatric Press, 1990.
U.S. General Accounting Office (GAO). Methadone Maintenance: Some Treatment Programs Are Not Effective: Greater Federal Oversight Needed. Washington, DC: United States Printing Office, 1990.
Wallace, B.C. Crack cocaine: What constitutes state of the art treatment! Journal of Addictive Diseases 1991 11(2).
James David, M.D. is Director of Undergraduate Medical Education in Psychiatry at Albert Einstein College of Medicine, Bronx, NY and Medical Director of the Substance Abuse Service of North Central Bronx Hospital, Bronx, NY.
The advent of a "smokable" form of cocaine has led to an epidemic of severe cocaine-related psychiatric consequences. The municipal psychiatric emergency services have been inundated with patients both acutely and chronically debilitated by this drug. Brought in by friends, families and police, these people present with varied clinical syndromes. The meaningful, integrated classification of these clinical conditions has not yet been accomplished. There are two predominant professional domains involved in this process: the field of Psychiatry/Mental Health and the field of Chemical Dependency. These two fields have not yet been successfully synthesized in the treatment of our patients.
The national data no longer support the dichotomy between the Psychiatry and Chemical Dependency practitioners. In a psychiatric clinical environment, the chemically-dependent patients often receive less than optimal diagnosis and treatment. In a chemical dependency clinical environment, the patients with concomitant psychiatric disorders (unrelated to drug use) often receive less than the optimal care. Practitioners genuinely fluent in both psychiatric and chemical dependency methods are exceedingly scarce. Our patients, however, frequently suffer from both psychiatric and addiction disorders.
The Epidemiologic Catchment Area (ECA) study, which surveyed in excess of 20,000 persons, found that of those patients with cocaine use disorders - three out of four had co-morbid diagnoses of a non-drug-related psychiatric disorder. This is a dramatic increase as compared to the general population's rate of mental disorders. Patients with Schizophrenia, Affective Disorders, Anxiety Disorders, and other severe diagnoses are consistently and markedly over-represented in the cocaine addicted population according to numerous studies. These "Dual-Diagnosis" patients are now more the rule than the exception. Our treatment facilities and our training programs do not yet reflect this high co-morbidity rate.
Edward Nunes, M.D. is an Assistant Professor at the College of Physicians and Surgeons of Columbia University, New York, NY and a clinican at New York State Psychiatric Institute, New York, NY.
Based out of the Depression Evaluation Service at New York State Psychiatric Institute, this author, Frederic Quitkin M.D. and colleagues have performed a series of clinical treatment trials aimed at better understanding and treatment of the dual diagnosis patient with both substance abuse and depressive disorder. Epidemiologic studies show that depression is common in drug users and is associated with poor treatment outcome.
The first study was a 12-week, randomized, placebo-controlled trial of imipramine in outpatient cocaine users, who were rated for presence or absence of depression prior to randomization. One hundred and thirteen patients were randomized and 61 completed a minimum adequate trial of at least 4 weeks. There was a small trend toward more abstinent weeks in the imipramine group but it was not clinically impressive. However, when the depressed subgroup was examined separately most of the drug placebo difference in abstinence was in that group. This suggested that depression at baseline might be a patient-treatment matching factor with respect to imipramine or desipramine treatment for cocaine use. This was consistent with the self-medication hypothesis, which holds that some drug users are attempting to medicate an underlying mood disorder with street drugs.
Subsequently, a series of studies in which drug users with depression are specifically selected for antidepressant trials. In a pilot study with out patient alcoholics, over 50% showed a substantial reduction in both depression and drinking after open-label imipramine treatment. Twenty three of these were randomly assigned to stay on imipramine or switch to placebo. The relapse rate was greater on placebo than imipramine suggesting imipramine was exerting a protective effect. A larger, randomized controlled trial of imipramine vs placebo for depressed alcoholics is nearing completion, and a fluoxetine versus placebo trial for depressed alcoholics is getting underway.
In a randomized controlled trial of imipramine for depressed methadone patients, treatment success, defined as substantial improvement in both mood and drug use, was 60% on imipramine versus 10% on placebo. The impact on ratings of mood was highly significant. There was, however, a weaker effect on self-reported drug use, and no difference in proportion of drug-positive urines. This suggests that depression can be reliably diagnosed and treated in the methadone population, although the impact of this treatment on drug use is less robust. A more intensive psychosocial treatment plan, in combination with antidepressant treatment, would probably be the most successful approach for depressed methadone patients.
Anna Rose Childress, Ph.D. is an Associate Professor of Psychology at the Addiction Treatment Research Center, University of Pennsylvania, School of Medicine, Philadelphia, PA.
High rates of relapse are common in cocaine addiction after physical withdrawal from the cocaine. Relapse may occur for a variety of reasons, however our group has been particularly interested in the possible role of learned or 'conditioned' factors in relapse. Simply put, any stimuli (drug-using friends, locations, paraphernalia, even mood states) repeatedly paired with drug use over the natural course of a patient's addiction can become strongly associated with the drug effects. As a result, these associated ('conditioned') stimuli may later trigger arousal and craving for the drug, leading to drug use and relapse.
While most drug treatment programs recognize the power of these "conditioned" factors in relapse, the common advice to their clients is to avoid all things associated with the drug. Practically speaking, many of our patients have difficulty avoiding all things associated with their drug. Many are trying to maintain abstinence from cocaine in an urban environment that is saturated with the drug and all its associated reminders. Our goal has been the development of treatment strategies to help patients reduce the craving and arousal they feel upon inevitable encounters with drug-related stimuli.
In the laboratory setting our group has developed a treatment protocol giving patients repeated, passive exposure to drug 'reminder' cues in a 'protected environment' where drugs are not available. Initially, patients in these protocols experience strong craving and arousal when they see cues that remind them of their drug. Eventually, craving to the repeated cues decreases.
Extinction Procedures. Patients begin treatment in an inpatient setting. Fifteen hours of extinction are scheduled over a two week inpatient stay, following detox for the cocaine addicted patient. Extinction sessions consist of exposure to drug-related audiotapes, videotapes and drug paraphernalia. Patients are exposed to three fifteen minute sessions of drug-related stimuli in each session (Figure 1).
| Figure 1 |
|---|
| Example Session: 15 Minutes Each |
| Example Sets: 5 Minutes Each - 3 Sets Per Session |
|
Outpatient Phase. The outpatient phase lasts for 2 months when patients are encouraged to come in for two outpatient sessions a week. The outpatient sessions are focused on individualized 'triggers' for craving, e.g., money, specific people, locations, or feelings. Each session deals with one or more specific triggers for craving, often those the patient encountered during the prior week. Technicians help the patients recreate their problem cue scenarios and explore alternative responses for coping with craving.
Our laboratory uses two methods for measuring patients' reactions to drug-related stimuli. Physiological measures are available for extinction sessions conducted in our laboratory chamber. Subjective measures are based on a brief structured interview called the Within-Session Rating Scale (WSRS). The WSRS was developed to help us and the patient monitor changes in craving, withdrawal, high-like feelings, mood or tension which may occur in the course of a treatment session. The scale is administered by a trained research technician immediately before and after each extinction session. In addition to the WSWR scale, physiological responses to the extinction stimuli are measured at the beginning, middle and end of the inpatient stay. Physiological measures include temperature, galvanic skin resistance, heart rate and respiration.
Cues which have repeatedly signalled drug administration (e.g., drug-related locations, paraphernalia, persons, or even mood states) can trigger strong arousal and drug craving, potentially leading to relapse. Patients receiving the passive cue exposure intervention showed enhanced outpatient retention and reduced cocaine use in the 8 weeks following hospital discharge. However, despite such benefits, these patients sometimes experienced craving in response to cues outside the treatment setting, and drug use tended to reinstate cue strength.
To circumvent these limitations, we have developed an approach which teaches cocaine patients several active coping strategies (deep relaxation, delay/behavioral alternatives, negative/positive consequences, aversive/positive imagery, mastery imagery, cognitive interventions) to counter the craving and arousal triggered by detailed recounting of an individualized craving episode in the presence of a therapist.
In a recently completed trial, 48 cocaine outpatients were randomly assigned to a 12-week protocol featuring either the active coping strategies or other control activities (videotapes about family relationships and addiction) which were not craving-focused. Both the experimental and control conditions were added to a standard treatment baseline of weekly drug counseling and regular urine monitoring. Thirty-six of the 48 randomly-assigned outpatients (75%) engaged in treatment, and attendance for treatment sessions was similar (about two-thirds of the scheduled sessions) for each condition. Patients taught active strategies for coping with drug craving had significantly more cocaine-free urines than patients in the control condition, suggesting the potential clinical importance of addressing cur reactivity in drug dependence treatment.
However, many patients still experience craving in response to cues which could not easily be incorporated into the treatment setting (e.g., the presence of an undressed sexual partner as a trigger for cocaine craving). To enhance carry-over of training to real-world cue situations, we have recently begun to teach patients active techniques for reducing conditioned craving and arousal to problematic cues. Patients are trained in a 'menu' of active techniques: deep relaxation, delay/behavioral alternatives, aversive imagery, mastery imagery, and cognitive interventions.
Despite the significant work performed much remains to be learned about drug signals, and particularly their effects on drug users. Presently in our laboratory the effectiveness of the active tools is being evaluated on a 1) standard cues in the laboratory, 2) craving induced within treatment sessions, and 3) the clinical outcome (drug use, retention) of patients randomly assigned to either counseling plus active tools, or to counseling plus control activities. Further research will assist us in refining these techniques and in answering questions regarding cocaine addiction. The best role for passive/active cue response may be as an adjunct to treatment and/or relapse prevention.
Childress, A.R.; Hole, A. and DePhillippis, D. The Coping with Craving Program: Active Tools for Reducing the Craving/Arousal to Drug-related Cues. Unpublished manual, 1991.
Childress, A.R. and O'Brien, C.P. Classically conditioned factors in addiction: Understanding and modifying the response to drug signals. In: Lowinson, J.; Ruiz, R.; Millman, R. and Langrod, J. (eds), Comprehensive Textbook of Substance Abuse. New York: Williams and Wilkins, 1991.
Childress, A.R.; Ehrman, R.N.; McLellan, A.T. and O'Brien, C.P. Update on behavioral treatments for substance abuse. In: Problems of Drug Dependence, 1988, p 183-192. Rockville: NIDA Research Monograph #90 (DHHS No. (ADM)89-1605), 1989.
Childress, A.R.; Ehrman, R.N.; McLellan, A.T. and O'Brien, C.P. Conditioned craving and arousal in cocaine addiction: A preliminary report. In: Problems of Drug Dependence, 1987, p 74-80. Rockville: NIDA Research Monograph #81 (DHHS No. (ADM)88-1564), 1988.
Childress, A.R.; McLellan, A.T. and O'Brien, C.P. Classically conditioned responses in cocaine and opioid dependence: A role in relapse? In: Learning Factors in Drug Dependence, p 25-43. Rockville: NIDA Research Monograph #84 (DHHS No. (ADM)88-1576), 1988.
Childress, A.R.; McLellan, A.T.; Ehrman, R.N. and O'Brien, C.P. Extinction of conditioned responses in abstinent cocaine or opioid users. In: Problems of Drug Dependence, 1986, p 137-144. Rockville: NIDA Research Monograph #76 (DHHS No. (ADM)87-1508), 1987.
Childress, A.R.; McLellan, A.T.; Natale, M. and O'Brien, C.P. Mood states can elicit conditioned withdrawal and craving in opiate abuse patients. In: Problems of Drug Dependence, 1986, p 189-195. Rockville: NIDA Research Monograph #76 (DHHS No. (ADM)87-1508), 1987.
Childress, A.R.; McLellan, A.T. and O'Brien, C.P. Abstinent opiate abusers exhibit conditioned craving, conditioned craving, conditioned withdrawal and reductions in both through extinction. British Journal of the Addictions 1986 81: 655-660.
Childress, A.R.; McLellan, A.T. and O'Brien, C.P. Conditioned responses in a methadone population: A comparison of laboratory, clinic and natural setting. Journal of Substance Abuse Treatment 1986 3: 173-179.
Childress, A.R.; McLellan, A.T. and O'Brien, C.P. Nature and incidence of conditioned responses in a methadone population: A comparison of laboratory, clinic and naturalistic setting. In: Problems of Drug Dependence, 1985, p 366-372. Rockville: NIDA Research Monograph #67 (DHHS No. (ADM)86-1448), 1986.
Childress, A.R.; McLellan, A.T. and O'Brien, C.P. Role of conditioning factors in the development of drug dependence. Psychiatric Clinics of North America 1986 9: 413-426.
Childress, A.R.; McLellan, A.T. and O'Brien, C.P. Assessment and extinction of conditioned opiate withdrawal-like responses. In: Problems of Drug Dependence, 1984, p 202-210. Rockville: NIDA Research Monograph #55, 1985.
Childress, A.R.; McLellan, A.T. and O'Brien, C.P. Behavioral therapies for substance abuse. International Journal of the Addictions 1985 20: 947-968. (20th Anniversary Edition)
Childress, A.R.; McLellan, A.T. and O'Brien, C.P. Measurement and extinction of conditioned withdrawal-like responses in opiate-dependent patients. In: Problems of Drug Dependence, 1983, p 212-219. Rockville: NIDA Research Monograph #49 (DHHS No. (ADM)84-1316), 1984.
Ehrman, R.N.; Robbins, S.J.; Childress, A.R. and O'Brien, C.P. Conditioned responses to cocaine related stimuli in cocaine abuse patients. Psychopharmacology 1992 107: 523-529.
McLellan, A.T.; Childress, A.R.; O'Brien, C.P. and Ehrman, R.N. Extinguishing conditioned responses during treatment for opiate dependence: Turning laboratory findings into clinical procedures. Journal of Substance Abuse Treatment 1986 3: 33-40.
McLellan, A.T.; Childress, A.R. and Woody, G.E. Drug abuse and psychiatric disorders: Role of drug choice. In: Alterman, A.I. (ed), Psychiatric Illness and Substance Abuse. New York: Plenum Press, 1985.
O'Brien, C.P.; Childress, A.R. and McLellan, A.T. Conditioning factors may help to understand and to prevent relapse in patients who are recovering drug dependence. In: Review on Improving Substance Abuse Treatment. Rockville: NIDA Research Monograph, 1990.
O'Brien, C.P.; Childress, A.R.; McLellan, A.T. and Ehrman, R.N. Integrating systematic cue exposure with standard treatment in recovering drug dependent patients. Addictive Behaviors 1990 15: 355-365.
O'Brien, C.P.; Childress, A.R. and McLellan, A.T. Types of conditioning found in drug-dependent humans. In: Learning Factors in Drug Dependence, p 44-61'. Rockville: NIDA Research Monograph #84 (DHHS No. (ADM)88-1576), 1988.
O'Brien, C.P.; Childress, A.R.; McLellan, A.T.; Ehrman, R.N. and Ternes, J. Progress in understanding the conditioned aspects of drug dependence. In: Problems of Drug Dependence, 1987, p 394-404. Rockville: NIDA Research Monograph #81 (DHHS No. (ADM)88-1564), 1988.
Robbins, S.J. and Ehrman, R.N. Designing studies of drug conditioning in humans. Psychopharmacology 1992 106: 143-153.
Robbins, S.J.; Ehrman, R.N.; Childress, A.R. and O'Brien, C.P. Using cue reactivity to screen medications for cocaine abuse: A test of amantadine hydrochloride. Addictive Behaviors 1992.
Rohsenow, D.; Niaura, R.; Childress, A.R.; Abrams, R. and Monti, P. Cue reactivity in addictive behaviors: Theoretical and treatment implications. International Journal of the Addictions 1990.
Merrill Herman, M.D. is Chief of Substance Abuse Services and Director of the Cocaine Acupuncture Program at the Montefiore Substance Abuse Treatment Program (SATP) MMTP, Bronx, NY.
Methadone maintenance has been a highly effective modality for the treatment of opiate dependence since the 1960's (GAO, 1990). Cessation of heroin use enables patients to improve health, employment and, social functioning. The use of crack/cocaine coupled with serious social, economic and health problems has contributed to a deterioration in the psychosocial functioning of affected patients. At the Montefiore Substance Abuse Treatment Program (SATP), an MMTP which treats 900 opiate-dependent patients at two sites in the Bronx, the prevalence of cocaine/crack use has approached 50-60%. Those patients using crack/cocaine did not utilize or respond to available therapeutic modalities at SATP (i.e., counseling, 12 step programs, group therapy). Consequently, their retention in treatment was effected by lack of compliance, increasingly disruptive behavior and street diversion of methadone. Cocaine abusers were routinely sent to inpatient detoxes, often relapsing soon after discharge. The clinical staff has felt increasingly helpless and demoralized.
While no clearly effective pharmacologic agent has emerged for the treatment of cocaine withdrawal and craving, the use of acupuncture has grown considerably since the report by Dr. H. L. Wen from China in 1973 documenting its use in treating addiction. Acupuncture has been used extensively for the treatment of opiate, alcohol, and nicotine dependence, and more recently for cocaine dependence (Brumbaugh, 1993; Bullock, Culliton & Stern, 1989; McLellan, Grossman, Blaine & Haverkos, 1993; Washburn, Fullilove, Fullilove, Keenan, McGee, Morris, Sorensen & Clark, 1993). Michael Smith, M.D., Director of the Lincoln Hospital Division of Substance Abuse, has refined and expanded the treatment protocol developed by Wen (Smith & Kahn, 1988). Despite acupuncture's rise in popularity for drug treatment, little has been written on its efficacy for cocaine use, especially during methadone maintenance (Margolin, Avante, Chang & Kosten, 1993).
In November of 1992, the SATP initiated the Cocaine Acupuncture Program (CAP) for the treatment of methadone patients using crack/cocaine. The CAP team consisted of a licensed acupuncturist, a supervisory physician and acupuncture technicians. Methadone patients meeting the DSM III-R criteria for cocaine dependence were asked to volunteer for the CAP after completing inpatient detoxification. Occasionally, patients who had difficulty getting into inpatient detoxification due to child care responsibilities or lack of medicaid were allowed to enter the CAP directly. Patients with a previous history of cocaine use, who were experiencing craving, but not currently using, could also enter the CAP directly. Patients signed a treatment agreement/consent form prior to entering the CAP, with risks and benefits, including possible side effects (i.e. sedation) being explained. Treatment consisted of a minimum of 3 weeks attendance with daily (M-F) acupuncture sessions lasting 45 minutes each. After completion of this intensive phase patients were eligible for the maintenance phase of acupuncture which included a reduction in acupuncture sessions (3x/wk, 2x/wk, 1x/wk). Acupuncture consisted of 5 needles in each ear at standard points (kidney, liver, lung, sympathetic, and Shen Men). Needles were disposable and never reused to protect against HIV transmission. Patients received acupuncture prior to methadone dosing to maximize effect. Random urine toxicology screens for methadone, illicit opiates, cocaine, benzodiazepines and alcohol were administered twice a week. Patients were referred to on-site cocaine/crack recovery groups and NA meetings as well as continued weekly drug abuse counseling.
Given the high initial acceptance rate, more rigorous treatment parameters were introduced to define "successful completion" of the daily phase and subsequent eligibility for the less frequent maintenance phase of acupuncture. Patients had to complete a minimum of 3 weeks of daily acupuncture, with no more than 1 day missed in a given week without justifiable explanation. Two consecutive weeks of drug-free urines were required. Weekly attendance at on-site crack/cocaine groups and NA meetings as well as counseling was expected. Referrals were generated by the counselors via Interdisciplinary Conference (IDC). CAP treatment status was communicated via distribution of Daily Logs and Treatment Updates/Progress Notes to the supervisory and counseling staff. Ongoing education and support to the clinical staff was provided by the CAP team to facilitate treatment.
Initial pilot data revealed that of 65 patients who began daily acupuncture, 42 patients (65%) completed the intensive daily phase (Mean Length of Stay 28.5 days with a range up to 151 days), while 23 patients (35%) dropped out (Mean LOS = 19.1 days). It is worth noting that the long length of stay for many patients in the daily CAP was due to the reluctance of patients to graduate to the less frequent maintenance acupuncture phase of treatment, even though they were doing well. Patients appreciated the daily camaraderie and group support provided by the CAP team, SATP staff and other patients participating in the pilot project. Of the 65% who completed daily acupuncture, 83.8% began maintenance acupuncture. Of the patients completing daily acupuncture, the mean percent of urines positive for cocaine for the 90 days prior to CAP was 73.7% (S.D. = 27.4). Prior to CAP the number of percent positive urine screenings for cocaine per patient ranged between 20% and 100%. During the daily CAP, there was a mean decrease of 41.1% per patient for percent of urines cocaine positive. Patients who completed the daily acupuncture phase reported less cravings, depression, and agitation than those who did not complete daily acupuncture, although the difference was not statistically significant. Some patients requested a decrease in methadone dosage of approximately 10 mg due to increased sedation while in the CAP. The rate of completion of daily CAP was not effected by whether or not the patients completed inpatient detoxification beforehand. Forty two inpatient detoxification patients successfully completed the daily phase (64.6%), while 23 direct CAP admission successfully completed the daily phase (35.4%).
Based on our preliminary data, acupuncture appears to be a feasible and promising modality for the treatment of cocaine use by methadone maintenance patients. Patients find this modality acceptable, especially within the regular routine of an MMTP. Although the 41.1% decrease in cocaine positive urines is significant, limitations in the current design of the study make conclusions difficult. Single blind randomized studies with sham acupuncture points for alcohol and opiate detoxification have shown positive results. As acupuncture is not a pill, it is difficult to perform a classic double-blinded study and the influence of the placebo effect is difficult to separate from the treatment.
The frequency and duration of acupuncture treatment need further clarification. The treatment effect, as patients move from daily to less frequent maintenance acupuncture will continue to be evaluated in our program. Integration of acupuncture with other treatment modalities (i.e., counseling, relapse prevention groups, 12 step groups, etc.) is an important issue. Perhaps further randomized studies can delineate the intervention of acupuncture with the utilization of recovery and rehabilitation services. While group attendance has improved significantly in our program, motivation and self-selection biases clearly play a role. Overall retention in methadone maintenance treatment is an excellent indicator of improved outcome. Acupuncture may play a significant role in improving retention for dually addicted methadone patients.
The lack of differential treatment response based on whether patients attended inpatient detoxification beforehand may be significant. Severity of use may determine whether inpatient detoxification is indicated. For many patients, inpatient detoxification may not be indicated and a well-integrated acupuncture program may be sufficient.
It is not clear why 35% of patients drop out of the CAP. We need to determine ways which will make the intervention more appropriate so that more patients can utilize the treatment. Does the duration, frequency, intensity or route of cocaine use (crack vs. nasal vs. IV) affect treatment response? Other drugs of abuse, such as alcohol may also affect treatment response. How does speedballing (heroin and cocaine injected together) interact with acupuncture and methadone dosing? Our study showed that patients who successfully completed CAP reported a decrease in depression, agitation and crack/cocaine cravings during CAP than those who did not complete it. Does co-occurring psychiatric symptomatology (mentally ill chemical abuser) or conditions affect treatment response.
Despite its popularity, little research exists as to the efficacy of acupuncture for drug treatment. It is hoped that by continuing to evaluate our CAP treatment model and by stimulating further inquiry and rigorous evaluation, acupuncture will become more accepted by the scientific and drug treatment community.
Brumbaugh, A.G. Acupuncture: New perspectives in chemical dependency treatment. Journal of Substance Abuse Treatment 1993 10: 35-43.
Bullock, M.; Culliton, P.; Stern, J.A. Controlled trial of acupuncture for severe recidivist alcoholism. Lancet 1989 June 24: 1435-1434.
Margolin, A.; Avants, S.K.; Chang, P.; Kosten, T. R. Acupuncture for the treatment of cocaine dependence in methadone maintained patients. American Journal on the Addictions 1993 2:194-201.
McLellan, A.T.; Grossman, D.S.; Blaine, J.D.; Haverkos, H.W. Acupuncture treatment for drug abuse: A technical review. Journal of Substance Abuse Treatment 1993 10: 569-571.
Smith, M.D.; Kahn, I. An acupuncture programme for the treatment of drug addicted persons. Bulletin of Narcotics 1988 40: 35-41.
Washburn, A.M.; Fullilove, R.E.; Fullilove, M.T.; Keenan, P.A.; McGee, B.; Morris, K.A.; Sorensen, J.L.; Clark, W.W. Acupuncture heroin detoxification: A single-blind clinical trial. Journal of Substance Abuse Treatment 1993 10: 345-351.
Wen, H.L.; Cheung, S.Y.C. Treatment of drug addiction by acupuncture and electrical stimulation. Asian Journal of Medicine 1973 9: 138-141.
|
Last Update: March 15, 2001 |
.