About 1.6 million Americans use cocaine every year, and roughly one-quarter of them meet diagnostic criteria for a cocaine use disorder (CUD) under DSM-5 criteria. Fortunately, CUD responds to many of the same psychosocial interventions as other substance use disorders.
Approximately one out of six users who take cocaine intravenously or smoke the drug develop moderate to severe CUD (or what was called “dependence” in DSM-IV terminology). Rates of addiction are lower for those who use cocaine intranasally (“snorting”) or orally.
Cocaine addiction carries serious consequences for patients, and it is associated with substantial medical and psychiatric morbidity (Degenhardt L & Hall W, Lancet 2012;379(9810):55–70) and a four- to eight-fold higher death rate than the general population (Degenhardt L et al, Drug Alcohol Depend 2011;113(2–3):88–95).
A person seeking treatment for CUD can choose from a variety of evidence-based psychosocial interventions. In contrast, despite hundreds of millions of dollars spent over three decades on basic research and drug development, we still have no well-established, broadly effective medication to treat cocaine addiction. (For more information about medications used to treat cocaine use disorder see “This Month’s Expert” and “Some Options, But No Magic Bullet”.)
Which Psychosocial Interventions Work?
CUD responds to the same types of psychosocial therapies that are used to treat other substance use disorders. These include contingency management (CM), cognitive behavioral therapy (CBT), relapse prevention therapy, and community reinforcement. Although widely used, the role of drug counseling, motivational enhancement therapy, and 12-step facilitation are much less certain.
As a broad generalization, about one-third of patients improve over the first three months of treatment, regardless of the treatment method (Dutra L et al, Am J Psychiatry 2008;165(2):179–187; Penberthy JK et al, Curr Drug Abuse Rev 2010;3(1):49–62), although most interventions have never been rigorously evaluated in randomized controlled trials.
A systematic review of 27 treatment studies involving 3,663 patients found that CM was more effective than other psychosocial interventions in keeping patients in treatment and reducing cocaine use, and was even more effective when combined with CBT (Knapp WP et al, Cochrane Database Syst Rev 2007;3:CD003023).
Factors Affecting Outcomes
Intensity and duration of treatment are important factors in improving outcome, regardless of the specific therapy. More intensive treatment, such as more frequent or longer visits (generally at least weekly visits for at least three months), is associated with better outcomes, especially during early abstinence (Simpson DD et al, Arch Gen Psychiatry 2002;59(6):538–544; Zhang Z et al, Addiction 2003;98(5):673–684).
A minimum treatment duration of three months is also associated with better outcomes. However, the benefits of increasing treatment intensity may hit a ceiling after four to six months (Schneider R et al, J Ment Health Adm 1996;23(2):234–245; Coviello DM et al, Drug Alcohol Depend 2001;61(2):145–154).
The likelihood of a favorable treatment outcome is also increased by adhering to the following general principles:
- Nonjudgmental empathy with the patient, along with avoiding argument or unnecessary confrontation
- Getting the patient addiction treatment as promptly as possible (ideally, within 24 hours of his or her decision to seek help) in an office-based setting or formal substance abuse treatment program
- Clear and realistic orientation of the patient to treatment goals and behavioral expectations (eg, treatment engagement and honest reporting of struggles, including ongoing substance use)
- Strict monitoring for all psychoactive substances, not just cocaine (eg, by frequent urine testing)
- Prompt and explicit feedback to the patient regarding violations of treatment expectations, with consistently applied consequences for such violations (eg, a reduction in clinic privileges)
- Involvement of the patient’s social network (to the extent possible)
- Attention to any concurrent medical, psychiatric, vocational, legal, or social problems
Let’s take a look at some of the psychosocial interventions used to treat CUD and what the research shows about their effectiveness.
CM provides the patient something of value (typically a gift card, voucher, or chance to win a prize) to reward a specific and measurable desired behavior. Extensively studied in controlled clinical trials, CM is also effective in the community, outside research settings. CM can be used to reinforce either treatment adherence or treatment outcome (eg, providing a drug-negative or “clean” urine sample).
A recent systematic review of 19 studies involving 1,664 patients found that CM, when combined with CBT or other psychological interventions, significantly improved treatment retention, reduced cocaine use, and had an additive benefit when combined with pharmacological treatment (Schierenberg A et al, Curr Drug Abuse Rev 2012;5(4):320–331). CM can be combined with medication to keep the patient in treatment until the therapeutic benefits of medication are experienced.
CM is effective in a broad range of patients, including those with serious psychiatric comorbidity or other substance use disorders, older patients (Weiss L & Petry NM, Am J Addict 2013;22:119–126), and those at a variety of socioeconomic levels (Secades-Villa R et al, J Subst Abuse Treat 2013;44(3):349–354).
Cognitive Behavioral Therapy
CBT, also called relapse prevention or coping skills training, aims to change how patients think about their drug use so they can unlearn ineffective behaviors and acquire new cognitive and behavioral techniques to avoid drug use. For example, patients may learn relaxation techniques to deal with stress.
The focus is on high-risk contexts for drug use, including emotional states such as depression, anxiety, or stress; low self-confidence; exposure to drug-associated cues; or acute withdrawal (Hendershot CS et al, Subst Abuse Treat Prev Policy 2011;6:17). A slip or lapse is not considered failure, but an opportunity to implement the skills learned to prevent it from becoming a full-blown relapse. CBT tends to be more effective than drug counseling or psychotherapy (Knapp et al, op cit; Penberthy JK et al, op.cit).
Community Reinforcement Approach
The community reinforcement approach (CRA) broadens the behavioral approach to treatment beyond drug use to include the patient’s total environment and activities, including skills training to enhance drug refusal and problem solving, family relations, social network, employment, and recreation. CRA is often combined with CM and CBT as an integrated treatment package, making it often impossible to evaluate the separate contribution of CRA. CRA plus CM is more effective than CRA alone or drug counseling (Knapp et al, op.cit).
Drug counseling is a nonspecific, supportive form of psychotherapy focusing on recovery issues, which is popular with community clinics because of its low cost. Some form of drug counseling is often the standard treatment or “treatment as usual” against which other treatments are compared. Drug counseling is not as effective as CM or CBT (Knapp et al, op.cit).
Motivational Enhancement Therapy
Motivational enhancement therapy (MET) or motivational interviewing (MI) uses a supportive, directive approach to enhance motivation for change. MET is widely used in primary care settings and addiction treatment. Although it is effective for treating alcohol use disorders (Miller WR & Wilbourne PL, Addiction 2002;97(3):265–277), the evidence is far less compelling for cocaine. One controlled study demonstrated that MI increased abstinence by one-third over the control condition (Bernstein J et al, Drug Alcohol Depend 2005;77(1):49–59).
However, two other controlled studies found that MET and MI offered no benefit, although the latter study found decreased cocaine use in the heaviest using patients (Marsden J et al, Addiction 2006;101(7):1014–1026; Stein MD et al, J Subst Abuse Treat 2009;36(1):118–125).
Psychodynamic psychotherapy focuses on the patient’s intrapsychic conflicts and psychological defense mechanisms. The therapist uses interpretations of psychological processes and behaviors to improve the patient’s understanding of the presumed underlying causes of his or her addiction. There is no evidence that this therapy approach is more effective than CBT or drug counseling (Knapp et al, op.cit).
Other Psychosocial Treatments
Several other approaches are described in the treatment literature including twelve-step facilitation (TSF); web-based self-help; and Cocaine Anonymous, a self-help organization modeled on Alcoholics Anonymous. Although TSF is still widely used, few high-quality studies have been conducted with cocaine abusers. TSF was inferior to CBT in a 12-week randomized trial (Maude-Griffin PM et al, J Consult Clin Psychol 1998;66(5):832–837).
CATR’s Take: Various psychosocial therapies are available for treating cocaine addiction. Longer, more intense treatments; concrete treatment goals and expectations; explicit and consistently enforced contingencies; and the proverbial “unconditional positive regard” are associated with better outcomes. Although broadly used, the evidence is thin for motivational enhancement therapy, 12-step facilitation, and supportive drug counseling.