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Family InvolvementA difficult history of problems usually accompanies a patient's drug use. Relationships often deteriorate, including those between spouses, parents and children, siblings, and friends. The user, if employed, often experiences difficulties in the workplace, for example, lack of concentration, mistakes, tardiness, absences, an inability to get along with coworkers, on-the-job accidents, and increased workers' compensation claims. Financial difficulties are common as the user may spend money on drugs that is needed for rent, food, utilities, and other bills. Legal problems may also develop if the user resorts to crime to support his or her drug addiction. The impact of drug use and the problems it causes the user's family cannot be underestimated. Family members can benefit from a psychoeducational program that teaches them about drug addiction and methadone and helps them cope with the methadone patient's stages of recovery. One such program is the Community Network Project in San Francisco, a training program for families and friends of methadone patients designed to get them involved in the patient's treatment (Bernal et al. 1985). Based within the context of the methadone program, the Community Network Project works with patient-selected "sponsors," family members or friends who are drug free and want to help in the treatment. During the 18 hours of training, the sponsor does the following:
A followup meeting of participants occurs 3 months after completion of the training. When provided early in treatment, it is also appropriate to address, during family psychoeducation, the family's feelings of resistance to psychiatric treatment for the patient. Other issues that can be discussed in family therapy include the following:
Contingency ManagementContingency management, also commonly referred to as contingency contracting, is a well-known behavioral intervention used particularly with methadone patients, including those who abuse cocaine. Contingency management is a way to reinforce desired behavior by providing immediate consequences. It can be used to improve compliance with treatment components such as attendance at counseling sessions, as well as to promote abstinence from illicit drugs. This approach is useful for treatment planning since it sets concrete goals and emphasizes positive behavior change.
Importance of Urine TestingWhen contingency management is used to address concurrent use of short-acting drugs like cocaine, it is important to base consequences on objective measures of recent drug use, such as urinalysis. There must be adequate frequency of urine testing (e.g., random testing at least once per week) to detect short-acting drugs. Take-Home IncentiveWith patients abusing cocaine, common techniques of contingency management in MTPs involve changing a patient's methadone take-home dose privileges contingent upon recent drug use status. Stitzer and coworkers (1992), in a well-controlled study with 54 patients, found successful results when patients could earn their first take-home methadone day after only 2 weeks of drug-free urines.3 A total of 32 percent of the patients who had been abusing cocaine became drug free for at least 4 weeks during the study, and most were drug free for much longer (a mean of 9.4 weeks drug free). Magura and colleagues (1988) also found that 1-month contracting for contingent take-homes produced a favorable response (e.g., drug abstinence) in 34 percent of their multidrug-abusing subjects. The take-home privilege is one of the most popular rewards available for attempting to change behavior in contingency contracting procedures, but it only motivates some patients to abstain from cocaine use. Methadone dose changes have sometimes been used in contingency management. Stine and coworkers (1992) found that contingent dose increases might be useful for deterring cocaine use. However, contingent dose decreases are not generally recommended, since adequate dosing needs to be maintained to deter heroin use (Kolar et al. 1990; Payte and Khuri 1993) and since dose decreases tend to result in patients dropping out of treatment (Iguchi et al. 1988; Stitzer et al. 1986). Often, the right to remain in the treatment program is used as a contingency with substance abusers. Dolan and colleagues (1985, 1986) found that the threat to terminate treatment effectively motivated about half the methadone patients studied to remain drug free for 30 days. Condelli and coworkers (1991) also used withdrawal from methadone as the contingency when patients tested positive for cocaine. Out of 79 patients approached, 60 agreed to participate in the contracting study. After 2 months of the intervention, positive tests for cocaine use dropped from 75 to 38 percent. Thus, the intervention was effective for those who participated voluntarily. Practitioners in the field are divided on the efficacy of discharge from methadone treatment. It is important to be aware of both schools of thought and to fully understand the clinic's philosophy on this controversial treatment issue. Application of Contingency ManagementIt has been recommended (for example, by Stitzer and Kirby 1991) that contingency incentives be incorporated into methadone treatment, either through individual treatment plans or clinicwide policy, even if they do not work with all patients, since contingent incentives can lead to periods of abstinence among multidrug abusers and can increase drug-free time in cases of poor prognosis for permanent abstinence. Further, some of the other treatments outlined in this chapter, for example, relapse prevention and psychotherapy, could be employed during such periods of abstinence to further improve the chances of long-term success. In summary, research has demonstrated that incentive programs using positive rewards (e.g., movie passes or methadone take-homes) are effective for promoting cocaine abstinence. However, reduction in methadone dosage or withdrawal from methadone are not recommended as initial approaches to obtaining cocaine abstinence. Other interventions (e.g., relapse prevention) may be usefully implemented during periods of abstinence.
Relapse PreventionRelapse prevention approaches seek to teach patients concrete strategies for avoiding drug use episodes. These include the following:
Classical relapse prevention approaches make a distinction between "slips" and relapses, with slips defined as mild episodes of use that are viewed as learning experiences. While this distinction prevails among treatment professionals, some clinicians believe that with cocaine-abusing methadone patients it may be counterproductive to discuss how to prevent a slip from turning into a full-blown relapse since this approach may implicitly encourage patients to use. However, no one has adequately researched this point regarding cocaine abusers. A recent study using naltrexone (Trexan) to treat alcoholism also looked at relapse prevention approaches used in that treatment. The study found that those patients given supportive therapy with no specific relapse prevention coping skills had higher rates of overall abstinence. However, they were more likely to have a full-blown relapse if any drinking occurred than those patients given coping skills therapy with a specific relapse prevention component (O'Malley et al. 1992). Whether these results would occur with cocaine abusers requires further study. Numerous relapse prevention treatment approaches have been developed and are currently in use. These are conceptually and therapeutically appealing. However, research that tests the effectiveness of relapse prevention approaches with drug abusers is lacking. While relapse prevention strategies use the same overall approach for all substance abuse, management of the multidrug user may require some modification and additional emphasis (Kosten 1991). In particular, relapse prevention therapy with multidrug abusers may require specific interventions for each substance abused because the associated risks of relapse may be different for each drug (Marlatt and Gordon 1980). For instance, a methadone patient may associate heroin use with socializing and may associate cocaine use with alleviating depression. Also, the therapist should be aware that the multidrug abuser may attempt isolated uses of the abused substances that previously had been used together, which increases the chance of sequential lapses that can lead to full-blown relapse (Kosten 1991). For these reasons, States may do well not to set limits on the length of treatment-most patients will relapse to substance abuse at some point. One of the most important components of relapse prevention is assisting the patient to identify the warning signs of relapse. To both empower the patient and to be able to confront him or her about denial, it is critical that the therapist be well educated on the warning signs that may contribute to a resumption of drug use. A patient's false or misleading beliefs can precede relapse and serve as intervention points for the therapist. Some of those beliefs include the following (Washton 1988):
Additional emphasis should be placed on dealing with drug cravings of multidrug users who abuse cocaine; drug hunger among these users can be particularly intense because of the powerful memory of the euphoria (Gawin and Ellinwood 1988; Gold 1992). Almost any stimulus that can be associated with cocaine use can remind the addict of the drug, even talcum powder, snow, or bread crumbs. Depending on the patient, a song, money, or the smell of a match could be a trigger (O'Brien et al. 1986). Extinction therapy has been useful in reducing cocaine use for some patients. The patient's route of administration (intranasal, injecting, or "freebase") should be considered when developing cues for extinction therapy. An injecting user, for example, may not be influenced by a cue affecting an intranasal user.
Four treatment stages for the extinction of conditioned craving are summarized below (Gawin and Ellinwood 1988):
Pharmacotherapies aimed at reducing craving may be used as adjuncts to relapse prevention although their effectiveness is still not clearly established by controlled clinical trials. (See the section on pharmacological interventions starting on page 41.) For patients in methadone treatment programs, retention in the program is a significant factor in preventing relapse because the goal is to have patients continue with pharmacotherapeutic treatment for an extended period. Retention in treatment refers to the patient's ability and willingness to remain in treatment over time. Discussions of continuing pharmacotherapy with methadone should be part of the ongoing process of assessing the efficacy of treatments provided to the patient (Payte and Khuri 1993). Medical staff should ensure that patients are receiving adequate doses of methadone based on their individual needs, potential for relapse to the use of illicit drugs, and desire to remain in treatment.
PsychotherapyPsychotherapy for drug abusers evolved out of methods initially developed to treat other conditions (Rounsaville and Carroll 1992). In general, an accurate definition of psychotherapy distinguishes it from counseling: psychotherapy focuses on intrapsychic processes that impair effective coping and damage relationships, while drug counseling historically has focused on external issues relating to the patient's life problems (Zweben 1993). Early versions of psychotherapy with substance abusers were found ineffective because they focused too heavily on intrapsychic conflict and not enough on symptom control (Rounsaville and Carroll 1992). The prevailing approach in substance abuse treatment programs is to emphasize reducing drug use while pursuing other goals only after drug use has been at least partially controlled. This strategy means either providing psychotherapy as part of a larger comprehensive program or employing techniques to reduce drug use as an integrated part of psychotherapy (Rounsaville and Carroll 1992). Views differ on when to introduce psychotherapy. Some researchers indicate that psychodynamically oriented psychotherapy may not be useful either because it is ineffective or because in some patients it may precipitate relapse by stimulating feelings the patient is not yet able to handle. They suggest that exploratory psychotherapy should be used after 6-12 months of abstinence and only with those who wish to explore psychological problems in depth (Washton 1988). On the other hand, psychotherapy oriented to the stages of recovery is useful. For example, during the first 90 days to 6 months of treatment, patients need substantial support to manage painful emotions and interpersonal stress (Wallace 1992). In this context, psychotherapy can play a key role in helping patients deal with their emotional states instead of self-medicating with drugs.
Cognitive and Behavioral TherapiesTrained substance abuse therapists can combine cognitive and behavioral therapies as one cognitive-behavioral therapy or use them as separate intervention techniques. When used as a combined technique, cognitive-behavioral therapy focuses on uncovering and understanding the relationship between automatic thoughts and underlying assumptions about problematic feelings and behaviors (Zweben 1993). When used separately, cognitive therapy focuses on restructuring self-destructive thought patterns to create healthy patterns of relating to oneself and others. Behavioral therapy focuses on modifying behaviors that lead to self-destructive ends and rewarding positive healthy behaviors that enhance self-care and lead to healthy relationships. Behavioral therapies are generally used in substance abuse treatment programs to suppress antisocial behavior of patients. In this sense, the behavioral intervention takes the form of rules and regulations about standards of behavior while in treatment and includes sanctions for rule breaking (Woody et al. 1985). With some patients who abuse cocaine, intense cravings can resurface weeks and sometimes months after abstinence has been achieved. If the patient is not aware of this phenomenon, relapse may be more likely (Carroll 1992). Behavior therapy using cue exposure treatment (extinction) is designed to reduce the drug-craving response. This therapy uses repeated exposure to such stimuli to help the patient master the experience without using drugs. For example, talcum powder can be used to provide a cocaine-like stimulus. The patient is helped to find a substitute image (e.g., a beach scene) to counter the drug craving experience, until he or she reports no more drug craving when exposed to that stimulus. Visual images can also be used as stimuli. The more authentic the stimulus is to the patient's experience, the more effective the technique. (Questionnaires to elicit information on both external and internal triggers can be found in appendix I.) Cravings, or urges, are normal for a patient who is attempting to stop abusing drugs (Kadden et al. 1992). It is helpful to devise other methods for coping with cravings before they occur. Some examples follow:
The purpose of urge surfing is to experience the cravings in a new way and to "ride them out" until they go away (Kadden et al. 1992).
Self-Help ProgramsSelf-help programs have been used for primary cocaine addiction. They are appropriate both during active participation in a treatment program and as a practical continuing care service for long-term, stabilized patients who no longer require intensive one-to-one primary care (Nurco et al. 1991). Historically, the most popular and widely used self-help model is that of 12-step recovery programs. Twelve-step recovery programs appropriate for multidrug abusers of opioids and cocaine include Narcotics Anonymous (NA), Cocaine Anonymous (CA), and Alcoholics Anonymous (AA). They can serve as a valuable source for social support, peer identification, and role modeling, and offer an effective conceptual framework for relapse prevention and successful recovery (Washton 1988). Members gain strength and security from meeting with others who understand and share their concerns and who can offer practical strategies for surviving "one day at a time" (Gold 1992). In addition to their effectiveness when used in conjunction with a treatment program, the ongoing nature, wide availability, and absence of fees of 12-step programs support the notion that recovery is a lifelong process involving permanent changes in attitude and lifestyle (Washton 1988). The programs are based on 12 steps that help members focus on gaining strength toward lasting recovery. Examples of the steps' themes are admitting powerlessness over the abused drug(s), accepting help from a power greater than oneself, and taking a fearless moral inventory of oneself. By accepting and carrying out the 12 steps and attending meetings regularly (as often as daily for some), many recovering addicts are able to reduce their sense of isolation and demoralization, leading to a better chance of ceasing drug use and remaining abstinent (Millman 1988). For methadone patients, 12-step programs can pose certain problems: since such programs espouse total abstinence and these patients are maintained on methadone, they often feel out of place and unwanted. As a result, they may try to hide the fact that they participate in an MTP (Nurco et al. 1991). The national office of AA maintains a clear position that people on appropriate medication are welcome (Zweben 1993). However, other 12-step programs (e.g., CA and NA) and some local AA groups may not welcome methadone patients. Clinics can help alleviate this problem by directing patients to meetings that are more accepting of them, by developing specialized 12-step meetings at the methadone treatment site, or by working with other methadone programs to establish a 12-step group (Zweben 1993). A variant of this idea, Methadone Anonymous (MA), was developed at Man Alive Research, Inc., in Baltimore, MD, in response to discrimination that methadone patients perceived in other 12-step groups. Methadone Anonymous defines methadone as a tool for recovery, not an obstacle to it. Issues related to the recovery process and how to overcome the discrimination directed toward methadone patients are discussed in MA meetings in conjunction with how to achieve and maintain sobriety over illicit drugs and how to avoid relapsing. Methadone Anonymous now has chapters in 47 States. Recovery-oriented psychotherapy (Zweben 1987) generally assumes 12-step participation by the patient while he or she is also receiving professional treatment. Recovery issues encountered in the 12-step program can be simultaneously addressed by the therapist, with the therapist's methods changing to match the evolving needs of the patient. In chapters where methadone patients are accepted, CA may be an appropriate choice of 12-step groups. Cocaine Anonymous can provide support, strength, and hope for its members. Like AA, the program from which CA developed its structure, participation is free of charge and open to all who wish to stop using cocaine and other mind-altering substances. In many areas of the country, there are also Co-Anon chapters for families of cocaine addicts. Co-Anon, a sister organization of CA, offers support and friendship for individuals struggling to cope with the cocaine addiction of a loved one (Bohlen 1989). However, CA is less well established than AA, and in some areas of the country patients may have difficulty finding a cohesive CA group. Some patients may find that the CA meeting provides stimuli and may provoke use. If the patient reacts in this way, it may be more appropriate to attend AA meetings. Several other self-help models have been developed, although they are not widespread. An example is the Clinically Guided Self-Help (CGSH) model, developed at the Social Research Center in Baltimore, MD, a viable and cost-effective adjunct to primary treatment (Nurco et al. 1991). Participation is voluntary and draws on patients' motivation to take greater responsibility and control of their lives. Staff members provide information and skills training necessary for the patients to run their own groups and set their own behavior standards. The groups are small (5-12 members) and are designed to provide stabilized patients with the following:
Preliminary assessments of the program suggest that those participating in the self-help process have lower relapse rates, as reflected by urinalysis, and greater treatment retention rates than those not participating (Nurco et al. 1991). Rational Recovery (RR) is a free self-help program that distinguishes itself from the traditional 12-step programs. Associated with the Institute for Rational-Emotive Therapy, RR stresses self-control and the power of the individual. It may appeal especially to those patients who do not accept the concept of the "higher power" that is the basis of AA, CA, and NA. Rational Recovery also differs from the traditional 12-step programs in its assertion that a person can recover from addiction, rather than always being in recovery (Rational Recovery Systems n.d.). Similar programs that have been advocated include Women for Sobriety and Secular Organization for Sobriety (SOS). Followup and Continuing CarePatient followup and continuing care are critical to ensure the patient's success in remaining abstinent from heroin and cocaine abuse. Given the likelihood that some patients will relapse, it then becomes important for programs to educate patients about the relapse process and facilitate reentry into treatment quickly if relapse occurs. Followup and continuing care services create a continuum of support for the patient and need to be properly funded.
Special IssuesDetoxificationIt is debatable whether detoxification is necessary or even helpful for treating withdrawal from cocaine. While development of tolerance and the presence of a withdrawal syndrome have been identified in individuals regularly using cocaine, most patients have little difficulty initially stopping the use of cocaine; detoxification may not be indicated. However, patients have difficulty in maintaining long-term abstinence. A variety of pharmacological approaches have been attempted during the early phases of abstinence from cocaine to promote the patient's ability to remain drug free and decrease chances of relapse. The efficacy of these approaches remains unclear (see chapter 7: Consensus Panel Recommendations for Further Research). Pharmacological InterventionsSome clinicians may be reluctant to prescribe medications for patients who need drug addiction treatment. Physicians in MTPs may have less difficulty with this concept, as they have accepted the notion that medication is appropriate for treating drug addiction. Yet, even doctors in MTPs may remain reluctant to give medications with addictive potential for problems other than for substance abuse. In deciding whether to initiate pharmacotherapy, several factors must be considered (Kosten 1992):
When appropriate, it is clear that pharmaco- therapies should be used:
For those patients who do receive medications, the following procedures have been found to be useful:
For methadone patients concurrently dependent on cocaine, a variety of pharmacotherapies are currently being evaluated for use in conjunction with opioid addiction, detoxification, or methadone treatment. Pharmacological treatment of cocaine abuse generally involves using antidepressants, dopamine agonists, increases in methadone dosage, or other pharmacologic agents that either block the acute effects of the cocaine, or reduce drug craving. Additionally, new long-acting maintenance agents for opioids, such as levo-alpha-acetylmethadol (LAAM) (recently approved by the FDA and marketed as Orlaam) and buprenorphine (Buprenex) are being explored. LAAM's effectiveness in reducing opioid drug craving and preventing opioid drug withdrawal is similar to that of methadone but does not require daily dosing. There is no information yet on LAAM's impact on concurrent cocaine abuse. Buprenorphine, which is being studied as an alternative to methadone, was originally thought to have some usefulness in treating cocaine abuse (Kosten 1991; Kosten et al. 1989b, 1989c; Mello et al. 1989), but the most recent research casts doubt on this finding (Schottenfeld et al. 1993). Some treatment successes have been documented for pharmacologic agents, but the efficacy of these medications is still being researched (see chapter 7). Of course, using such drugs to treat concurrent cocaine abuse is a different issue than using psychotropic medications for clearly comorbid conditions, for example, antidepressants for depressed cocaine/opioid abusers. Treatment Implications for Patients With Psychiatric ComorbidityIt is important to recognize psychiatric disorders in cocaine and heroin abusers because they are prevalent and are associated with poor treatment outcomes. The most commonly encountered psychiatric disorders in this population are listed in table 1, in the approximate order of their expected prevalence in heroin and cocaine abusers (Kosten et al. 1989a; Rounsaville et al. 1982). The frontline clinician working with cocaine- and heroin-abusing patients may be in the best position to recognize these disorders in the patients. Therefore, the clinician should have a working familiarity with how the disorders present. Definitive diagnosis and treatment may be best handled by referral to an experienced mental health clinician (e.g., psychiatrist, psychologist, or psychiatric social worker). It is ideal for a mental health clinician to be an integral part of the treatment team and to diagnose and treat on site. This capability will not be possible at all clinical sites, in which case ready availability of outside consultants and referral sources is recommended. Symptoms of cocaine, other-stimulant, and narcotic abuse can mimic a variety of psychiatric disorders and symptoms. To avoid misdiagnosis, the clinician must carefully elicit the patient's lifetime history to determine whether any psychiatric disorder has occurred during periods of abstinence or minimal drug use. For example, patients who present symptoms of hyperactivity, impulsivity, or inattentiveness may indeed be abusing cocaine. However, these symptoms are also characteristic of attention deficit hyperactivity disorder (ADHD), and it is essential that clinicians be aware of the possibility that ADHD may be an underlying problem. Psychiatric diagnosis should usually be withheld until the patient has been stabilized in substance abuse treatment (minimum, 5-7 days; preferable 2-4 weeks) and drug use is either reduced or eliminated. Although several weeks of abstinence will allow the clinician to diagnose more accurately, severe psychiatric symptoms (e.g., suicidality or a psychotic reaction) need to be attended to promptly (Ziedonis 1992). Many psychiatric syndromes, however, will be resolved once the drug abuse is treated. An overview of psychiatric disorders to aid clinicians in screening patients and to indicate the range of possible treatment options is provided in appendix H. Exact DSM-IV criteria can be found in the DSM-IV manual and handbooks (American Psychiatric Association 1994). The Structured Clinical Interview (SCID) for DSM-IV may also be a useful tool for clinicians, since it suggests standard questions for eliciting the various disorders. The following characteristics of this population should be considered in developing a therapeutic response (Borant 1992):
The following principles are essential in the clinical management of patients with psychiatric comorbidity:
Cocaine-dependent methadone patients diagnosed with depression have improved treatment outcomes if psychotherapy and pharmacotherapy are both integrated into their treatment plans (Ziedonis and Kosten 1991). When treating cocaine and heroin abusers for depression, it is important that depressed addicts acknowledge their need for drug rehabilitation and abandon their common belief that the addiction will disappear when the depression lifts (Dackis and Gold 1992). Substance abuse treatment requires effort and sacrifice on the part of the patient, while affective illness usually responds well to pharmacotherapy. Cognitive therapies can be effective with this population when used with pharmacotherapy. Interpersonal therapy (IPT) can also be effective in treating depressed heroin and cocaine addicts (Rounsaville et al. 1985). In treating anxiety disorder among cocaine and heroin addicts, it is important to guard against indiscriminate use of medication. Anxiety is a cardinal feature of early recovery and may not indicate a disorder unless the anxiety symptoms persist after detoxification (Dackis and Gold 1992). Patients with anxiety disorder are likely to self-medicate with opioids, which can cause a vicious cycle of craving and euphoria (Dackis and Gold 1992; Kosten et al. 1986b). The therapist will need to be aware of this risk.
According to DSM-IV, a diagnosis of antisocial personality (ASP) disorder should be made only if the associated characteristics occurred prior to age 15 and are not the result of the addict's lifestyle; in other words, they must precede the substance abuse. Conventional psychotherapy is not effective in treating substance abusers with ASP (Shamise 1981; Woody et al. 1985). Many patients with this diagnosis do not respond well to treatment (Rounsaville et al. 1983; Woody et al. 1991). However, behavioral interventions have been used to suppress antisocial behavior of patients whether or not full-blown ASP was indicated (Walker 1992; Woody et al. 1991). In addition, there is evidence of a strong association between high-risk behavior (such as needle sharing) and patients suffering from psychological stress (Metzger et al. 1991).
Prescribing Psychotropics for Patients With Other Psychiatric ProblemsA variety of psychiatric problems may accompany narcotic addiction and require concurrent use of psychotropic medications with methadone. Clinicians should carefully review possible drug interactions when combining psychotropic medications with methadone (Woody et al. 1991). Drug interactions that may not normally be present in nonsubstance abusers may appear in substance abusers because they tend to experiment with drugs. For example, using benzodiazepines with methadone may produce a clinically significant high not normally obtained when either drug is used alone. When monoamine oxidase (MAO) inhibitors are prescribed for depression, the clinician needs to be aware that serious drug interactions may occur if the patient uses prescribed medications (e.g., meperidine [Demerol]), or illicit drugs (e.g., cocaine). Kleber (1983) summarizes the use of psychotropics for various disorders as follows:
Patient NoncomplianceTo assist patients who concurrently abuse opioids and cocaine to comply with program rules, it is necessary to (1) understand the psychosocial factors influencing the patient and (2) implement action based on understanding the patient's problem. It is also essential to provide a fair set of treatment options that responds to the patient's needs. Patients can become extremely opposed to the total abstinence ideal if they feel pushed too far (Barthwell and Gastfriend 1993). To assess a patient's motivation for treatment, the clinician should first review what is known about the patient. If this information does not explain the patient's compliance problem, the clinician may need to collect more data about the patient. Collecting more data usually leads to enhancement of services, including moving to a more intensive level of care, such as a day program or therapeutic community. Understanding the patient's resistance to treatment may be facilitated by asking a series of questions:
Approach a patient's resistance to treatment sensitively. If the patient feels overwhelmed by the demands of the treatment regime, he or she may drop out of treatment and feel more discomforted and demoralized than before admission (Miller and Rollnick 1991; Millman 1988). Be aware of limit setting within treatment strategies that can directly affect patient motivation. Although limit setting is necessary, effective treatment involves collaboration between the patient and therapist, reflecting the need to promote autonomy and responsible decision making on the part of the patient (Zweben 1993). It may be helpful, especially in more difficult cases, to meet with the treatment team and review their recommendations in addition to those of the counselor. If necessary, the clinical supervisor should intervene by evaluating the patient and providing supervision to the counselor. The treatment team and the clinical supervisor may provide a more powerful intervention than the counselor alone. On a more procedural level, it is important to develop a program philosophy that distinguishes the needs of different types of drug abusers. An overgeneralized treatment approach does not adequately engage a patient in treatment (Millman 1988). Also, the program's policies should be reviewed by asking the following questions:
Cocaine-abusing patients in methadone programs have been shown to have higher rates of noncompliance with program rules and regulations than those who do not abuse cocaine (Condelli et al. 1991). A variety of strategies can be used to help motivate patients to comply with their program and stay in treatment. The list in the text box to the left gives some of the major points of consideration.
Several program elements should be considered that can affect patient compliance and subsequent retention in treatment:
Spiritual IssuesA drug user with a high degree of religious motivation sometimes finds that treatment programs that include spiritual guidance or counseling can produce positive outcomes (Muffler et al. 1992). Since affiliation with religious organizations has long been an important component of American culture, it makes good sense to draw on these resources to help treat substance abusers. Larson and colleagues (1988) have noted, however, that more effective collaboration between religious organizations and other community providers (e.g., mental health professionals) would increase the benefits to individuals seeking help for their substance abuse problems. More than ever, Protestant and Catholic churches are responding to the needs of this part of their congregations, usually by sponsoring and providing meeting space for AA or NA groups (Muffler et al. 1992). One advantage offered by church-oriented programs is the support offered by others in a socially sanctioned group. Churches have a long history of commitment to serving their parishioners in time of need. They are finding that contemporary social problems require a reexamination of the services they deliver. For example, people who work in programs developed for the HIV/AIDS population or the homeless recognize that alcohol and other drug abuse can be a major deterrent to achieving a functional lifestyle. This recognition has compelled churches and other religious associations to find ways to address substance abuse within their established programs (Muffler et al. 1992). Participation in church-sponsored programs is not for everyone; however, for patients for whom religion or spirituality is an important part of their cultural milieu, the churches may play a pivotal role in helping the substance abuser resolve to seek help. Issues for Special PopulationsAlthough cocaine dependency touches the lives of many different groups who are part of the same clinic environment, certain populations warrant special attention. Among these are women, especially pregnant women; adolescents and young adults; families with children; persons with HIV/ AIDS; and persons with TB. Clinics may be able to offer specialized services to some of these groups. For example, some clinics have obtained special funding for services to pregnant women or children of substance abusers. Optimally, more specialized services would be available in drug treatment programs, since such ready access to these popu- lations provides opportunities for public health intervention. This section provides an overview of issues to consider when treating special populations. When working with these populations, it is important for clinics to do the following:
WomenIt is well accepted by clinicians that women need to be treated with sensitivity to their special needs and problems. Such sensitivity may be critical to successful treatment. Women who have been long-term substance abusers may have complex and multiple medical problems, including gynecological infections, amenorrhea, hypertension, hepatitis, TB, pneumonia, sexually transmitted diseases, and HIV infection (Brown et al. 1992). Women face both external and internal barriers to entering treatment:
It is important to recognize these issues when planning treatment interventions for women and to provide educational information about possible health risks specific to women. Pregnant WomenThe use of opioids and cocaine during pregnancy can cause medical and obstetrical complications and affect the development of the fetus. Clinicians should take care to designate pregnant drug-dependent women as "high risk" and closely monitor the medications given for drug dependence treatment over the course of the pregnancy. In addition to biomedical consequences found in any opioid-dependent person, heroin is known to cause neonatal abstinence syndrome, low birth weight, prematurity, stillbirth, and sudden infant death syndrome (Finnegan and Kandall 1992). Increased numbers of pregnancy complications are specifically associated with the use of cocaine. These include spontaneous abortion, poor weight gain, and precipitous delivery (Finnegan and Kandall 1992). The appetite suppressant effect of cocaine may compromise the nutritional needs of the mother and fetus and can interfere with a successful delivery. Cocaine has also been found to pass into breast milk (Smith 1986). Possible effects on the fetus associated with cocaine use include mild neurodysfunction, transient electro- encephalogram abnormalities, cerebral infarction and seizures, vascular disruption syndrome, and smaller head circumference. There is some evidence that cocaine use may cause congenital anomalies. However, other factors may also be responsible, including alcohol, nicotine, or other drug use; general poor nutrition; and the patient's lifestyle. The use of methadone treatment for narcotic dependency during pregnancy has been well-studied and established. Research indicates that methadone can be successfully used during pregnancy without major adjustments in dosage and, in fact, may provide the following advantages (CSAT 1993a):
Withdrawal from methadone maintenance is rarely appropriate during pregnancy. When attempted, methadone should be withdrawn slowly under close medical supervision and with careful fetal monitoring. It is generally accepted that if the patient insists that the dose should be lowered, this step should be taken during the middle trimester of pregnancy, not the first or third. Split dosing or raising doses in the last trimester of pregnancy (Pond et al. 1985) is recommended by some clinicians since plasma levels of methadone are decreased in the last trimester because of expansion of blood volume. In any case, all factors should be considered while making an individualized assessment. Neonatal abstinence syndrome may occur in a fetus exposed to methadone, and the baby will require careful monitoring after birth. The use of medication to reduce craving for cocaine during pregnancy is not as well studied. It is generally recommended that pregnant women withdrawing from cocaine should not be medicated except in very specific instances and under certain conditions. Guidelines for treatment options for cocaine withdrawal during pregnancy have been developed by a Consensus Panel (CSAT 1993a). Sensitivity to and elimination of the barriers women often encounter will help them to enter and continue treatment. Removing these barriers may mean addressing the needs of family members through family services, which may include the following:
All staff in methadone programs should be trained to meet the needs of pregnant women. It is equally important that public assistance workers be cross-trained about MTPs. In addition, pregnant women should be informed by MTP staff that some States regard drug use during pregnancy as child abuse and require the program to file a report with child welfare authorities. Some women are driven from treatment because of these laws. Others may be mandated to treatment by a child welfare agency in order to keep their babies who might otherwise be put in foster care. To keep families together, treatment programs must maintain honesty and credibility with such child welfare agencies.
Persons With HIV InfectionThe most common behaviors associated with HIV exposure of methadone patients concurrently dependent on cocaine are sharing injection equipment and engaging in unprotected sex with partners at risk of HIV infection. Increasing HIV rates among injecting drug users are a significant problem for patients concurrently dependent on heroin and cocaine because injection is usually the primary route of administration. Treatment providers have noticed that these patients need intensive medical intervention and that other medical problems associated with injecting drug use, such as TB or hepatitis, are exacerbated by the HIV infection. In addressing HIV issues within this population, both prevention and intervention strategies should be employed. An advantage of MTPs is that patients inject heroin less frequently or quit altogether, thereby decreasing their risk of HIV exposure through needle sharing. Yet methadone-maintained patients who inject cocaine and share injection equipment continue to be at risk of HIV infection. For this reason, all staff need extra training to work with cocaine-abusing HIV patients. In addition, during acute use of cocaine, cocaine's aphrodisiac qualities can lead to increased sexual drive, prolongation of the sexual interaction, and participation in multiple-partner sex marathons (Winick 1992). The risk of HIV exposure can remain very high if concurrently dependent p | |||||||||||||||||||||||||||||||||||||||||||
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