Treatment of Cocaine Use Disorders

Treatment of Cocaine Use Disorders

One of the greatest challenges in the early stages of cocaine treat-ment is to prevent early drop out. It has been estimated that up to80% of patients drop out of treatment programs (Higgins et al., 1994). Frequent clinical contacts, especially in the early weeks of treatment, can help to establish a therapeutic alliance that will as-sist in engaging the patient in the treatment process. Many pro-grams offer 3 to 6 days per week of substance abuse treatment sessions within outpatient partial hospital programs or intensive outpatient chemical dependency programs. Assessments by the program physician and counseling staff can identify other areas requiring specific interventions (comorbid medical or psychiatric disorders) and can expedite the initiation of appropriate pharma-cotherapies. These interventions will increase treatment retention. Often patients must be helped to realize that their drug use is having a significant and adverse impact on their lives. Many patients come to treatment because of family, legal, or social pressures. They can be ambivalent about the need for treatment and require education about their addiction and assistance in reviewing the consequences of cocaine use in their lives. This inventory should occur in the initial visits to the substance abuse treatment program.

Initial treatment should include the encouragement of ab-stinence from all drug and alcohol use. Patients who abuse alco-hol and marijuana often do not perceive these drugs as problems. Education regarding the use of such drugs as conditioned stimuli to the use of cocaine should be emphasized. The “disease model” of chemical dependency may be used to assist in the initiation of abstinence. Emphasis is placed on the patients recognizing chem-ical dependency as a disease needing treatment to control, but one for which there is no cure. Comprehensive drug education should also be provided in the initial treatment phase. Frequent contact with a drug counselor is an important part of treatment. Individual, group and (where clinically indicated) family or mar-ital therapy should be available. Attendance at 12-step or other self-help groups is often a useful adjunct to treatment and can be particularly helpful during the early stages of treatment when support for sobriety is essential.

The early recovery phase of treatment varies in duration from 3 to 12 months and is characterized by multiple weekly con-tacts and participation in therapeutic modalities with the goal of initiation and maintenance of abstinence. The focus during early recovery should be on relapse prevention and development of new and adaptive coping skills, healthy relationships and life-style changes that will facilitate abstinence.

Relapses are common during early recovery. Patients often feel pleased about their progress in treatment, become overly confident about their ability to control use, and test themselves by deliberately encountering what they know to be a high-risk situ-ation for their drug use. Experimentation with cocaine to prove that drug use can be controlled often results in relapse and is associated with guilt. Patients should be informed about the po-tential for relapse from the start of the treatment process. Relapse should be reviewed with the patient in a supportive way with an emphasis on helping the patient to gain an understanding of the events leading to relapse. Relapse should, however, also trigger a review of the treatment plan and consideration of the need for ad-ditional interventions or whether a higher level of care is needed to assist the patient in the recovery process.

Success with initiating and maintaining abstinence over several months is followed by a reduced frequency of contact (e.g., a decrease to weekly group or individual therapy sessions). The focus should be on maintaining a commitment to abstinence, addressing renewed denial and continued improvement of inter-personal skills. Participation in self-help groups should continue to be encouraged. Self-help groups based on 12-step principles encourage patients to continue to view themselves as addicts in recovery – a cognitive structuring that many recovering drug abusers find helpful in maintaining sobriety.