Chapter 1 - Introduction and Treatment Philosophy

Cocaine abuse and addiction represent a significant health problem in the United States (NIDA 1994). In recent years, this problem has increased, inflicting much harm on addicted individuals, their families, and society. Many individuals with cocaine problems have other substance use disorders, medical problems, psychiatric disorders, and psychosocial problems.

Cocaine is taken by mouth, inhaled, injected into the veins, and smoked. In recent years, the number of cocaine users who smoke crack cocaine has increased. Cocaine stimulates the central nervous system (CNS) to produce an increase in energy and psychomotor activity; a heightened sense of sensory arousal, pleasure, and euphoria; and a decrease in appetite and the need for sleep. It affects judgment and behavior, as well. Physical, behavioral, and social problems are common among cocaine addicts and may include any of the following specific consequences (Weaver and Schnoll 1999, pp. 105-120):

• Physical: Cardiovascular (for example, hypertension, arrhythmia, cardiomyopathy, myocarditis, myocardial ischemia, myocardial infarction), head and neck (erosion of dental enamel, rhinitis, perforation of nasal septum), CNS (headache, seizures), lung damage, pneumonia, chronic cough, acute renal failure, sexual dysfunction, spontaneous abortion in pregnant women, and infections (HIV, hepatitis B or C, tetanus) from sharing needles.
• Psychological: Poor judgment, anxiety, depression, suicidal feelings and behaviors, insomnia, emotional instability, irritability, aggressive behavior, and psychotic symptoms. Symptoms of psychiatric disorders such as schizophrenia, panic disorder, depression, or mania can be triggered or exacerbated by cocaine use or withdrawal.
• Social/family: Damaged or lost relationships, child abuse or neglect, lost jobs, accidents, prostitution, spread of infections, criminal behaviors, violent behaviors, and homicide.

As a result of the significant health and social problems caused by cocaine abuse and addiction, the National Institute on Drug Abuse (NIDA) has sponsored a number of studies of different cocaine treatment approaches. This Group Drug Counseling (GDC) manual describes one of the psychosocial treatments developed for use in a multisite clinical trial called the Collaborative Cocaine Treatment Study (CCTS). The study was conducted at Brookside Hospital in Nashua, New Hampshire, the University of Pennsylvania in Philadelphia, the University of Pittsburgh Medical Center (Western Psychiatric Institute and Clinic) in Pittsburgh, and Harvard Medical School (McLean Hospital in Belmont, Massachusetts, and Massachusetts General Hospital in Boston) (Crits-Christoph et al. 1997, pp. 721-726). All study sites randomly assigned cocaine dependent clients to one of four treatment conditions:

• Individual Drug Counseling (IDC) with GDC (Mercer and Woody 2000).
• Individual Supportive-Expressive Psychotherapy (SEP) with GDC (Luborsky 1984).
• Individual Cognitive Therapy (CT) with GDC (Beck et al. 1993).
• GDC alone.

Each of the three individual treatments, IDC, SEP, and CT, and the GDC treatment were described in manuals that guided the clinical approach used with clients. All study therapists participated in intensive training and ongoing supervision during the course of the pilot study and the main clinical trial, and their work was taped and independently rated to ensure that they adhered to the specific model of treatment they were using. IDC, SEP, and CT involved 6 months of active treatment. During the first 3 months of treatment, counselors offered clients individual sessions twice a week. During months four through six, counselors offered clients individual treatment sessions once a week. Clients were offered monthly booster sessions during months seven through nine. Clients could select a total of 39 individual therapy sessions while they participated in the treatment protocol. In addition, all clients assigned to the three individual treatment groups were offered GDC sessions weekly for 24 sessions: 12 weekly sessions in a structured psychoeducational group and 12 weekly sessions in an unstructured problem solving group. Thus, clients assigned to any of the three individual treatments could attend up to 63 individual and group sessions during the study.

One of every four clients was randomly assigned to GDC alone, and short case management sessions were available to them as needed. These clients primarily participated in group sessions and were offered 24 sessions during a 6-month period, followed by monthly individual case management sessions during months seven through nine.

The GDC approach was developed based on extensive clinical experience conducting addiction recovery groups and on a review of the relevant literature. Group therapy is one of the primary approaches used to treat drug addiction, including cocaine dependence (Rawson et al. 1989; Washton 1989; McAuliffe and Albert 1992; Vannicelli 1995; Washton 1997; Khantzian et al. 1999). Treatment groups are used throughout the continuum of care, from inpatient to intensive out-patient to aftercare programs. Clients often complain that addiction treatment that is provided only in groups is too limited, and many want individual as well as group sessions. Experience in this study as well as in clinical work supports the notion that a combination of individual and group treatment for cocaine addiction is preferable.

The GDC model addresses common issues in the early and middle stages of recovery from addiction. The philosophy of the GDC approach is that cocaine addiction, and other chemical addictions are complex biopsychosocial diseases that are often chronic and debilitating. Many biological, psychological, sociocultural, and spiritual factors interact to contribute to the development and maintenance of cocaine and other types of substance addictions (Daley and Marlatt 1997).

Addiction causes or exacerbates a variety of biopsychosocial problems in the addicted person as well as in the family. Adverse consequences associated with addiction include medical diseases, psychological and psychiatric disorders, family and interpersonal problems, and legal, economic, occupational, academic, and spiritual problems (Weiss and Mirin 1995; Earley 1991).

Although the research study found that all treatments helped patients improve, the combination of IDC and GDC produced the best results (Crits-Christoph et al. 1999, pp. 493-502). Community addiction outpatient treatment programs may not be able to offer as many treatment sessions as were offered in the treatment research study due to constraints imposed by managed care and changes in funding substance abuse services. Even with limited sessions, an IDC + GDC treatment model can be offered. For example, if a client is approved for 20 outpatient sessions, 12 could be offered as group sessions and 8 as individual sessions. While group sessions can be provided weekly, individual sessions can be spread out every several weeks or more so that patients stay connected to treatment for at least 3 months. Evidence shows that drug abusers need a minimum of 3 months in outpatient treatment to benefit from treatment (Simpson et al. 1997). Because keeping clients in treatment for 3 months or longer is important, clinicians should use multiple strategies to improve treatment adherence (Daley and Zuckoff 1999; Carroll 1998; Blackwell 1976; Meichenbaum and Turk 1987; Daley et al. 1998).

Although each client may evidence a unique pattern of cocaine addiction, he or she will manifest three or more of the symptoms listed below. These are based on the following criteria for substance dependency from DSM-IV of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association 1994, pp. 175-272).

• Excessive or inappropriate use of cocaine (or other substances): For example, getting high on cocaine or other drugs or getting drunk on alcohol and not being able to fulfill obligations at home, at work, or with others; feeling as if cocaine or other substances are needed to fit in with others or function at work or at home; or driving under the influence of substances.
• Preoccupation with getting or using chemicals: For example, living mainly to get high on cocaine, other drugs, and/or alcohol; making substance use too important in life; or being obsessed with using cocaine or other substances.
• Change in one’s tolerance for addictive substances: For example, needing more cocaine or other substances to get high or getting high much more easily and by using less of the substance than was used in the past.
• Having trouble reducing or abstaining from cocaine or other substance use: For example, not being able to control how much or how often one uses cocaine or other substances or using more cocaine or other substances than planned.
• Withdrawal symptoms: For example, getting sick physically, including having the shakes, feeling nauseous, having gooseflesh, having a runny nose, etc., once one cuts down or stops using cocaine or other substances; or experiencing mental symptoms such as depression, anxiety, or agitation.
• Using cocaine and other substances to avoid or stop withdrawal symptoms: For example, using cocaine or other substances to prevent withdrawal sickness or drinking or using drugs to stop withdrawal symptoms once they’ve started.
• Using cocaine or other substances even though they cause problems in one’s life: For example, not taking a doctor’s, therapist’s, or other professional’s advice to stop using because of problems substances have caused in one’s life.
• Giving up important activities or losing friendships because of cocaine or other substance use: For example, discontinuing participation in activities that once were important, giving up friends who don’t get high, losing friends because of how cocaine or other substance use affects relationships with others.
• Stopping cocaine or other substance use for a period of time (days, weeks, or months), only to begin again: For example, promising to quit using cocaine or other substances only to begin getting high again or being unable to remain abstinent from cocaine or other drugs.
• Getting into trouble because of cocaine or other substance use: For example, losing jobs or being unable to find a job, getting arrested or having other legal problems; sabotaging relationships or having trouble with family or friends, or having money problems because of cocaine or other substance use.

Because cocaine addiction is a disease that involves losing control of cocaine and other substance use, addicted individuals often enter treatment feeling demoralized and out of control. They enter a treatment program to help them regain control of their lives. Thus, treatment must provide a safe, structured environment through regular, frequent contact with the treatment staff.

Abstinence from all drugs is the primary goal of treatment in the treatment protocol. Changing one’s lifestyle, solving problems, and improving coping skills are additional goals that help support the overall goal of abstaining from cocaine or other substances.

The GDC model strongly encourages participation in 12-Step self-help recovery programs such as Cocaine Anonymous (CA), Narcotics Anonymous (NA), and Alcoholics Anonymous (AA). The importance of actively participating in these programs is emphasized in group sessions. Talking at meetings, learning and using the 12 Steps, using slogans, socializing before and after meetings, calling other members, and relating to a sponsor are ways clients can actively participate in the fellowship. Analysis of data from the CCTS showed that clients who actively participated in self-help activities had better outcomes than those who attended meetings without actively participating (Weiss 1996).

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