Home > The evidence base for treatment of problem cocaine use.

Long, Jean and Keenan, Eamon (2007) The evidence base for treatment of problem cocaine use. Drugnet Ireland , Issue 21, spring 2007 , pp. 16-18.

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Introduction

Cocaine is a central nervous system stimulant that leads to immediate but short-term euphoria, alertness and a sense of well-being. It may also reduce anxiety and social inhibitions while increasing energy and self-esteem. For the user, the desire for the positive short-term effects of cocaine often overrides concern about the longer-term consequences of acquiring and using the drug. Cocaine dependence is a common and serious condition which has become a substantial public health problem. There is a wide and documented range of consequences associated with chronic use of cocaine, such as medical, psychological and social problems.

 

On 3 May 2006 the Heath Service Executive (HSE) organised a workshop on cocaine. Dr Brion Sweeney, clinical director of the HSE Northern Area Addiction Services, presented the evidence base for the treatment of problem cocaine use and stated that cognitive behavioural therapy in conjunction with other interventions was the most successful form of treatment. He went on to state that prompt, accessible and tailored interventions increased the effectiveness of such treatment. He pointed out that the evidence indicated that medication had limited effect in the treatment of cocaine dependence, but said that new developments were expected in this area.

 

This article presents details of the summary evidence presented at the workshop. Where possible, the evidence is based on systematic reviews.1 A systematic review is an overview of primary studies that used explicit and reproducible methods.

 

Indicators

The indicators used to measure the success of treatment for problem cocaine use are: the absence of drug metabolites in the urine during and following treatment; retention in and completion of treatment interventions; and attendance at aftercare.

 

Treatment

Therapeutic management of people addicted to cocaine is based on abstinence from cocaine use. In the initial period following cessation, the person being treated may experience an intense craving for cocaine, and symptoms such as depression, fatigue, irritability, anorexia and sleep disturbance. The past decade has seen a sustained search for an effective medication for the management of cocaine dependence.

 

Medications

A number of studies have concentrated on finding a medicine to alleviate depression associated with cocaine use and to reduce cocaine craving. Lima and colleagues2 completed a systematic review of 18 randomised control trials on the use of antidepressants in treating cocaine dependence. The authors found that trials had not shown that antidepressants helped reduce cocaine dependence, although this might have been partly because many people stopped using the antidepressants too early. More people might have benefited if they had continued to use antidepressants for an appropriate period of time. The findings and recommendations were similar for cocaine users who were also dependent on heroin or were on methadone programmes. Individuals attending methadone treatment programmes may benefit from supervised consumption of anti-depressants and this approach should be tested using an appropriate research method.

 

Because chronic use of cocaine decreases dopamine concentrations in the brain, it was thought that pharmacological treatment that controlled dopamine levels could theoretically reduce these symptoms and contribute to a more successful therapeutic approach. Soares and colleagues3 evaluated the efficacy and acceptability of dopamine agonists for treating cocaine dependence through a systematic review of 17 studies. The authors reported that dopamine agonists had been used for reducing the symptoms that patients experienced during the initial period of abstinence from cocaine. This review of trials found that the evidence of success was not adequate to support the use of dopamine agonists as a treatment for cocaine dependence.

 

The anti-convulsant carbamazepine (a tricyclic medication that is widely used to treat a variety of neurological and psychiatric disorders) has been used for treatment of cocaine dependence. Lima-Reisser and colleagues4 examined whether carbamazepine was effective in the treatment of cocaine dependence through a systematic review of five studies. The review of trials found that carbamazepine had not been shown to help reduce cocaine dependence. The drop-out rate from treatment was high, adverse effects were common, and there was no significant fall in the participants’ cocaine use.

 

Silva de Lima and colleagues5 reviewed the efficacy of pharmacotherapy in treating cocaine dependence. The drug treatments included in the trials were grouped into the following categories: antidepressants, carbamazepine, dopamine agonists, and miscellaneous other drugs. The miscellaneous treatments included naltrexone, mazindol, lithium, disulfiram, phenytoin, nimodipine, lithium carbonate, NeuRecover-SA and risperidone. The effects of these drugs were compared with each other or with a placebo. Seven studies were included in the review. The authors concluded that there was no current evidence to support the clinical use of most of these drugs, including disulfiram, in the treatment of cocaine dependence. 

 

Acupuncture

Auricular acupuncture (insertion of acupuncture devices into a number of specific points in the outer ear) is a widely used treatment for cocaine dependence. Gates and colleagues6 assessed its effectiveness in a review of seven study trials, all of which were of low methodological quality. The review found no evidence that auricular acupuncture was effective in the treatment of cocaine dependence. High-quality randomised trials of auricular acupuncture may be justified.

 

Therapeutic communities

Therapeutic communities are a popular treatment for the rehabilitation of drug users in the USA and Europe. In a review of seven studies, Smith and colleagues7 examined the effectiveness of therapeutic communities compared to other treatments for substance misusers, and investigated whether their effectiveness was modified by client or treatment characteristics. Differences between the studies reviewed precluded any pooling of data; results were summarised for each trial individually. The authors concluded that there was little evidence that therapeutic communities offered significant benefits in comparison with other residential treatments, or that one type of therapeutic community was better than another. There was some evidence of reduced re-offending among prisoners who had participated in therapeutic communities while in prison.  However, methodological limitations may have introduced bias to the studies, and firm conclusions could not be drawn due to the limitations of the existing evidence.

 

Cognitive behavioural therapy

Cognitive behavioural therapy is a system of psychotherapy which attempts to reduce excessive emotional reactions and self-defeating behaviours by modifying underlying erroneous thinking and maladaptive beliefs. According to experts in this area, the cognitive approach, when applied to substance abuse, helps individuals deal with the problems leading to emotional distress and gain a better perspective on their reliance on drugs. Specific cognitive strategies are said to help individuals establish stronger internal controls and reduce their urges to take drugs. In addition, cognitive therapy can help patients to combat depression, anxiety or anger, which increase addictive behaviours.

 

Since there were no systematic reviews in the Cochrane Library that examined the evidence of effectiveness of psychotherapeutic interventions (such as cognitive behavioural therapy) in the treatment of cocaine dependence, some individual studies were reviewed for the purposes of this article.

 

Crits-Christoph and colleagues8 examined combinations of psychosocial treatments for cocaine dependence. They compared four different treatments – cognitive therapy, psychodynamic therapy, individual drug counselling, and group drug counselling alone. The first three treatments mentioned included group drug counselling along with the specific individual therapy. Treatments were intensive and provided over a six-month period. The clients were followed up at six and at twelve months. The authors found that, when compared to the two forms of psychotherapy and to group drug counselling alone, individual drug counselling plus group work showed the greatest improvement in the number of days the clients did not use cocaine over a one-month period. The authors were surprised by this finding because in 1991 Carroll and colleagues9 reported that relapse-prevention therapy (a form of cognitive behaviour therapy) was more effective than interpersonal psychotherapy, and had higher abstinence and recovery rates. In 1994, Higgins and colleagues10 reported that relapse prevention therapy with the addition of incentives was more effective than relapse prevention therapy alone. The clients who received incentives were more likely to complete their treatment and had a longer duration of cocaine-negative urines. Crits-Christoph and colleagues reviewed the evidence from the earlier studies mentioned and pointed out that the counsellors selected to participate in their study followed a detailed manual and provided intensive counselling with a strong focus on drug abstinence. They reported that psychotherapy was more effective in clients with psychiatric symptoms, and pointed out that their own study involved a relatively small number of such clients. In a follow-up analysis of the same cohort,11 the authors noted that there was no difference between the four types of treatment in other important measures of success, such as psychiatric symptoms, alcohol use and employment rates, nor in relation to interpersonal, social and family issues.

 

Brief intervention

Bernstein and colleagues12 conducted a randomised control trial to determine whether brief motivational counselling was more effective that written information in reducing cocaine use among clients attending an outpatient clinic in Boston. Six months following intervention, they found marginally higher rates of abstinence among those who attended brief motivational counselling than among those who received written information. For those reporting both cocaine and opiate use, the abstinence rates were 22% among those who were given brief motivational counselling, compared to 17% among those who received information; among cocaine users, the corresponding abstinence rates were 17% and 13% respectively. It is interesting to note that providing information on cocaine itself and its associated treatment options did encourage some respondents to seek help. Indeed, despite the title of this paper, the differences in abstinence rates for the two interventions were neither clinically nor statistically significant.

 

Vaccine

Hall and Carter13 state that ‘a cocaine vaccine is a promising immunotherapeutic approach to treating cocaine dependence which induces the immune system to form antibodies that prevent cocaine from crossing the blood brain barrier to act on receptor sites in the brain. The most promising application of a cocaine vaccine is to prevent relapse to dependence in abstinent users who voluntarily enter treatment’. Two published studies examined the use of cocaine vaccine among human populations14,15 Both studies showed some promising results; however, general availability of a cocaine vaccine is not imminent.

 

Management of cocaine dependence in the UK

The Drug Treatment Agency (DTA) in the UK emphasises a number of key practices which improve the success of cocaine treatment.  According to the DTA, once the initial contact with a treatment service is made, rapid intake, proactive reminders, and practical help with attendance improve treatment uptake rates. Once cocaine users start treatment, they tend to stay longer and respond better if they feel that their concerns are being positively addressed and that their key worker is empathic and understanding. This indicates the crucial role that key workers play in motivating and retaining clients.

 

The above evidence and experience indicate that the following strategies would help cocaine users manage their dependence:

 

  • Ensure seamless pathways through a four-tier service with clear strategies at each level.
  • Provide information or brief intervention at accident and emergency, harm reduction and opiate treatment services. The information should cover the dangers of cocaine use, the symptoms of dependence and the treatment services available.
  • Once contact is made with treatment services, ensure rapid intake, provide proactive reminders, and give practical help with attendance.
  • Complete an assessment of the client’s situation and needs.
  • Address the client’s immediate concerns and practical needs.
  • Assign a key worker who is empathic and understanding.
  • Develop basic criteria for assigning clients to either cognitive therapy or individual counselling.
  • Ensure that extensive training and detailed manuals are available for those providing therapy and counselling (examples on the US National Institute on Drug Abuse website (www.nida.nih.gov).
  • Enhance compliance with anti-depressant medication through directly observed treatment approaches and by dealing with complications as soon as possible.
  • Consider the provision of incentives for particular client groups if and when necessary.
  • Provide complementary therapies to enhance the client’s’ well-being, rather than dealing solely with their addiction.
  • Include interventions implemented to address problem cocaine use in surveillance systems and research projects so as to add to the existing evidence base. 

 

1.      Greenhalgh T (1997) How to read a paper: Papers that summarise other papers (systematic reviews and meta-analyses) British Medical Journal, 315: 672–675.

2.      Lima MS, Reisser Lima AAP, Soares BGO and Farrell M (2003) Antidepressants for cocaine dependence. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD002950. DOI: 10.1002/14651858.CD002950.

3.      Soares BGO, Lima MS, Lima Reisser A and Farrell M (2003) Dopamine agonists for cocaine dependence. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD003352. DOI: 10.1002/14651858.CD003352.

4.      Lima Reisser A, Lima MS, Soares BGO and Farrell M (2002) Carbamazepine for cocaine dependence. Cochrane Database of Systematic Reviews, Issue 2. Art. No.: CD002023. DOI: 10.1002/14651858.CD002023.

5.    Sivla de Lima M, de Oliveira Soares BG,  Pereira Reisser AA and Farrell M (2002) Pharmacological treatment of cocainedependence: a systematic review. Addiction, 97(8): 931–949.

6.      Gates S, Smith LA and Foxcroft DR (2006) Auricular acupuncture for cocaine dependence. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD005192. DOI: 10.1002/14651858.CD005192.pub2.

7.      Smith LA, Gates S and Foxcroft D (2006) Therapeutic communities for substance related disorder. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD005338. DOI: 10.1002/14651858.CD005338.pub2.

8.      Crits-Christoph P, Siqueland L, Blaine J, Frank A, Luborsky L, Onken LS et al. (1999) Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Archives of General Psychiatry, 56(6): 493–502.

9.      Carroll KM, Rounsaville BJ and Gawin FH (1991) A comparative trial of psychotherapies for ambulatory cocaine abusers: relapse prevention and interpersonal psychotherapy. American Journal of Drug & Alcohol Abuse, 17(3): 229–247.

10.   Higgins ST, Budney AJ, Bickel WK, Foerg FE, Donham R and Badger GJ (1994) Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Archives of General Psychiatry, 51(7): 568–576.

11.   Crits-Christoph P, Siqueland L, McCalmont E, Weiss RD, Gastfriend DR, Frank A et al. (2001) Impact of psychosocial treatments on associated problems of cocaine-dependent patients. Journal of Consulting and Clinical Psychology, 69(5): 825–830.

12.   Bernstein J, Bernstein E, Tassiopoulos K, Heeren T, Levenson S, Hingson R (2005) Brief motivational intervention at a clinic visit reduces cocaine and heroin use. Drug and Alcohol Dependence, 77(1): 49–59.

13.   Hall W and Carter L. (2004) Ethical issues in using a cocaine vaccine to treat and prevent cocaine abuse and dependence. Journal of Medical Ethics, 30(4): 337–340.

14.   Martell BA, Mitchell E, Poling J, Gonsai K and Kosten TR (2005) Vaccine pharmacotherapy for the treatment of cocaine dependence. Biological Psychiatry, 58(2):158–64.

15.   Kosten TR, Rosen M. Bond J, Settles M, Roberts JS, Shields J, Jack L and Fox B (2002) Human therapeutic cocaine vaccine: safety and immunogenicity. Vaccine, 20(7–8):1196–1204.

Item Type:Article
Issue Title:Issue 21, spring 2007
Date:January 2007
Page Range:pp. 16-18
Publisher:Health Research Board
Volume:Issue 21, spring 2007
EndNote:View
Accession Number:HRB (Available)
Subjects:B Substances > Cocaine
HJ Treatment method > Treatment outcome
HJ Treatment method > Substance disorder treatment method
L Social psychology and related concepts > Inducement for participation (incentive)

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