Academic journal article Journal of Drug Issues

Behavioral Treatments of Cocaine Addiction: Assessing Patient Needs and Improving Treatment Entry and Outcome

Academic journal article Journal of Drug Issues

Behavioral Treatments of Cocaine Addiction: Assessing Patient Needs and Improving Treatment Entry and Outcome

Article excerpt

Our studies have evaluated behavioral interventions for cocaine dependence among low-income, minority, inner city clients. These clients have multiple treatment needs, and like other populations of cocaineaddicted individuals, it can be difficult to entice them to enter treatment, stay in treatment, and effect positive treatment outcomes. Our research has three foci: (I) gaining better awareness of what types of problems we encounter in this population and the best ways of assessing these patient needs, (2) finding ways to increase rates of treatment entry, and (3) improving treatment outcomes. The purpose of this review is to summarize some of our findings in the first two areas, and to present some preliminary data regarding a procedure that appears to be promising for assisting patients in initiating cocaine abstinence and maintaining treatment gains.

Assessing Patient Needs

Our clinic serves a population that is primarily young (mean age=32 years), Black (83%), inner-city (84%), male (78%), unemployed (88%), poor (median annual legal income = $3,000), and crack cocaine dependent (87% smoked cocaine and 13% ingested cocaine by other routes). Approximately one-half of our clients have 12th grade or equivalent education (53%; with actual scholastic skill acquisition being far below this level), and few have any post secondary training (15%). Given this profile, it is not surprising to report that these individuals have multiple social and economic problems that extend beyond their cocaine use. Below we report the results of some assessments that reveal additional problems regarding drug use, psychiatric illness, and neuropsychological function. We also discuss our experiences with different assessment tools and suggest what we believe to be the best ways of ascertaining these patient needs. Poly-Substance Dependence

In addition to cocaine dependence, substantial numbers of our subjects meet diagnostic criteria for comorbid alcohol dependence (30% current and 37% lifetime), cannabis dependence (14% current and 23% lifetime), and opioid dependence (6% current and 11% lifetime) as assessed by the structured clinical interview for the DSM-III-R (SCID; see Marlowe, Husband, Lamb, et al. 1995). Sedative dependence is relatively rare (2% current and 4% lifetime), as is dependence on stimulants other than cocaine (0% current and 10% lifetime). Thrice-weekly EMIT(R) analyses confirm roughly similar proportions of subjects' urine samples testing positive for cannabis (17% of the samples), opiates (4%), benzodiazepines (5%), and barbiturates (4%). However, the moderate rates of alcohol dependence have not been supported by thrice-weekly breathalysers. Positive blood-alcohol levels have been detected in only 5% of the samples. Thus, although approximately one-third of subjects meet official diagnostic criteria for alcohol dependence, a substantially smaller percentage exhibit recent ingestion. This smaller percentage is likewise detected through the Michigan Alcoholism Screening Test (MAST) (Selzer 1971), which identifies only approximately 5% of subjects as having a "serious" alcohol problem.

Despite common assumptions, drug substitution is relatively rarely observed in our population. Some subjects who enter treatment abusing multiple substances continue to show positive urinalysis for other drugs (typically marijuana) following early cocaine abstinence; however, less than 8% initiate or increase use of a different drug.

Psychiatric Comorbidity

Prevalence rates of comorbid psychiatric disorders in our population differ substantially from those reported in alcoholic and opiate-dependent samples (see Marlowe et al. 1995). SCI-based estimates of non-substance-use Axis I disorders are equivalent to expected population base rates. Current and lifetime affective and anxiety disorders were diagnosed in approximately 10% of the subjects, with comorbid major depression, generalized anxiety disorder and panic disorder each accounting for less than 5% of cases. …

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