Outpatient Cocaine Treatment Research Articles

Plasma profile of pro-inflammatory cytokines and chemokines in cocaine users under outpatient treatment: influence of cocaine symptom severity and psychiatric co-morbidity.

The treatment for cocaine use constitutes a clinical challenge because of the lack of appropriate therapies and the high rate of relapse. Recent evidence indicates that the immune system might be involved in the pathogenesis of cocaine addiction and its co-morbid psychiatric disorders. This work examined the plasma pro-inflammatory cytokine and chemokine profile in abstinent cocaine users (n = 82) who sought outpatient cocaine treatment and age/sex/body mass-matched controls (n = 65). Participants were assessed with the diagnostic interview Psychiatric Research Interview for Substance and Mental Diseases according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR). Tumor necrosis factor-alpha, chemokine (C-C motif) ligand 2/monocyte chemotactic protein-1 and chemokine (C-X-C motif) ligand 12 (CXCL12)/stromal cell-derived factor-1 (SDF-1) were decreased in cocaine users, although all cytokines were identified as predictors of a lifetime pathological use of cocaine. Interleukin-1 beta (IL-1β), chemokine (C-X3-C motif) ligand 1 (CX3CL1)/fractalkine and CXCL12/SDF-1 positively correlated with the cocaine symptom severity when using the DSM-IV-TR criteria for cocaine abuse/dependence. These cytokines allowed the categorization of the outpatients into subgroups according to severity, identifying a subgroup of severe cocaine users (9-11 criteria) with increased prevalence of co-morbid psychiatric disorders [mood (54%), anxiety (32%), psychotic (30%) and personality (60%) disorders]. IL-1β was observed to be increased in users with such psychiatric disorders relative to those users with no diagnosis. In addition to these clinical data, studies in mice demonstrated that plasma IL-1β, CX3CL1 and CXCL12 were also affected after acute and chronic cocaine administration, providing a preclinical model for further research. In conclusion, cocaine exposure modifies the circulating levels of pro-inflammatory mediators. Plasma cytokine/chemokine monitoring could improve the stratification of cocaine consumers seeking treatment and thus facilitate the application of appropriate interventions, including management of heightened risk of psychiatric co-morbidity. Further research is necessary to elucidate the role of the immune system in the etiology of cocaine addiction.

Predictors of Treatment Outcome in Outpatient Cocaine and Alcohol Dependence Treatment

We examined the ability of several baseline variables to predict treatment outcome in a pharmacotherapy trial that included 164 participants who were both cocaine- and alcohol-dependent and were selected for a randomized, double-blind, placebo-controlled study. Predictor variables included results from the baseline Addiction Severity Index (ASI), initial Urine Drug Screen results, cocaine and alcohol craving and cocaine and alcohol withdrawal symptoms at the start of treatment. Successful treatment was defined as four continuous weeks of self-reported cocaine abstinence verified by urine drug screens. In respect to demographic characteristics, there were no significant differences between patients who achieved four weeks of abstinence from cocaine and those who did not. Baseline variables that most consistently predicted cocaine abstinence included initial urine drug screen (UDS) results, the initial Cocaine Selective Severity Assessment (CSSA) scores, and initial self-reported cocaine use in past 30 days, whereas cocaine craving, cocaine composite scores, alcohol craving, alcohol withdrawal symptoms, and alcohol composite scores did not. The results of this study suggest that cocaine dependence severity in general, and initial UDS results, the CSSA scores and frequency of recent cocaine use in particular, have a significant impact on treatment outcome in the treatment of cocaine-dependent patients with comorbid alcoholism. Initial UDS results and CSSA scores are very useful predictors of treatment outcome and could be used as stratifying variables in outpatient cocaine and alcohol medication trials.

Cocaine abstinence symptomatology and treatment attrition.

Premature termination from outpatient cocaine treatment predicts a number of poor outcomes, including higher rates of relapse and unemployment. This study attempted to predict dropouts from outpatient cocaine treatment, as well as those unable to achieve initial abstinence from cocaine, using two baseline variables that had previously been shown to predict treatment dropout: a measure of the severity of cocaine abstinence symptomatology using the Cocaine Selective Severity Assessment (CSSA) and the initial urine toxicology. Results of logistic regression analyses indicated that those with more intense abstinence symptoms, as measured by the CSSA, were five times more likely to terminate treatment prematurely. When combined with the CSSA, the initial urine did not significantly predict dropouts. The CSSA and the baseline urine were equal in their ability to predict those who would fail in their initial attempts to achieve abstinence. Implications for treatment are discussed.

Does Intensive Outpatient Cocaine Treatment Reduce AIDS Risky Behaviors?

Summary The purposes of this study were: (1) to examine the characteristics of 447 cocaine dependent, first admission outpatients in relation to their AIDS risky behavior at intake; (2) to ascertain whether there was a reduction in risky behavior at follow-up 9 months after admission; and (3) to determine whether reductions in risky behavior were related to patient characteristics, group as compared to individual treatment, or time in treatment. In this sample of cocaine dependent patients entering outpatient treatment, those engaging in higher AIDS risky behaviors were not characterized by any particular demographic profile or by a lack of knowledge about HIV/AIDS. They did have higher scores on the SCL-90-R symptom scales, the Beck Depression Inventory, and higher ratings on the Drug, Alcohol, Family, and Medical scales of the ASI. At 9-month follow-up, AIDS risky behaviors as measured by the RAB were found to have decreased significantly. The degree of improvement was not associated with demographic variables but was predicted by higher intake problem severity and psychological symptomatology scale scores. While improvement in risky behavior was not related to type of treatment or duration of treatment, it was related to decreased substance use. The individuals whose risky behavior decreased were those whose substance use had decreased. Improvement, then required not only being in a treatment program, but also participation and involvement in the program. Treatment and not merely attendance would seem to be critical.

Carbamazepine Reduces Cocaine Craving

Few studies have demonstrated the efficacy of psychopharmacological treatments for psychostimulant abuse. This 12-week, randomized, double-blind, fixed-dose study examined the efficacy of carbamazepine (400 or 800 mg) as an adjunct to traditional outpatient cocaine treatment. Of 242 subjects screened for the study, 183 completed the screening and were randomized at baseline; …

Assessment of coercive and noncoercive pressures to enter drug abuse treatment

This paper reports preliminary data derived from a standardized interview scoring procedure for detecting and characterizing coercive and noncoercive pressures to enter substance abuse treatment. Coercive and noncoercive pressures stemming from multiple psychosocial domains are operationalized through recourse to established behavioral principles. Inter-rater reliability for the scoring procedure was exceptional over numerous rater trials. Substantive analyses indicate that, among clients in outpatient cocaine treatment, ‘coercion’ is operative in multiple psychosocial domains, and that subjects perceive legal pressures as exerting substantially less influence over their decisions to enter treatment than informal psychosocial pressures. Implications for drug treatment planning, legal and ethical issues, and directions for future research are proposed.

Patients' perspective on the process of change in substance abuse treatment.

Understanding how methadone patients view treatment for their cocaine dependence and the process of recovery from cocaine addiction, is important in helping to design treatment strategies that will effectively motivate and engage these patients. There has been little development or testing of treatment approaches for cocaine-dependent, methadone-maintained patients and research on the effectiveness of outpatient cocaine treatment has excluded the perspectives of patients. This article presents the patient's view, using ethnographic interviews with 17 patients enrolled in a relapse prevention treatment program for cocaine dependence, that was set up in an inner-city methadone maintenance clinic. Findings suggest that despite initial ambivalence or resistance, patients became highly engaged by the positively reinforcing treatment intervention. In addition, patients found the highly structured nature of the program and the cognitive behavioral techniques critical in reducing their cocaine use. Finally, patients responded positively to the psychodynamic issues addressed within a cognitive behavioral format, and reported improvements in certain areas of psychological functioning.

The effect of a no-smoking policy on recruitment and retention in outpatient cocaine treatment.

Historically, directors of substance abuse treatment programs have been reluctant to adopt a smoke-free policy because of the fear of patient attrition. According to a recent survey, however, a number of program directors now believe that such fears may be unwarranted. The purpose of the present study was to examine the impact on admissions and attendance of adopting a smoke-free policy at a cocaine treatment program offering outpatient group therapy sessions 3 half days a week. Results indicated that implementation of this policy had no impact on the number of patients who sought treatment at the facility or the number of group sessions patients attended. It was also noteworthy that for a sample of cases active in the month prior to and the month following the ban there were no changes in attendance patterns or in the proportion of patients failing to return from a 10-15 minute therapy break despite the fact that 89% of these patients were cigarette smokers.

Psychiatric Comorbidity in Cocaine Dependence: Diverging Trends, Axis II Spectrum, and Gender Differentials

One hundred consecutive admissions to an intensive outpatient cocaine treatment clinic in Camden, NJ, were assigned DSM‐III‐R Axis I and II psychiatric diagnoses by means of the SCID. Prevalence rates for non‐substance‐use Axis I disorders were equivalent to expected population base rates. By far the most common diagnoses were on Axis II (73% of subjects), with over one‐third of subjects receiving more than one personality disorder diagnosis, frequently crossing DSM‐III‐R “clusters.” In the distribution of psychopathology, certain gender differences were noted. The authors discuss implications for the clinical management and treatment of cocaine‐addicted individuals in urban environments.

Pretreatment dropout as a function of treatment delay and client variables

Utilizing a retrospective analysis we examined factors correlated with preintake dropout in patients phoning to make intake appointments for cocaine treatment. Inquiries of 235 individuals calling our outpatient cocaine treatment program over a 7-month period were analyzed for relationships between patient age and gender; residence in the city where the program is located; marital status; referral source; reported problems with alcohol, marijuana, and heroin; reported last use of cocaine or other illicit stimulants; assigned counselor gender; person who made the appointment; days to the intake appointment; and attending the scheduled intake session. Only days to appointment was significantly ( Wald = 12.4587, df = 1, p < .05 and χ 2 = 17.7, df = 8, p < .05) correlated with attending the scheduled intake session. Appointments scheduled the same day differed significantly ( χ 2 = 4.3, n = 235, df = 1, p < .05) from appointments scheduled later. This suggests that client and situational variables are not significantly related to initial attendance and enhances the significance of systemic variables that are under a clinic's control, such as appointment delay. The results indicate that the longer the delay between the initial phone contact and the scheduled appointment, the less likely a client is to attend an appointment. Further, they suggest that the greatest decrease in initial attendance occurs in the first 24 hours following the phone inquiry. Taking a “microscopic” look at the appointment delay variable is valuable in understanding and addressing preintake dropout.

Crack/cocaine abusers in the general hospital: assessment and initiation of care.

Cocaine, either smoked (as "crack") or taken intranasally, is now a common cause of psychiatric illness. This study was designed to assess the impact of cocaine abuse on a general psychiatric service and an obstetrics service in an urban general hospital and to evaluate a program for engaging affected patients in addiction treatment. The charts of 300 general psychiatric patients (not admitted for addiction treatment) and 60 cocaine-abusing prenatal or postpartum patients were reviewed. A treatment referral program based on professionally directed peer leadership was established for patients with cocaine abuse. Results of evaluation and referral of 100 other cocaine-abusing psychiatric patients and the 60 prenatal or postpartum patients were then determined. Fully 64% (N = 191) of the 300 psychiatric patients were diagnosed as substance abusers; 38% (N = 113) of them abused cocaine. Almost one-third of these cocaine abusers had no axis I diagnosis other than substance abuse/dependence, and the majority were homeless. Urine samples were positive for cocaine in a majority of the obstetric patients studied. A majority of the psychiatric patients who were referred through the peer-led program enrolled in outpatient cocaine treatment--three times as many as in the chart review group. Most of the obstetric patients suitable for referral enrolled for treatment as well. Cocaine abuse may be responsible for a large portion of psychiatric admissions in urban public general hospitals. Cocaine abusers in psychiatric and obstetrics services are apparently responsive to a peer-oriented mode of referral into treatment.

Client demographics and outcome in outpatient cocaine treatment.

A number of studies have begun to investigate the characteristics of cocaine abusers who are admitted to outpatient cocaine treatment programs. One study has published success rates for such treatment. A review of this literature indicates that much of what is known is based on clinical experience with what may be nonrepresentative samples of upper-middle socioeconomic status Caucasians. More systematic study and more representative samples are needed; the current study attempts to address these issues by sampling 81 clients admitted to a comprehensive outpatient cocaine program in a public agency, assessing demographics and treatment success. The results indicate that this sample is indeed different from those in most recent studies in race, marital status, income, employment, and other demographic variables. For example, the sample in this study included higher percentages of clients who were non-Caucasians, single, blue-collar or unemployed, and had relatively lower annual incomes. Fewer demographic variables than expected correlated with treatment success. Among factors that did correlate with such measures of treatment outcome as continuing in treatment (vs dropping out), percent of sessions attended, and alcohol- and drug-free were educational level, length of abstinence from cocaine prior to beginning treatment, number of previous treatments, secondary substance currently used, and quality of current living situation. Retention in treatment is similar to other published data but indicates that cocaine abusers are indeed difficult to engage and keep in treatment long enough to make a significant impact on their drug use.