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Cognitive Behavioral Therapy and Naltrexone for Cocaine Dependence. Joy M. Schmitz, Ph.D. Substance Abuse Research Center University of Texas Medical School Houston Supported by NIDA (DA-09262, DA-6143, DA-15801). APA 2004. Why Combine Behavior Therapy and Medication?.
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Cognitive Behavioral Therapy and Naltrexone for Cocaine Dependence Joy M. Schmitz, Ph.D. Substance Abuse Research Center University of Texas Medical School Houston Supported by NIDA (DA-09262, DA-6143, DA-15801) APA 2004
Why Combine Behavior Therapy and Medication? • For the treatment of cocaine dependence, little benefit from pharmacotherapy or psychotherapy alone • Each form of treatment may address distinct symptom areas, providing broader coverage • Offset the potential drawbacks associated with either treatment • Patient heterogeneity leads to differential response to treatment
Study Design Pharmacotherapy (Naltrexone) 50 mg 0 mg Drug Counseling (DC) Psycho- Therapy Relapse Prevention (RP)
Pharmacotherapy • Naltrexone • Opiate antagonists attenuate cocaine's euphoric effects (Bain & Kornetsky, 1986; Kosten et al., 1992; Hubbell & Reid, 1995; Reid et al., 1993; 1996) • Opiate antagonists decrease cocaine self-administration (DeVry et al., 1989; Mello et al., 1990; Ramsey & vanRee, 1991; Corrigall & Coen, 1991; Reid et al., 1995; 1996; 1997) • Opiate antagonist treatment associated with lower rates of cocaine use(Kosten et al., 1989; Rosen & Kosten, 1991)
Relapse Prevention (RP) Coping Skills Relapse Prevention Theory (Marlatt & Gordon, 1985) Components include functional analysis of situational factors associated with craving or drug use, self-monitoring and specific home practice exercises, general lifestyle modifications, handling a lapse training. Drug Counseling (DC) General education, nondirective support, encouragement for abstinence-oriented behaviors (Woody et al., 1983; Luborsky et al., 1982) Components include assessment of problem areas (e.g., health, family, vocation), education about recovery,crisis management. Psychotherapy
Retention Log Rank Statistic = 1.72, df = 3, p = .63.
Cocaine Use * Therapy x Medication x Time: F (2, 60) = 3.69, p < 0.03.
Does homework compliance predict outcome? • Cognitive-behavioral psychotherapies are based on the premise that clients are more likely to improve if they apply skills learned in treatment to situations outside treatment (i.e., homework). • The relationship between homework compliance and treatment outcome is reliable and robust across different client problems (Kazantzis et al., 2002).
CBT Homework Examples: • Self-monitoring • Trigger sheet • Recognizing assertiveness • Goal setting • Coping records • Awareness of problem thinking
Low motivation High motivation Motivation and homework completion on cocaine use during treatment
Conclusions • In cocaine-dependent patients, the combination of naltrexone 50 mg and Relapse Prevention therapy was effective in reducing cocaine use. • Treatment integrity measures showed evidence of therapy adherence and discriminability. • For CBT, a positive relationship between homework compliance and cocaine outcome was found. Motivation to change affected the direction of this relationship. • Need to replicate and extend to determine the robustness of this treatment.
Naltrexone Studies • Naltrexone and relapse prevention treatment for cocaine-dependent patients • Naltrexone and relapse prevention treatment for cocaine-alcohol dependent patients
Study Design Pharmacotherapy (Naltrexone) 50 mg 0 mg Drug Counseling (DC) Psycho- Therapy Relapse Prevention (RP)
TABLE 1 Characteristics of Participants in Each Treatment Group a Attended at least six weeks of treatment.
Retention Log Rank (df = 3) = 3.62, ns.
Cocaine Use Time x Therapy F (11, 332) = 2.09, p < 0.02.
Conclusions • Naltrexone did not reduce cocaine or alcohol use in this sample of dually-dependent patients. • Patients receiving Drug Counseling used less cocaine over time than those receiving Relapse Prevention. • Naltrexone’s lack of efficacy in treating this type of comorbidity, also reported by Hersh et al., 1998, may be due to greater impairment in this population.
Combined Treatment for Cocaine-Alcohol Dependence R01 DA15801 Pharmacotherapy (Naltrexone) 100 mg 0 mg Relapse Prevention (RP) Behavior Therapy RP + Conting. Manag. Proc
Women Results: % cocaine abstinent Ss Pettinati et al, 2004 Men
Conclusions • Among cocaine dependent patients: • Naltrexone 50mg • reduced cocaine use • was well tolerated • worked best with CBT • Among cocaine-alcohol dependent patients: • Naltrexone 50 mg • ineffective with/without CBT
Future Considerations • Optimal dosing • Combination pharmacotherapy • Relapse prevention vs abstinence initiation • Enhancing compliance, increasing motivation • Patients’ conceptualization of behavior therapy + medication