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Cognitive Behavioral Therapy and Naltrexone for Cocaine Dependence

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

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  1. 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

  2. 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

  3. Study Design Pharmacotherapy (Naltrexone) 50 mg 0 mg Drug Counseling (DC) Psycho- Therapy Relapse Prevention (RP)

  4. 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)

  5. 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

  6. Therapy Adherence

  7. Retention Log Rank Statistic = 1.72, df = 3, p = .63.

  8. Cocaine Use * Therapy x Medication x Time: F (2, 60) = 3.69, p < 0.03.

  9. 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).

  10. CBT Homework Examples: • Self-monitoring • Trigger sheet • Recognizing assertiveness • Goal setting • Coping records • Awareness of problem thinking

  11. Low motivation High motivation Motivation and homework completion on cocaine use during treatment

  12. 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.

  13. Naltrexone Studies • Naltrexone and relapse prevention treatment for cocaine-dependent patients • Naltrexone and relapse prevention treatment for cocaine-alcohol dependent patients

  14. Study Design Pharmacotherapy (Naltrexone) 50 mg 0 mg Drug Counseling (DC) Psycho- Therapy Relapse Prevention (RP)

  15. TABLE 1 Characteristics of Participants in Each Treatment Group a Attended at least six weeks of treatment.

  16. Retention Log Rank (df = 3) = 3.62, ns.

  17. Cocaine Use Time x Therapy F (11, 332) = 2.09, p < 0.02.

  18. 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.

  19. Combined Treatment for Cocaine-Alcohol Dependence R01 DA15801 Pharmacotherapy (Naltrexone) 100 mg 0 mg Relapse Prevention (RP) Behavior Therapy RP + Conting. Manag. Proc

  20. Women Results: % cocaine abstinent Ss Pettinati et al, 2004 Men

  21. 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

  22. Future Considerations • Optimal dosing • Combination pharmacotherapy • Relapse prevention vs abstinence initiation • Enhancing compliance, increasing motivation • Patients’ conceptualization of behavior therapy + medication

  23. Treatment expectancies

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