Cognitive Behavioral Therapy and Naltrexone for Cocaine Dependence
Joy M. Schmitz, Ph.D.Substance Abuse Research CenterUniversity of Texas Medical SchoolHouston
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)
0 mg 50 mg
Psycho-Therapy
Drug Counseling (DC)
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)
Psychotherapy 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.
Therapy Adherence
0 1 2 3 4 5Focus on support
Encourage 12-stepAssess gen. Functioning
Focus on recoveryPassive, non-direct
Educational handoutsTotal DC elements
Coping skillsActive, direct
Functional analys.Self-monitor
Problem-solvingHome practiceCogn. Techn.
Total RP elements
Criteria present (5 = very much)
DCRP
Retention
0
20
40
60
80
100
1 2 3 4 5 6 7 8 9 10 11 12Week in Treatment
Perc
ent R
emai
ning
in T
reat
men
t
DC-50mgDC-0mgRP-50mgRP-0mg
Log Rank Statistic = 1.72, df = 3, p = .63.
Cocaine Use
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Intake (detox) Wk 1-4 Wk 5-8 Wk 9-12
Prop
ortio
n co
cain
e-ne
gativ
e urin
es
DC-50mgDC-0mgRP-50mgRP-0mg
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
Motivation and homework completion on cocaine use during treatment
0
10
20
30
40
50
60
0 10 20 30 40 50 60 70 80 90 100Homework completed (%)
% c
ocai
ne p
ositi
ve u
rines
High motivation
Low motivation
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)
0 mg 50 mg
Psycho-Therapy
Drug Counseling (DC)
Relapse Prevention (RP)
Retention
0
1020
30
4050
60
70
8090
100
1 2 3 4 5 6 7 8 9 10 11 12
Week in Treatment
Perc
ent R
emai
ning
in T
reat
men
t
DC-50mgDC-0mgRP-50mgRP-0mg
Log Rank (df = 3) = 3.62, ns.
Cocaine Use
00.10.20.30.40.50.60.70.80.9
1
Intake Wk 1-4 Wk 5-8 Wk 9-12
Prop
ortio
n co
cain
e-ne
gativ
e urin
es
DC-50mgDC-0mgRP-50mgRP-0mg
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)
0 mg 100 mg
BehaviorTherapy
Relapse Prevention (RP)
RP +Conting. Manag. Proc
Results: % cocaine abstinent Ss Results: % cocaine abstinent Ss Pettinati et al, 2004Pettinati et al, 2004
MenMen WomenWomen
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2 3 4 5 6 7 8 9 10 11 12 13
Week
% Neg
ative Ur
ines
Placebo Naltrexone 150mg
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
2 3 4 5 6 7 8 9 10 11 12 13
Week
% Neg
ative Ur
ines
Placebo Naltrexone 150mg
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
Treatment expectanciesWhich part of treatment do you expect will be most
beneficial?
Medication
Therapy
Medication andTherapy