Treating crack cocaine dependence: the critical role of relapse prevention

In order to adequately address the treatment needs of crack cocaine dependent persons, a multidimensional approach to relapse prevention must be utilized. The value of a biopsychosocial model of crack addiction and the concept of phases of recovery in providing a rationale for the recommended approach to relapse prevention are emphasized. Research findings on the determinants of relapse for crack dependent patients and the psychosocial characteristics of the crack dependent individual justify the utility of certain relapse prevention strategies. Specifically, an approach to relapse is advocated that includes the provision of pharmacological adjuncts, psychoeducation on the multideterminants of relapse, and psychotherapy that attempts to remediate underlying psychological problems that are typically found in crack dependent patients.     

Crack Cocaine:

The paper presents a standard against which treatments should be measured; it recognizes the importance of a biopsychosocial approach to crack addiction, individualized assessment of patients to determine their needs, matching patients to interventions of appropriate intensity, timing the delivery of specific interventions in accordance with the phase of recovery a patient interventions in accordance with the phase of recovery a patient is negotiating, delivering relapse prevention, and appreciating crack smokers' characteristics. Summary analysis of two state of the art outpatient treatment models permits identification of key features of such programs. Analysis reveals that outpatient programs achieve excellence in service delivery to crack patients by referring the most severely addicted to inpatient treatment first and providing comrehensive and intensive outpatient services on a nearly daily basis for six months to a year. Recommendations for policymakers, administrators, treatment professionals, and researchers are provided in light of the paper's analysis.     

Crack cocaine: what constitutes state of the art treatment?

The paper presents a standard against which treatments should be measured; it recognizes the importance of a biopsy-chosocial approach to crack addiction, individualized assessment of patients to determine their needs, matching patients to interventions of appropriate intensity, timing the delivery of specific interventions in accordance with the phase of recovery a patient is negotiating, delivering relapse prevention, and appreciating crack smokers' characteristics. Summary analysis of two state of the art outpatient treatment models permits identification of key features of such programs. Analysis reveals that outpatient programs achieve excellence in service delivery to crack patients by referring the most severely addicted to inpatient treatment first and providing comprehensive and intensive outpatient services on a nearly daily basis for six months to a year. Recommendations for policymakers, administrators, treatment professionals, and researchers are provided in light of the paper's analysis.     

自愿戒毒和劳教戒毒后复发因素的调查分析

目的:对自愿戒毒与劳动教养戒毒两种戒毒模式中海洛因成瘾者戒毒后复发因素进行调查分析,探讨戒毒防复发的策略与方法。方法:使用31项《阿片类物质依赖复发情况问卷》,对自愿和劳教戒毒患者两组人群进行复发因素的量表测评和问卷式调查。对其"躯体生理因素、心理因素、药物成瘾性因素和社会环境因素"4个因子结果,以及社会支持量表和抑郁症自评量表等结果进行统计学分析和比较。结果:影响海洛因成瘾戒毒复发的最主要的影响因素依次是"精神心理因素、社会环境因素、躯体生理因素和药物成瘾因素"。劳教戒毒组中"精神心理因素"和"社会环境因素"更加突出。结论:造成海洛因成瘾戒毒后复发的因素是多方面的,劳教戒毒较自愿戒毒的复发因素更为复杂,提示:海洛因成瘾者在接受药物治疗的同时,更要注重心理治疗和回归社会后帮教措施的落实。     

宜昌市阿片类物质依赖者复发情况调查

目的:了解宜昌市阿片类物质依赖人群中戒毒治疗后复发的一般情况和复发影响因素,为复发的预防干预提供依据。方法:应用《阿片类物质依赖复发情况问卷》,在调查人员指导下,对宜昌市220名阿片类物质依赖者进行调查。问卷由被调查对象集体自行匿名填写完成,由调查员检查验收。结果:本次调查目标人群220例,回收问卷220份,可进行统计分析的有效问卷217份(98.6%)。217例调查对象的年龄33.3a±s6.0a,既往滥用药物时间8.8a±s3.7a;曾经戒毒的总次数范围2-108次;出戒毒所后最易复发的时间段为"戒毒后的d1-5"(43.4%);调查问卷将复发影响因素设计为"躯体生理因素、心理因素、药物成瘾性因素和社会环境因素"4个因子,因子分分别为185.3、219.0、234.8和242.7;对4个因子的差异进行秩和检验,结果显示差异具有统计学显著性(χ2=154.249,P<0.001);4个因子按照因子分排序为"社会环境因素"、"药物成瘾性因素"、"心理因素"和"躯体生理因素";保持操守不复发的前3位因素均为"社会环境因素"。结论:宜昌市阿片类物质依赖者在戒毒后复发的主要影响因素是社会环境因素,进行预防复发干预的关键时间段是"戒毒(出戒毒所)后的前5d",提示预防复发的重要措施是针对不同个体的具体情况,提供社会支持和心理干预。     

纳曲酮用于阿片类药物依赖者抗复吸治疗的结果分析

目的··：了解纳曲酮抗复吸治疗效果。方法··：采用回顾性临床资料分析方法，分析５４例阿片类药物依赖后自愿戒断者使用纳曲酮脱瘾及抗复吸治疗的临床资料。结果··：纳曲酮对于有固定职业、戒毒愿望强烈、家庭关注较多和个人支持系统相对较好者抗复吸疗效好，能明显延长探亲时间，减少吸毒冲动，觅药行为，无明显副作用。结论··：纳曲酮在抗复吸中有很好的运用前景。     

音乐心理剧对海洛因依赖者戒毒动机的干预

目的:研究音乐心理剧对我国海洛因依赖者的戒毒动机和操守的临床干预效果。方法:将62名女性海洛因依赖者随机分为实验组(n=31)和对照组(n=31)。实验组进行为期12周的Joseph.J.Moreno音乐心理剧临床干预;对照组常规治疗。将实验组干预后的戒毒动机与干预前及对照组进行比较;追踪所有被试的复吸情况并进行统计;对总体戒毒动机、操守率和各戒毒动机因子进行相关分析,了解干预的方法对戒毒动机和操守率的干预效果。结果:实验组总体戒毒动机与对照组和干预前相比显著提高(P<0.05);总体戒毒动机与"家庭因子"呈显著正性相关(r=0.364)。实验组操守情况(58.06%,18/31)优于对照组(35.48%,11/31),但无统计学意义上的显著性差异(P>0.05)。结论:音乐心理剧临床干预对提高海洛因依赖人群的戒毒动机有明显作用,但在提高复吸率方面效果不明显。提高戒毒动机需要从家庭角度进行干预。由于文化上的差异,本法在临床运用的过程中有些技术的使用存在一定的局限性。     

Relapse to substance abuse: empirical findings within a cognitive-social learning approach

A cognitive-social learning model of relapse prevention, specifically Albert Bandura's theory of self-efficacy, is one of the most influential theoretical frameworks that has been applied to the problem of relapse in the substance abuse field. Theory and related empirical findings within this approach are reviewed, including the following: the assessment of a client's high-risk situations for relapse; the development of an individualized treatment plan; the distinction between treatment strategies aimed at "initiation" versus "maintenance" of behavior change; the importance of growth in client self-efficacy; the difference between the process of lapse versus relapse; the use of drugs in relapse prevention counseling; and the role of client-treatment matching. On the basis of the empirical evidence reviewed, it is concluded that a cognitive-social learning approach to relapse prevention is showing promise. Future directions for research are suggested.     

Culture and social class as intervening variables in relapse prevention with chemically dependent women

Craving and relapse are complex, poorly understood phenomena. A distinctive and baffling characteristic of the disease of chemical dependency is the continuing impulse to use alcohol and/or other drugs, even after lengthy periods of sobriety. This article discusses relapse prevention, focusing on public-sector chemically dependent women. Relapse among these women must be seen in the total context of their lives. Poverty and social disorganization do not directly cause relapse, but problems related to daily life under such conditions represent significant risk factors. The Eagleville Hospital treatment model and relapse prevention programs are described, and it is noted that public-sector women typically present with problems related to being raised in addicted households, residing in drug-saturated inner-city environments, deficits in child-rearing skills, destructive (often abusive) relationships with men, social interactions involving other substance abusers, few (if any) work skills, minimal educational achievement, low self-esteem, and poor self-image. A case study illustrates the course of treatment and relapse prevention efforts with a typical public-sector chemically dependent woman.     

Crack cocaine use in rural migrant populations: living arrangements and social support

Correlates of crack cocaine use were studied among a targeted sample of migrant workers and their sexual partners (n = 571) in rural Southern Florida. Employment among men and recent drug-user treatment among men and women are positively related to crack use, as is involvement in crime and prostitution. Among women but not men, living with children is negatively related to crack use. Drug use and HIV prevention programs should intervene with individuals and their families and social groups. Migrant workers and their sexual partners also need effective drug-user treatment with long-term relapse prevention services.     

Crack Cocaine Use in Rural Migrant Populations: Living Arrangements and Social Support

Correlates of crack cocaine use were studied among a targeted sample of migrant workers and their sexual partners (n = 571) in rural Southern Florida. Employment among men and recent drug-user treatment among men and women are positively related to crack use, as is involvement in crime and prostitution. Among women but not men, living with children is negatively related to crack use. Drug use and HIV prevention programs should intervene with individuals and their families and social groups. Migrant workers and their sexual partners also need effective drug-user treatment with long-term relapse prevention services.     

Substitution therapy for alcoholism: time for a reappraisal?

A number of compounds already in use as medications for various indications substitute for ethanol at clinically relevant brain pathways, in particular, at gamma-aminobutyric acid (GABA) receptors. Nevertheless, although substitute medications have been recognized for heroin and tobacco dependence, patients with alcohol dependence are rarely offered an analogous approach. Benzodiazepines may have paradoxical effects, and abuse and dependence are known. Baclofen (GABA(B) agonist) has not been associated with dependence or misuse and has been effective in several trials in preventing relapse, although research is required to establish the optimal dosing regimen. GABA-ergic anticonvulsants, helpful in treating withdrawal, have yet to emerge as effective in relapse prevention. Clomethiazole and sodium oxybate, the latter having been shown to be effective in relapse prevention, have incurred a reputation for dependence and abuse. However, data have emerged showing that the risk of abuse of sodium oxybate is lower than many clinicians had foreseen. For a condition where existing therapies are only effective in a proportion of patients, and which has high morbidity and mortality, the time now seems right for reappraising the use of substitute prescribing for alcohol dependence.     

A Relapse Prevention Group for Patients with Bipolar and Substance Use Disorders

Although bipolar disorder is the Axis I disorder associated with the highest risk of having a coexisting substance use disorder, no specific treatment approaches for this dually diagnosed patient population have thus far been developed. This paper describes a 20-session relapse prevention group therapy that the authors have developed for the treatment of patients with coexisting bipolar disorder and substance use disorder. The treatment uses an integrated approach by discussing topics that are relevant to both disorders and by highlighting common aspects of recovery from and relapse to each disorder.     

New achievements and pharmacotherapeutic approaches in the treatment of alcohol dependence

The treatment of alcohol dependence mainly consists of psychological, social, and pharmacotherapeutic interventions aiming to reduce physical withdrawal, craving, and alcohol relapse. During the last years, it has become increasingly clear that adjuvant pharmacotherapy is efficacious especially in rehabilitation programs for alcohol dependent patients. The development of alcohol dependence seems to involve adaptive changes in amino acid neurotransmitter systems, stimulation of dopamine and opioid peptide systems, and changes in serotonergic activity. Disulfiram, naltrexone and acamprosate are approved treatments for the management of abstinence maintenance treatment. New compounds are under investigation. This review discusses the neurobiological basis of alcohol addiction, pharmacological targets for relapse prevention treatment and pre-clinical and clinical results with the most promising drugs.     

Predictors of early relapse among adolescent crack users

Relapse is associated with a poor prognosis among drug users. Crack cocaine users are more prone to severe dependence because of the intensity of use. Additionally, initiating drug use during adolescence worsens users' prognosis due to the increased rates of impulsivity and other risk behaviors. This study aimed to identify the predictors of early relapse among adolescent crack users discharged from inpatient treatment. A cohort study was conducted with 89 psychiatric inpatients aged 12–17 years from two different hospitals in southern Brazil who met the criteria for crack abuse or dependence. Demographic data, substance use disorders, psychiatric comorbidities, and crack consumption profile were assessed during hospitalization using the Teen Addiction Severity Index, Schedule for Affective Disorders and Schizophrenia for School Age Children—Present and Lifetime, and Crack Consumption Profile. Participants were re-assessed at 1 and 3 months after hospital discharge to determine their crack cocaine use based on self-report, family/caregiver information, and urine tests, whenever possible. There were extremely high rates of relapse (valid percent) in the first and third months, 65.9 and 86.4%, respectively. Statistically significant associations were observed between relapse in the first month and length of cocaine/crack cocaine use, and length of hospital stay. Data at 3 months were not analyzed because of the small number of patients who did not relapse. The high rates and significant associations found in this study suggest that intensive outpatient treatment strategies targeting this population should be developed and implemented to prevent early relapse after detoxification. One of the possible approaches, based on recent studies, might explore motivation as a strategy to reduce the rate of early relapse.     

Relapse prevention and smoking cessation

A multicomponent smoking relapse prevention treatment based on Marlatt and Gordon's (1980) model of the relapse process was developed and evaluated. Behavior-analytic methods were used to develop assessment instruments, training situations, and coping responses. The prevention components were presented in the context of a basic broad-spectrum stop-smoking program, and were compared with the basic program plus discussion control, and the basic program alone. Smoking-related dependent variables generally did not differ between groups at any time from pre-treatment to 12 month follow-up. Only the subjects in the relapse prevention condition improved problem-solving and social skills needed to cope with high-risk situations. These subjects also tended to take longer to relapse and smoke fewer cigarettes at the time of relapse. Subjects above the median level of competence on measures of social skill at post-treatment remained abstinent significantly longer. Maintenance of non-smoking was found to be related to the degree of competence with which individuals deal with high-risk situations. Results are discussed in relation to models of compliance with therapeutic regimens.     

Treatment of crack-cocaine-induced compulsive behavior with trazodone

Foraging is a compulsive behavior of searching for pieces of crack cocaine that the individual believes might have been accidentally misplaced. Three clinical cases of compulsive foraging behavior associated with crack cocaine are described. Due to the development of side effects secondary to the antidepressant desipramine, the patients were switched to the antidepressant trazodone. The use of trazodone led to remission of the foraging behavior. The authors hypothesize this remission was due to trazodone serotonin reuptake inhibitory action. In all three cases, the patients did not relapse into abusing crack cocaine.     

Integrating contingency management with relapse prevention skills: comment on Silverman et al. (2001)

The study by K. Silverman, D. Svikis, E. Robles, M. L. Stitzer, and G. E. Bigelow (2001) demonstrates the effectiveness of a voucher-based reinforcement intervention in the treatment of pregnant women in treatment for substance abuse. The effects of prolonged initial abstinence as a form of "sobriety sampling" may serve to enhance long-term recovery by providing patients with rewards for maintaining abstinence. Several limitations to the study are addressed, including selection of the treatment sample and the absence of any follow-up data on drug use or relapse following completion of the 24-week treatment program. Recommendations are made to enhance maintenance of abstinence by providing coping-skill training for relapse prevention as an addition to the contingency management approach.