Cocaine Treatment: Early Results From Various Approaches (Letter Report,
06/07/96, GAO/HEHS-96-80).

Pursuant to a congressional request, GAO reviewed the extent to which
federally funded cocaine treatment therapies have proven successful and
additional research initiatives that are needed to increase knowledge of
cocaine treatment effectiveness.

GAO found that: (1) cocaine treatment research is still in its early
stages; (2) preliminary study results have shown that relapse
prevention, community reinforcement and contingency management, and
neurobehavioral therapy may produce prolonged periods of abstinence
among cocaine users; (3) relapse prevention programs have the highest
abstinence rates, followed by community reinforcement and
neurobehavioral programs; (4) community reinforcement programs have the
highest retention rates, followed by relapse prevention and
neurobehavioral programs; (5) pharmacological agents have not proven to
be consistently effective in preventing cocaine use, and none have been
submitted for Food and Drug Administration approval; (6) animal
researchers have demonstrated the positive effects of a new immunization
procedure in blocking the stimulant effects of cocaine; (7) few
researchers have assessed the effectiveness of acupuncture treatment,
but some research findings are favorable; and (8) experts believe that
more rigorous treatment evaluation studies that focus on important
treatment components, appropriate treatment intensities and durations,
and clients' readiness and motivation for treatment are needed before
standard cocaine treatment protocols can be formulated.

--------------------------- Indexing Terms -----------------------------

 REPORTNUM:  HEHS-96-80
     TITLE:  Cocaine Treatment: Early Results From Various Approaches
      DATE:  06/07/96
   SUBJECT:  Drug abuse
             Drug treatment
             Statistical methods
             Rehabilitation programs
             Pharmacological research
             Narcotics
             Public health research
             Mental health care services
IDENTIFIER:  NIDA Treatment Outcome Prospective Study
             
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Cover
================================================================ COVER


Report to Congressional Requesters

June 1996

COCAINE TREATMENT - EARLY RESULTS
FROM VARIOUS APPROACHES

GAO/HEHS-96-80

Cocaine Treatment Outcomes

(108234)


Abbreviations
=============================================================== ABBREV

  AIDS - acquired immunodeficiency syndrome
  CSAT - Center for Substance Abuse Treatment
  FDA - Food and Drug Administration
  MDD - Medications Development Division
  NIDA - National Institute on Drug Abuse
  TOPS - Treatment Outcome Prospective Study

Letter
=============================================================== LETTER


B-265688

June 7, 1996

The Honorable William F.  Clinger, Jr.
Chairman
The Honorable Cardiss Collins
Ranking Minority Member
Committee on Government Reform and Oversight
House of Representatives

The Honorable Henry A.  Waxman
House of Representatives

Cocaine use in the United States remains a serious and costly
epidemic.  In 1994, the National Household Survey on Drug Abuse
conservatively estimated that more than three-quarters of a million
people had used cocaine at least once a week within the past year. 
In 1993, cocaine was associated with almost 4,000 deaths.\1 Today, an
estimated $10 billion per year is lost in cocaine-related crimes and
productivity.\2

Although cocaine admissions to state-supported drug abuse treatment
programs between 1985 and 1990 increased dramatically--from almost
39,000 people to more than 200,000--we found in 1991 that an
effective treatment for cocaine addiction had not yet been
identified.\3 Today, public/private expenditures on cocaine-related
treatment total about $1 billion per year. 

Because of cocaine's serious health, economic, and criminal justice
implications for the nation, we have provided a status report on
recent progress made in finding an effective treatment for cocaine
users.\4 Specifically, we reviewed the various types of federally
funded treatment approaches evaluated over the past 5 years (1991
through 1995) to (1) determine the extent to which these therapies
have proven successful and (2) identify additional research
initiatives necessary to increase our knowledge of cocaine treatment
effectiveness. 

To conduct our work, we reviewed the literature on cocaine treatment
published from 1991 through 1995, examined records from the National
Institute on Drug Abuse and the Center for Substance Abuse Treatment,
synthesized the latest cocaine treatment research findings related to
drug use and client retention in treatment programs, and assessed the
utility of the various types of treatment approaches.  In addition,
we interviewed 20 cocaine treatment experts to determine important
next steps in the development of an effective cocaine treatment
strategy.  (See app.  I for further detail on our methodology.) We
did our work from March 1995 to March 1996 in accordance with
generally accepted government auditing standards. 


--------------------
\1 Drug Abuse Warning Network, Annual Medical Examiner Data 1993,
Statistical Series 1, No.  13-B (Rockville, Md.:  Substance Abuse and
Mental Health Services Administration, 1995), p.  21. 

\2 RAND, "Treatment:  Effective (But Unpopular) Weapon Against
Drugs," RAND Research Review, Vol.  XIX, No.  1 (Spring 1995), p.  4. 

\3 Drug Abuse:  The Crack Cocaine Epidemic:  Health Consequences and
Treatment (GAO/HRD-91-55FS, Jan.  30, 1991), p.  24. 

\4 "Treatment" does not refer to a singular therapeutic approach. 
Treatment approaches for individuals primarily using crack or
cocaine, for example, may not be most appropriate for methadone
clients who use cocaine as a secondary drug of choice. 


   RESULTS IN BRIEF
------------------------------------------------------------ Letter :1

Given the relative recency of the epidemic, cocaine treatment
research is still in the early stages of development.  Attempts to
treat cocaine users with approaches initially developed for other
drugs had limited success.  As a result, the federal government began
to fund more cocaine-related treatment studies.  Preliminary results
of these studies show that three cognitive/behavioral treatment
approaches--relapse prevention, community reinforcement/contingency
management, and neurobehavioral therapy--have shown early promise
with cocaine-abusing and cocaine-dependent clients, many of whom are
classified as "hardcore" users.  Clients treated with these
approaches have demonstrated prolonged periods of cocaine abstinence
and high rates of retention in treatment programs.  For example, more
than 60 percent of the cocaine-addicted clients who attended a
relapse prevention program in New York were continuously abstinent
from cocaine during the 6- to 24-month follow-up period; more than 70
percent completed the relapse prevention program.  About half the
cocaine-dependent clients receiving community
reinforcement/contingency management in a Vermont outpatient program
remained continuously abstinent through 4 months of treatment; 58
percent completed the entire 6-month course of therapy.  And 36
percent of the cocaine-using clients enrolled in a California
neurobehavioral therapy program were abstinent from cocaine 6 months
after entering treatment; the average length of stay in the program
was 18 weeks. 

Research results on the effectiveness of pharmacological agents have
been less favorable.  Twenty major medications for the treatment of
cocaine addiction have been studied by the National Institute on Drug
Abuse (NIDA).  While some medications have yielded favorable results
in one or more clinical trials, no medication has demonstrated
consistent effectiveness in treating cocaine users.  Further, no
medication has yet been submitted to the Food and Drug Administration
(FDA) for approval for cocaine treatment. 

Cocaine treatment experts emphasized the importance of conducting
more rigorous treatment evaluation studies, including identifying the
important components of treatment, determining appropriate
intensities and durations of treatment, and developing better
assessments of clients' readiness and motivation for treatment. 


   BACKGROUND
------------------------------------------------------------ Letter :2

Cocaine addiction has been associated with a variety of serious
health consequences:  cardiovascular and respiratory problems,
psychiatric disorders, acquired immunodeficiency syndrome (AIDS),
sexually transmitted diseases, early child development abnormalities,
and death.  Because cocaine use became epidemic in the early 1980s,
research opportunities have been limited, and a standard cocaine
treatment has not yet been found.  Many substance abuse centers have
provided cocaine users with the same treatment approaches provided to
opiate and other drug users.  But these treatments have not been as
successful for cocaine users, who have demonstrated high relapse and
dropout rates.  The large-scale Treatment Outcome Prospective Study
(TOPS)\5 showed that about one-third of the clients who reported
returning to cocaine use in the year after treatment began to do so
as early as the first week following treatment termination.  Another
25 percent began using the drug within 2 to 4 weeks following
treatment termination, for a cumulative first-month relapse rate of
57 percent.  Studies of crack cocaine users found that 47 percent
dropped out of therapy between the initial clinic visit and the first
session; three-quarters dropped out by the fifth session. 

Because of this lack of treatment success, in the late 1980s and
early 1990s the federal government began playing a more active role
in sponsoring cocaine-related treatment research, principally through
NIDA\6 and the Center for Substance Abuse Treatment (CSAT).\7 NIDA is
the largest federal sponsor of substance abuse-related research,
conducting work in treatment and prevention research, epidemiology,
neuroscience, behavioral research, health services research, and
AIDS.  Since 1991, NIDA has funded about 100 cocaine treatment grants
and conducted in-house research through its laboratory facilities. 
CSAT's mission includes developing treatment services, evaluating the
effectiveness of these services, and providing technical assistance
to providers and states.  Since 1991, CSAT has funded approximately
65 substance abuse research projects with implications for cocaine
addiction treatment. 

CSAT cocaine-related data were not yet available at the time this
report was published.  Results therefore derive from a literature
review of studies published from 1991 through 1995 and ongoing
NIDA-supported cocaine studies, for which some outcome data were
available. 

During the 5-year period, two broad types of cocaine treatment
approaches received research emphasis:  cognitive/behavioral therapy
and pharmacotherapy.  Additionally, acupuncture has emerged as a
potential therapy in the treatment of cocaine.  Much of this research
has been conducted in outpatient treatment settings, with a focus on
"cocaine-dependent"\8 clients--many of whom are considered to be
"hardcore" drug users.\9


--------------------
\5 TOPS, a national research study of community treatment programs,
was initiated in the late 1970s.  The study was conducted by the
Research Triangle Institute and supported by NIDA. 

\6 NIDA is a part of the Department of Health and Human Services'
National Institutes of Health. 

\7 CSAT is part of the Substance Abuse and Mental Health Services
Administration of the Department of Health and Human Services. 

\8 Cocaine dependence is the most serious of all the cocaine
diagnoses.  Clients diagnosed as "cocaine-dependent" demonstrate
myriad symptoms, including continual cocaine use and withdrawal
symptoms; frequent intoxication; social and occupational problems;
and physical, psychological, and emotional maladies. 

\9 Treatment of Hardcore Cocaine Users (GAO/HEHS-95-179R, July 31,
1995). 


      COGNITIVE/BEHAVIORAL
      THERAPIES
---------------------------------------------------------- Letter :2.1

Cognitive/behavioral therapies aim to modify the ways clients think,
act, and relate to others, thereby facilitating initial abstinence
and a continued drug-free lifestyle.  These therapies include the
psychotherapies, behavior therapies, skills training, and other
counseling approaches.  Three types of cognitive/behavioral therapies
have received recent attention:  relapse prevention, community
reinforcement/contingency management, and neurobehavioral therapy. 

Relapse prevention focuses on helping clients to identify high-risk,
or "trigger," situations that contribute to drug relapse and to
develop appropriate behaviors for avoiding, or better managing, these
situations.  For example, Yale University's Substance Abuse Treatment
Unit has three principal elements in its 12-week relapse prevention
program.  First, clients identify personal triggers by keeping a
daily log of the situations in which they crave the drug.  Second,
they work with therapists to learn more effective ways of coping with
and avoiding these and other commonly perceived triggers.  And third,
therapists help clients extinguish the drug-craving reactions to
these triggers.  Clients are taught that relapse is a process, that
social pressures to use drugs can be formidable, and that lifestyle
changes are necessary to discourage future substance abuse. 

Community reinforcement/contingency management aims to help the
client achieve initial abstinence as well as an extended drug-free
lifestyle.  The therapy consists of several key community-oriented
components, including the participation of a client's significant
other (family member or friend) in the treatment process; providing
management incentives or rewards\10 for drug abstinence; providing
employment counseling when needed; and encouraging client
participation in recreational activities as pleasurable, healthy
alternatives to drug use.  If clients remain abstinent, they receive
vouchers from the program and earn the right to participate in
desired activities with their significant other.  If clients test
positive for drug use, or do not submit to urine testing, negative
sanctions are applied (for example, their vouchers are rescinded). 
In this manner, community reinforcement therapy teaches clients about
the consequences of their actions and strengthens family and social
ties. 

Neurobehavioral treatment is a comprehensive, 12-month outpatient
treatment approach that includes individual therapy, drug education,
client stabilization, and self-help groups.  Relapse prevention
techniques are included but constitute only a subset of
neurobehavioral treatment.\11

Five major stages of recovery are distinguished during the treatment
process--withdrawal, "honeymoon," "the wall," adjustment, and
resolution--with emphasis on addressing the client's behavioral,
emotional, cognitive, and relational problems at each stage of
recovery.  For example, in the withdrawal stage, depression, anxiety,
self-doubt, and shame (emotional problems) and concentration
difficulties, cocaine cravings, and short-term memory disruption
(cognitive problems) are addressed.  In the first 6 months,
individual counseling is emphasized; in the second 6 months, weekly
group counseling is provided, with optional individual and couple
therapy sessions. 


--------------------
\10 The incentive or reward programs are typically referred to as
"contingency management" or "voucher incentive" programs because
vouchers for material goods are provided on a contingency basis (that
is, when tests show that the client has not been using drugs). 

\11 Rewards for remaining abstinent are less emphasized in
neurobehavioral therapy, as compared with community reinforcement. 


      PHARMACOTHERAPY
---------------------------------------------------------- Letter :2.2

Pharmacotherapy involves the use of medications to combat cocaine
abuse and addiction.  Recently, NIDA's pharmacotherapy research has
focused on two objectives:  facilitating initial abstinence and
supporting an extended, drug-free lifestyle.  To facilitate initial
abstinence, research has focused on medications that treat the
withdrawal symptoms of cocaine addiction and block the euphoric high
induced by the drug.  To help maintain an extended drug-free
lifestyle, research has focused on blocking the client's craving for
cocaine, treating the underlying psychopathologies, and treating the
toxic effects of cocaine on the brain. 


      ACUPUNCTURE
---------------------------------------------------------- Letter :2.3

The use of acupuncture in drug abuse treatment has not been limited
to cocaine addiction.  It has also been used during the past 20 years
to treat addictions to opiates, tobacco, and alcohol.  A Yale
University acupuncture treatment program for cocaine abuse involved
the insertion of needles into each ear at five strategic points, for
a period of 50 minutes per session, over an 8-week period.  Through
the first 6 weeks, clients received the acupuncture therapy 5 days a
week; in weeks 7 and 8, treatment was reduced to 3 days a week. 
Treatment was provided in a group context. 


   THREE COGNITIVE/BEHAVIORAL
   THERAPIES APPEAR FAVORABLE, BUT
   NO PHARMACOLOGICAL THERAPY HAS
   BEEN CONSISTENTLY EFFECTIVE
------------------------------------------------------------ Letter :3

The results from NIDA's cocaine treatment grants are only now
becoming available.  Because cocaine therapies are still in their
early stages of development, treatment outcome results cannot be
generalized to all cocaine users.  However, early results from a
review of the literature and ongoing NIDA studies reveal the promise
of three cognitive/behavioral approaches to treatment.  Moreover,
while a pharmacological treatment has not yet been consistently
demonstrated, NIDA is continuing to actively pursue the biology of
cocaine addiction.  Further, few well-designed methodological studies
of acupuncture exist, but the limited research in this area
demonstrates at least some positive findings. 


      THREE COGNITIVE/BEHAVIORAL
      TREATMENTS APPEAR EFFECTIVE
      IN OUTPATIENT SETTINGS
---------------------------------------------------------- Letter :3.1

Early research indicates relapse prevention, community
reinforcement/contingency management, and neurobehavioral therapy are
potentially promising cocaine-addiction treatment approaches for
promoting extended periods of client abstinence and treatment
retention in outpatient treatment settings.\12 Table 1 provides an
overview of cognitive/behavioral study methodologies and results. 



                                         Table 1
                         
                         Methodology and Results of Illustrative
                               Cognitive/Behavioral Studies

Study group/
publication
date/         Sample        Client diagnosis/                                 Study
affiliation   design/size   demographics              Treatment outcomes      period
------------  ------------  ------------------------  ----------------------  -----------
Relapse prevention
-----------------------------------------------------------------------------------------
Carroll and   Random;       Clients met criteria for  Cocaine-abstinent at    12 wks.
others        N=121         cocaine dependence        least 70% of the time
(1994); Yale                                          in treatment
University,                 average age: 29
New Haven,                  male: 79%
Conn.                       white: about 50%
                            unemployed: about 40%
                            single/divorced: about
                            70%
                            at least high school
                            graduate: about 80%

Carroll and   Random; N=42  Clients met criteria for  54% of high-severity    12 wks.
others                      both cocaine abuse and    cocaine users were
(1991); Yale                dependence                able to attain at
University,                                           least 3 weeks of
New Haven,                  average age: 27           continuous abstinence;
Conn.                       male: 67%                 only 9% of high-
                            white: 67%                severity cocaine users
                            average years of          receiving standard
                            education: 13             psychotherapy could
                                                      achieve this

Washton and   Consecutive   Clients met criteria for  More than 60%           About 28
Stone-        admissions;   severe psychoactive drug  abstinent from cocaine  wks.
Washton       N=60          dependence (85% were      during 6-to 24-month
(1993);                     cocaine addicts)          follow-up period
Washton
Institute,                  average age: about 35
New York                    male: about 80%
                            white: about 70%
                            employed: about 90%

Wells and     Alternative   Cocaine was primary drug  Average number of days  24 wks.
others        assignment;   of choice                 of cocaine use cut by
(1994);       N=110                                   71% within 6 months
University                  average age: 29
of                          male: 64%
Washington,                 white: 84%
Seattle                     employed full time for
                            past 3 years: 68%
                            average years of
                            education: 13


Community reinforcement/contingency management
-----------------------------------------------------------------------------------------
Higgins and   Consecutive   Clients met criteria for  46% were continuously   12 wks.
others        admissions;   cocaine dependence        abstinent from cocaine
(1991);       N=25                                    for 8 treatment weeks
University                  average age: 29
of Vermont,                 education ï¿½12 years: 46%
Burlington                  employed: 62%
                            single: 54%

Higgins and   Random; N=38  Clients met criteria for  42% were continuously   24 wks.
others                      cocaine dependence        abstinent from cocaine
(1993);                                               for 16 treatment weeks
University                  average age: 29
of Vermont,                 male: 89%
Burlington                  white: 100%
                            unmarried: 89%
                            completed high school:
                            63%
                            employed: 42%


Contingency management only
-----------------------------------------------------------------------------------------
Silverman     Frequency of  Clients met criteria for  Nearly 50% of the       12 wks.
and others    cocaine-      heroin and cocaine        clients receiving
(1994,        positive      dependence                vouchers for cocaine-
1995); Johns  urines                                  free urines remained
Hopkins       during        average age: 36           continuously abstinent
University,   initial 5     black: 26%                from cocaine for 7 to
Baltimore     weeks of      married: 16%              12 weeks
              methadone     completed at least high
              therapy;      school: 74%
              N=37          employed full time: 47%


Neurobehavioral therapy
-----------------------------------------------------------------------------------------
Shoptaw and   Random;       Clients met criteria for  36% remained            12 mos.
others        N=146         stimulant abuse or        continuously abstinent
(1994);                     dependence                from cocaine for at
Matrix                                                least 8 treatment
Institute,                  average age: 31           weeks; 38% were
Los Angeles                 male: 84%                 abstinent from cocaine
                            white: 63%                at 6-month follow-up
                            Hispanic: 25%
                            average years of
                            education: 13
                            unmarried: 78%

Rawson and    Open trial;   Cocaine-using clients     At least 40% at two     6 mos.
others        N=486                                   treatment sites
(1993);                     average age: 30           remained continuously
Matrix                      male: 74%                 abstinent from cocaine
Institute,                  white: 76%                through 6 months of
Los Angeles                 average years of          treatment
                            education: 14
                            single: 54%

Rosenblum     Random; N=77  Methadone clients who     Clients attending 3 to  6 mos.
and others                  met criteria for cocaine  19 sessions reduced
(1994);                     dependence                past-month cocaine use
National                                              by 5%; those attending
Development                 age 24 to 43: 87%         85 to 133 sessions
and Research                Hispanic: 64%             reduced past-month
Institutes,                 black: 31%                cocaine use by 60%
Inc., New                   unemployed: 77%
York                        married/common law: 38%
                            completed at least high
                            school: 42%

Magura and    Random; N=62  Methadone clients who     Group demonstrated      6 mos.
others                      met criteria for cocaine  significant decrease
(1994);                     dependence                in cocaine use between
National                                              entering treatment and
Development                 average age: 36           6-month follow-up;
and Research                male: 56%                 clients not receiving
Institutes,                 Hispanic: 72%             neurobehavioral
Inc., New                   black: 23%                therapy showed no
York                        married/common law: 49%   significant decrease
                            completed at least high
                            school: 38%
-----------------------------------------------------------------------------------------

--------------------
\12 Since journals frequently do not publish studies with
nonsignificant findings, we cannot determine how many attempted
cognitive/behavioral studies have proven unsuccessful.  This report
is based only on available findings. 


         RELAPSE PREVENTION
-------------------------------------------------------- Letter :3.1.1

Clients who received relapse prevention treatment have demonstrated
favorable abstinence rates not only during the period of treatment,
but during follow-up periods as well.  Client treatment retention
results also appear to be favorable.  For example, cocaine-dependent
clients participating in a 12-week Yale University program focusing
on relapse prevention were able to remain cocaine abstinent at least
70 percent of the time while in treatment.\13 A year after treatment,
gains were still evident:  clients receiving relapse prevention
treatment and a placebo medication were reported to have used cocaine
on average fewer than 3 days in the past month.\14

Positive outcome results were also found in two other programs:  more
than 60 percent of the primarily middle-class, cocaine-addicted
clients attending a relapse prevention program at the Washton
Institute in New York were abstinent from cocaine during the 6- to
24-month follow-up period.\15 Similarly, in the Seattle area,
cocaine-using clients cut their average number of days of cocaine use
by 71 percent within 6 months.\16

Among high-severity\17 cocaine addicts participating in another Yale
program, it was also found that 54 percent receiving relapse
prevention therapy were able to attain at least 3 weeks of continuous
abstinence, while only 9 percent of those receiving the interpersonal
psychotherapy could remain abstinent for that period of time.\18

Retention rates were also favorable:  67 percent of the relapse
prevention clients completed the entire 12-week Yale program and more
than 70 percent completed the Washton program. 


--------------------
\13 Kathleen Carroll, Bruce Rounsaville, Lynn Gordon, Charla Nich,
Peter Jatlow, Roseann Bisighini, and Frank Gawin, "Psychotherapy and
Pharmacotherapy for Ambulatory Cocaine Abusers," Archives of General
Psychiatry, Vol.  51 (1994), pp.  177-187. 

\14 Unpublished 12-month data provided by Kathleen Carroll and Charla
Nich, Oct.  19, 1995. 

\15 Arnold Washton and Nannette Stone-Washton, "Outpatient Treatment
of Cocaine and Crack Addiction:  A Clinical Perspective," National
Institute on Drug Abuse Research Monograph #135 (Rockville, Md.: 
National Institute on Drug Abuse, 1993), pp.  15-30. 

\16 Elizabeth Wells, Peggy Peterson, Randy Gainey, J.  David Hawkins,
and Richard Catalano, "Outpatient Treatment for Cocaine Abuse:  A
Controlled Comparison of Relapse Prevention and Twelve-Step
Approaches," American Journal of Drug and Alcohol Abuse, Vol.  20,
No.  1 (1994), pp.  1-17. 

\17 "Severity" is defined in terms of median splits on the drug use
subscale of the Addiction Severity Index.  Subjects in the
high-severity group demonstrated high weekly use of cocaine (4.9
grams/week); were chronic drug users (43.2 months of regular use);
and had high levels of family/social, occupational, and legal
problems. 

\18 Kathleen Carroll, Bruce Rounsaville, and Frank Gawin, "A
Comparative Trial of Psychotherapies for Ambulatory Cocaine Abusers: 
Relapse Prevention and Interpersonal Psychotherapy," American Journal
of Drug and Alcohol Abuse, Vol.  17, No.  3 (1991), pp.  229-47. 


         COMMUNITY
         REINFORCEMENT/CONTINGENCY
         MANAGEMENT
-------------------------------------------------------- Letter :3.1.2

Community reinforcement/contingency management programs have also
appeared promising in fostering abstinence and retaining clients in
treatment.  Almost one-half (46 percent) of the cocaine-dependent
clients participating in a 12-week community
reinforcement/contingency management program at the University of
Vermont were able to remain continuously abstinent from cocaine
through 2 months of treatment;\19 when the program was extended to 24
weeks, 42 percent of the participating cocaine-dependent subjects
were able to achieve 4 months of continuous abstinence.\20 By
comparison, only 5 percent of those in the control group receiving
drug abuse counseling alone could remain continuously abstinent for
the entire 4 months. 

A year after clients began treatment, community reinforcement/
contingency management treatment effects were still evident:\21 65 to
74 percent\22 of those in the community reinforcement group reported
2 or fewer days of cocaine use in the past month.  Only 45 percent of
those in the counseling control group achieved such gains.\23

Contingency management was also studied independently in an
inner-city Baltimore program.\24,25

Positive results were found when tying the 12-week voucher reward
system to cocaine drug testing.  Nearly half of the cocaine-abusing
and cocaine-dependent clients (who were also heroin users) given
vouchers for cocaine-free urine test results were able to remain
continuously abstinent for 7 to 12 weeks.  Among clients receiving
vouchers unpredictably--not tied to urine test results--only 1 client
achieved abstinence for more than 2 weeks. 

Client treatment retention was also high.  Within the Vermont
community reinforcement/contingency management group, 85 percent of
the clients completed the 12-week program, compared with only 42
percent of those in the 12-step drug counseling control group.  The
24-week program was completed by about five times as many clients in
the community reinforcement group as those receiving drug counseling
therapy (58 percent versus 11 percent). 


--------------------
\19 Stephen Higgins, Dawn Delaney, Alan Budney, Warren Bickel, John
Hughes, Florian Foerg, and James Fenwick, "A Behavioral Approach to
Achieving Initial Cocaine Abstinence," American Journal of
Psychiatry, Vol.  148, No.  9 (1991), pp.  1218-24.  To test the
accuracy of self-reported client data, researchers at the University
of Vermont compared self-reports to urine test results.  In 98
percent of the cases in which a client indicated nonuse, urinalysis
data confirmed the report. 

\20 Stephen Higgins, Alan Budney, Warren Bickel, John Hughes, Florian
Foerg, and Gary Badger, "Achieving Cocaine Abstinence With a
Behavioral Approach," American Journal of Psychiatry, Vol.  150, No. 
5 (1993), pp.  763-69. 

\21 Unpublished 12-month data provided by Stephen Higgins, June 6,
1995. 

\22 The percentage range represents outcome results across two
clinical trials. 

\23 Since not every client was using cocaine the same number of times
per month at the point of treatment entry, Higgins calculated a
magnitude-of-change score between treatment entry and 12-month
follow-up for each group.  At intake, 10 to 21 percent of community
reinforcement clients reported ï¿½ 2 days of cocaine use in the past
month; 12 months after treatment entry, 65 to 74 percent were using ï¿½
2 days in the past month, for a positive gain of 53 to 55 percent. 
This gain was higher than that experienced by the drug counseling
control group (29 percent). 

\24 K.  Silverman, R.K.  Brooner, I.D.  Montoya, C.R.  Schuster, and
K.L.  Preston, "Differential Reinforcement of Sustained Cocaine
Abstinence in Intravenous Polydrug Abusers." In L.S.  Harris (ed.),
Problems of Drug Dependence 1994:  Proceedings of the 56th Annual
Scientific Meeting, The College on Problems of Drug Dependence. 
National Institute on Drug Abuse Research Monograph #153 (Rockville,
Md.:  National Institute on Drug Abuse Research, 1995), p.  212.

\25 K.  Silverman, C.J.  Wong, A.  Umbricht-Schneiter, I.D.  Montoya,
C.  R.  Schuster, and K.L.  Preston, "Voucher-Based Reinforcement of
Cocaine Abstinence:  Effects of Reinforcement Schedule." In L.S. 
Harris (ed.), Problems of Drug Dependence 1995:  Proceedings of the
57th Annual Scientific Meeting, The College on Problems of Drug
Dependence.  National Institute on Drug Abuse Research Monograph, in
press.  Also cited in NIDA Notes, Vol.  10, No.  5 (Sept./Oct. 
1995), pp.  10, 14. 


         NEUROBEHAVIORAL THERAPY
-------------------------------------------------------- Letter :3.1.3

Several programs have demonstrated that a neurobehavioral therapeutic
approach can also be effective in promoting cocaine abstinence and
treatment retention.  Thirty-six percent of the cocaine-abusing and
cocaine-dependent clients participating in a neurobehavioral therapy
program through the Matrix Institute in California succeeded in
remaining continuously abstinent from cocaine for at least 8
consecutive weeks while in treatment.\26

Follow-up results obtained 6 months after treatment entry showed that
38 percent of these clients still tested drug free.  In a separate
examination of two neurobehavioral outpatient treatment sites, at
least 40 percent of the cocaine clients in each site remained
continuously abstinent through the entire 6-month course of
therapy.\27

Given the high rate of cocaine use among methadone clients,\28 \29
\30 the neurobehavioral model was adapted in New York for use among
methadone clients meeting the diagnostic criteria for cocaine
dependence.  In an intensive 6-month program, a strong relationship
was found between the number of treatment sessions attended and
cocaine use reduction.\31 Clients attending 3 to 19 sessions
experienced a 5-percent reduction in cocaine use during the previous
month.  Those attending 85 to 133 sessions experienced a 60- percent
reduction in their past 30-day use of cocaine.  In another New York
study with cocaine-addicted methadone clients,\32 those clients
receiving neurobehavioral treatment demonstrated a significant
decrease in cocaine use between entering treatment and 6-month
follow-up; the control group showed no statistically significant
decrease.\33

Neurobehavioral retention rates also proved favorable.  In the
California study of two treatment sites, clients were retained an
average of about 5 months and 3 months, respectively; in the other
California study, the average length of stay for cocaine users was
about 4-1/2 months.  For the first New York study, a total of 61
percent of the cocaine-dependent methadone clients completed the
initial 6-month cocaine treatment regimen. 


--------------------
\26 Steven Shoptaw, Richard Rawson, Michael McCann, and Jeanne Obert,
"The Matrix Model of Outpatient Stimulant Abuse Treatment:  Evidence
of Efficacy," Journal of Addictive Diseases, Vol.  13, No.  4 (1994),
pp.  129-41. 

\27 Richard Rawson, Jeanne Obert, Michael McCann, and Walter Ling,
"Neurobehavioral Treatment for Cocaine Dependency:  A Preliminary
Evaluation," Cocaine Treatment:  Research and Clinical Perspectives. 
National Institute on Drug Abuse Research Monograph #135 (Rockville,
Md.:  National Institute on Drug Abuse, 1993), pp.  92-115. 

\28 Methadone Maintenance:  Some Treatment Programs Are Not
Effective; Greater Federal Oversight Needed (GAO/HRD-90-104, Mar. 
22, 1990), p.  18. 

\29 S.  Magura, Q.  Siddiqi, R.  Freeman, and D.  Lipton, "Changes in
Cocaine Use After Entry to Methadone Treatment," Journal of Addictive
Diseases, Vol.  10, No.  4 (1991), pp.  31-45. 

\30 W.  Condelli, J.  Fairbank, M.  Dennis, and J.  V.  Rachal,
"Cocaine Use By Clients in Methadone Programs:  Significance, Scope,
and Behavioral Interventions," Journal of Substance Abuse Treatment,
Vol.  8 (1991), pp.  203-12. 

\31 Andrew Rosenblum, Stephen Magura, Jeffrey Foote, Michael Palij,
Leonard Handelsman, Meg Lovejoy, and Barry Stimmel, "Treatment
Intensity and Reduction in Drug Use for Cocaine-Dependent Methadone
Patients:  A Dose Response Relationship." Prior version of this paper
was presented at the American Society of Addiction Medicine Annual
Conference, New York, Apr.  1994. 

\32 Stephen Magura, Andrew Rosenblum, Meg Lovejoy, Leonard
Handelsman, Jeffrey Foote, and Barry Stimmel, "Neurobehavioral
Treatment for Cocaine-Using Methadone Patients:  A Preliminary
Report," Journal of Addictive Diseases, Vol.  13, No.  4 (1994), pp. 
143-60. 

\33 At treatment entry, 100 percent of both the neurobehavioral and
control groups were using cocaine.  But at 6-month follow-up, only 64
percent of the former had used cocaine, compared with 84 percent of
the control group. 


      NO EFFECTIVE MEDICATION FOR
      TREATING COCAINE ADDICTION
      HAS YET BEEN FOUND
---------------------------------------------------------- Letter :3.2

Currently, there is no FDA-approved pharmacotherapy for cocaine
addiction.  While some medications have proven successful in one or
more clinical trials, no medication has demonstrated "substantial
efficacy" once subjected to several rigorously controlled trials. 

Twenty major medications have been considered by NIDA's Medications
Development Division (MDD).  Fourteen have been tested with humans,
five are in the animal experimentation stage, and one is being tested
on both humans and animals for different treatment effects.  Table 2
provides a summary of the medications tested, their current phase of
testing, and therapeutic uses. 



                          Table 2
          
          Medications Tested for the Treatment of
                          Cocaine

Medication          Therapeutic use
------------------  --------------------------------------
Human trials
----------------------------------------------------------
Amantadine          Supports maintenance therapy

Bromocriptine       Supports maintenance therapy

Buprenorphine       Blocks euphoria

Bupropion           Helps achieve initial abstinence

Carbamazepine       Treats withdrawal

Desipramine         Treats withdrawal

Fluoxetine          Treats withdrawal

Flupenthixol        Treats withdrawal

Imipramine          Treats withdrawal

L-DOPA              Serves as replacement therapy

L-tryptophan        Serves as functional antagonist

Mazindol            Treats withdrawal

Methylphenidate     Supports maintenance therapy

Nifedipine          Blocks euphoria

Sertraline          Treats withdrawal


Animal trials
----------------------------------------------------------
Diltiazem           Blocks euphoria/treats cocaine
                    cardiotoxicity

Nifedipine          Treats cocaine cardiotoxicity

Monoclonal          Serves as functional blocker
antibodies

SCH23390            Blocks euphoria

Sulpiride           Blocks euphoria

Verapamil           Blocks euphoria/treats cocaine
                    cardiotoxicity
----------------------------------------------------------
Of the 20 medications tested, MDD has labeled 6 as "disappointing": 
buprenorphine, carbamazepine, desipramine, imipramine, mazindol, and
nifedipine.  The remainder are still under investigation, but
numerous clinical trials thus far have yielded mixed results.  For
example, a 1992 study by Ziedonis and Kosten indicated that
amantadine was effective in reducing cocaine craving; yet a 1989
study by Gawin, Morgan, Kosten, and Kleber indicated that this
medication was not as effective as a placebo in reducing cocaine
craving.\34 Additional pharmacological studies are cited in the
bibliography. 

Thus, no pharmacotherapy for cocaine exists that compares with
methadone, which reduces heroin craving, enables the client to
stabilize psychological functioning, and eliminates or reduces the
heroin withdrawal process.  Nor has any medication proven effective
as a supportive therapy, to be used in combination with one or more
cognitive/behavioral therapies, to enhance cocaine abstinence. 

But recent animal research\35 has demonstrated the positive effects
of a new immunization procedure in protecting rats against the
stimulant effects of cocaine.  When vaccinated, rats produced
antibodies that acted like biological "sponges" or blockers,
diminishing by more than 70 percent the amount of cocaine reaching
the brain.  As a result, inoculated rats experienced significantly
lower cocaine stimulation levels than noninoculated rats.  Further
research needs to be conducted before human clinical trials can be
planned. 


--------------------
\34 Tabular summaries of cocaine pharmacological studies provided by
the Regulatory Affairs Branch, Medications Development Division,
NIDA, Dec.  28, 1994. 

\35 "NIDA Media Advisory," Dec.  14, 1995. 


      FEW WELL-DESIGNED
      ACUPUNCTURE OUTCOME RESEARCH
      STUDIES EXIST
---------------------------------------------------------- Letter :3.3

Some treatment centers are now offering acupuncture as therapy for
cocaine and other substance abuse.  For example, in 1993, the Lincoln
Hospital Substance Abuse Treatment Clinic treated about 250 clients
per day with acupuncture therapy.  To date, however, few
well-designed evaluation studies have assessed the utility of
acupuncture treatment. 

But the limited research findings are somewhat favorable.  Almost 90
percent of a group of inner-city, cocaine-dependent methadone clients
who completed an 8-week course of acupuncture remained abstinent for
more than a month.\36 These individuals had been regular users of
cocaine, on average, for 13 years.  Fifty percent of the clients,
however, did not complete the 2-month program.  Inner-city,
cocaine-dependent methadone clients participating in a second
acupuncture research study decreased their frequency of cocaine use
and craving for the drug after just 6 weeks of therapy.\37 These
participants had been regular cocaine users, on average, for more
than 10 years.  And chronic crack cocaine users demonstrated a
statistically significant tendency toward greater day-to-day
reductions in cocaine use during a 4-week course of acupuncture
therapy.  But they did not differ from the control group in their
overall percentage of drug-free test results.\38 \39


--------------------
\36 Arthur Margolin, S.  Kelly Avants, Patrick Chang, and Thomas
Kosten, "Acupuncture for the Treatment of Cocaine Dependence in
Methadone-Maintained Patients," The American Journal on Addictions,
Vol.  2, No.  3 (1993), pp.  194-201. 

\37 S.  Kelly Avants, Arthur Margolin, Patrick Chang, Thomas Kosten,
and Stephen Birch, "Acupuncture for the Treatment of Cocaine
Addiction:  Investigation of a Needle Puncture Control," Journal of
Substance Abuse Treatment, Vol.  12, No.  3 (1995), pp.  195-205. 

\38 Vincent Brewington, Michael Smith, and Douglas Lipton,
"Acupuncture as a Detoxification Treatment:  An Analysis of
Controlled Research," Journal of Substance Abuse Treatment, Vol.  11,
No.  4, pp.  289-307. 

\39 Douglas Lipton, Vincent Brewington, and Michael Smith,
"Acupuncture and Crack Addicts:  A Single-Blind Placebo Test of
Efficacy," Presentation at Advances in Cocaine Treatment, NIDA
Technical Review Meeting, Aug.  1990. 


   MORE RESEARCH IS NEEDED TO
   FORMULATE A STANDARD COCAINE
   TREATMENT APPROACH
------------------------------------------------------------ Letter :4

Much has been learned about cocaine treatment in the 15-year period
since the epidemic began.  Studies show that client abstinence and
retention rates can be positively affected through a number of
promising treatment approaches.\40 However, according to cocaine
treatment experts, additional research is needed before standard,
generalizable cocaine treatment strategies can be formulated for
cocaine addicts of varying demographic and clinical groups.  (See
app.  II for a summary of the experts' suggestions.)

In the cognitive/behavioral area, for example, the experts indicated
a need for additional clinical research aimed at identifying the
important components of promising treatment practices, further
development and testing of client reward systems (contingency
contracting), additional study of the triggers that promote relapse,
and identification of appropriate intensities and durations of
treatment. 

In the pharmacological area, the experts recommended further
development and testing of medications to block the effects of
cocaine and reduce craving, examining the human toxicity effects of
pharmaceutical agents found useful in animal experiments, conducting
outcome studies combining cognitive/behavioral and pharmacological
therapies, developing maintenance medications, and conducting more
longitudinal studies of medication treatment effectiveness. 

The experts also highlighted the need for further research into
client/treatment matching, client retention, client readiness and
motivation for treatment, and long-term treatment outcomes. 


--------------------
\40 In addition to investigation of these specific treatment
approaches, research is also being conducted more globally in
institutional settings (see app.  III).



   SUMMARY
------------------------------------------------------------ Letter :5

Three cognitive/behavioral treatment approaches--relapse prevention,
community reinforcement/contingency management, and neurobehavioral
therapy--have demonstrated favorable results in the treatment of
cocaine addiction.  Preliminary findings show that clients exposed to
these therapies were able to remain abstinent and in treatment for
prolonged periods of time.  These findings are particularly
encouraging since initial treatment approaches of the early 1980s
were not very successful.  Although currently an insufficient number
of studies within each treatment area exists to draw definitive
conclusions about the utility or generalizability of any specific
treatment approach, more study results should become available within
the next few years.  Research experts agreed that continued research
and study are needed to enhance and confirm or deny these early
results. 


   AGENCY COMMENTS
------------------------------------------------------------ Letter :6

NIDA reviewed a draft of this report and provided comments, which are
included in appendix IV.  NIDA officials generally agreed with our
conclusions on the effectiveness of cognitive/behavioral and
pharmacological therapies for cocaine treatment.  However, they felt
we were too positive about the early results of acupuncture
treatment, particularly given the lack of well-designed outcome
studies.  We agreed with NIDA on this point and reworded our
statements on acupuncture's use in treating cocaine addiction to
clarify the preliminary nature of the results and the need for more
well-controlled studies.  Other technical and definitional changes
were incorporated, as appropriate. 

We are sending copies of this report to the Director of the National
Institute on Drug Abuse, the Director of the Center for Substance
Abuse Treatment, and other interested parties.  We will also make
copies available to others on request.  If you have any questions
about this report, please call me at (202) 512-7119 or Jared
Hermalin, the Evaluator-in-Charge, at (202) 512-3551.  Dwayne Simpson
of Texas Christian University and George DeLeon of the National
Development and Research Institutes served as independent reviewers. 
Mark Nadel and Karen Sloan also contributed to this report. 

Sarah F.  Jaggar
Director, Health Financing and
 Public Health Issues


METHODOLOGY
=========================================================== Appendix I

To determine the extent to which cocaine therapies have proven
successful, we identified studies with current reportable data on two
outcome variables:  drug abstinence and treatment retention.  We
reviewed the literature published between 1991 and 1995; examined
Center for Substance Abuse Treatment (CSAT) and National Institute on
Drug Abuse (NIDA) agency records of cocaine-related grants awarded
during this time period; and, as necessary, contacted project
investigators. 

The approximately 65 cocaine-related grants supported by CSAT were
still in progress at the time of this writing; neither abstinence nor
retention data were available for inclusion in this report.  Most of
the approximately 100 NIDA longitudinal studies were also in
progress.  Our report was therefore based on articles published
during the 5-year period, unpublished documents provided by federal
drug agencies, and those available abstinence and retention findings
from ongoing NIDA-supported studies. 

We classified the studies from each of these sources into two
treatment categories:  cognitive/behavioral and pharmacological
treatments.  We then classified the cognitive/behavioral studies as
either relapse prevention, community reinforcement/contingency
management, or neurobehavioral therapy and the pharmacological
studies by drug type. 

We then reviewed those studies with reported abstinence and/or
retention findings within each treatment area to determine the
utility of each approach.  In making determinations about treatment
utility, we gave consideration to whether or not the studies had
appropriate designs for determining treatment effectiveness. 

The intent of this report was not to provide an exhaustive evaluation
synthesis of the cocaine studies currently available (particularly
given the limited number of studies available), nor to assess the
qualitative methodology of each study.  Rather, the objective was to
determine whether particular treatment approaches appeared favorable
or promising, and to provide examples of such favorable cocaine
treatment approaches in the text.  Given the relatively limited
number of studies available, additional work is necessary before
determinations can be made about the utility of any treatment
approach for specific demographic and clinical groups. 

To identify additional research initiatives necessary for increasing
our knowledge of cocaine treatment effectiveness, we conducted
telephone interviews with 20 cocaine treatment experts.  Each of the
experts we selected was either a principal investigator or
coinvestigator on a currently funded cocaine-related federal grant or
contract, a member of a federal cocaine grant/contract review
committee within the past 2 years, or an author of at least two
cocaine peer-reviewed publications.  The names and affiliations of
the 20 experts who participated are listed below.  (Two additional
individuals chose not to participate.)

M.  Douglas Anglin
University of California, Los Angeles
Neuropsychiatric Institute

Kathleen Carroll
Yale University

George DeLeon
National Development and Research Institutes

Frank Gawin
University of California, Los Angeles

Dean Gerstein
National Opinion Research Center

Edward Gottheil
Thomas Jefferson University

John Grabowski
University of Texas
Health Science Center

Barbara Havassy
University of California, San Francisco

Stephen Higgins
University of Vermont

Herbert Kleber
Columbia University

Thomas Kosten
Yale University

William McAuliffe
Harvard University

Thomas McLellan
Philadelphia Veterans Administration Medical Center
University of Pennsylvania

Stephen Magura
National Development and Research Institutes

Jerome Platt
Medical College of Pennsylvania and Hahnemann University

Richard Rawson
Matrix Institute on Addictions

Harvey Siegel
Wright State University

Dwayne Simpson
Texas Christian University

Michael Thase
University of Pittsburgh

Arnold Washton
Washton Institute


RESEARCH INITIATIVES NECESSARY FOR
INCREASING UNDERSTANDING OF
COCAINE TREATMENT EFFECTIVENESS
========================================================== Appendix II

Following are the responses of the 20 treatment experts to the GAO
question, "What important knowledge gaps remain in our understanding
of cocaine treatment effectiveness in each of the following two
areas:  cognitive/behavioral and pharmacological interventions?"
Relevant individual response items were placed into six clinical and
methodological categories:  cognitive/behavioral issues,
pharmacological issues, the cognitive/behavioral and pharmacological
synergy, clinical assessment/outcome issues, population subgroup
treatment issues, and methodological issues.  The frequency count for
each category is also provided. 


      COGNITIVE/BEHAVIORAL ISSUES
------------------------------------------------------ Appendix II:0.1

Identifying important components of promising treatment practices,
developing and testing contingency contracting strategies,
recognizing the triggers of relapse, determining appropriate
intensity and duration of treatment protocols, assessing the utility
of low-intensity treatments, defining and increasing important
aspects of social and community support, and codifying appropriate
treatment practices. 

Categorical frequency:  12. 


      PHARMACOLOGICAL ISSUES
------------------------------------------------------ Appendix II:0.2

Developing drugs to diminish the craving for cocaine; developing
drugs to block the effects of cocaine; developing maintenance
medication for continued relapse prevention; examining the utility of
multiple untried drugs indicated in the Physician's Desk Reference;
longitudinally testing the effects of drugs; assessing human toxicity
effects of drugs found useful in animal experiments; developing
detoxification medication; and further investigating vaccines,
agonists, and antagonists. 

Categorical frequency:  14. 


      COGNITIVE/BEHAVIORAL AND
      PHARMACOLOGICAL SYNERGY
------------------------------------------------------ Appendix II:0.3

Testing drugs as adjuncts to cognitive/behavioral therapies,
determining the impact of combined drug and cognitive/behavioral
therapies on the extension of relapse prevention, and assessing the
combination of drugs and cognitive/behavioral therapies that works
best for various subgroups. 

Categorical frequency:  6. 


      CLINICAL ASSESSMENT/OUTCOME
      ISSUES
------------------------------------------------------ Appendix II:0.4

Improving the effectiveness of recruitment and retention of clients
in treatment, better assessing readiness and motivation for
treatment, better assessing impact of dual disorders on treatment
outcome, investigating unknown long-term drug treatment outcomes,
developing information on long-term incentives for maintaining drug
abstinence, increasing knowledge about "aftercare" treatment
planning, increasing knowledge of treatment outcome for managed
care/health maintenance organizations to plan client treatments, and
improving the effectiveness of outpatient care. 

Categorical frequency:  11. 


      POPULATION SUBGROUP
      TREATMENT ISSUES
------------------------------------------------------ Appendix II:0.5

Better matching client needs to treatment services as well as
determining which clients do well with specific therapies, what
groups can be effectively treated, who can become abstinent without
use of drugs, what subgroups learn or do not learn about relapse risk
factors in treatment settings, and what educational/IQ levels are
necessary for making effective use of cognitive approaches. 

Categorical frequency:  10. 


      METHODOLOGICAL ISSUES
------------------------------------------------------ Appendix II:0.6

Need for the following:  more clinical trials to demonstrate the
efficacy of basic treatment services; testing treatments on a wider
population of cocaine users; more systematic data collection;
improved technology for conducting randomized, longitudinal trials;
evaluating the patient selection process (volunteers may represent a
biased sample); and conducting cost-effectiveness studies. 

Categorical frequency:  7. 


COCAINE OUTCOMES BY TREATMENT
SETTING
========================================================= Appendix III

In addition to the study of particular treatment approaches (such as
relapse prevention, community reinforcement/contingency management,
and neurobehavioral therapy), researchers are also beginning to
examine the results of cocaine treatment in different types of
settings (that is, outpatient, inpatient, day-hospital, and
therapeutic communities).  In general, outpatient and day- hospital
stays tend to be less costly than extended inpatient stays.  Results
of recent studies suggest that cocaine treatment can be effective in
these less costly settings, but further replication is necessary
before any firm conclusions can be drawn. 

Clients attending a California-based Veterans Administration
intensive outpatient program with a self-help component were able to
remain cocaine abstinent 73 percent of the time, when followed up 24
months after treatment admission.\41 This result was comparable to
that found among clients attending a more costly program consisting
of both an inpatient stay and a highly intensive outpatient/self-help
program.  The California-based program results also surpassed those
achieved by clients who participated in both an inpatient and a
low-intensity outpatient/self-help program (56 percent).  These
results point to the conclusion that clients with a cocaine problem
may be able to do quite well in an intensive outpatient setting that
consists of at least four visits per month for at least 6 months. 

In a second California study, cocaine-dependent inpatients fared
better than outpatients at both 6 and 12 months following treatment
entry, although both groups fared well.\42 Allowing for up to two
slips (or brief episodes of use), at the 6-month period the inpatient
abstinence rate was 79 percent, whereas the outpatient rate was 67
percent.  At the 12-month period, the abstinence rates were 72
percent and 50 percent, respectively. 

The effects of day-hospital versus inpatient treatment were assessed
in Philadelphia.\43 About one-half (53 percent) of those
cocaine-dependent clients attending a day-hospital program were able
to remain continuously abstinent throughout the 6 months following
treatment completion.  This rate was comparable to that of
inpatients:  47 percent. 

And finally, the impact of a day-treatment program (using therapeutic
community techniques) was compared with standard methadone
maintenance treatment in New York.\44 At 6-month follow-up, only 19.1
percent of those remaining in the day-treatment program had used
cocaine during the past 30 days.  These results were substantially
better than those of participants in the standard methadone
maintenance treatment program, where 41.8 percent were using cocaine
at 6-month follow-up.  The day-treatment therapeutic community group
also demonstrated significantly greater reductions in heroin use,
needle use, criminal activity, and psychological dysfunction scores. 



(See figure in printed edition.)Appendix IV

--------------------
\41 M.  Elena Khalsa, Alfonso Paredes, and M.  Douglas Anglin, "A
Natural History Assessment of Cocaine Dependence:  Pre- and
Post-Treatment Behavioral Patterns," unpublished manuscript. 

\42 Unpublished inpatient-outpatient data provided by Barbara
Havassy, Sept.  25, 1995. 

\43 Arthur L.  Alterman, Charles P.  O'Brien, A.  Thomas McLellan,
Donna S.  August, Edward C.  Snider, Marian Droba, James W.  Cornish,
Charles P.  Hall, Arnold H.  Raphaelson, and Francis X.  Schrade,
"Effectiveness and Costs of Inpatient Versus Outpatient Hospital
Cocaine Rehabilitation," The Journal of Nervous and Mental Disease,
Vol.  182, No.  3 (1994), pp.  157-63. 

\44 George DeLeon, Graham Staines, Theresa Perlis, Stanley Sacks,
Karen McKendrick, Robert Hilton, and Ronald Brady, "Therapeutic
Community Methods in Methadone Maintenance (Passages):  An Open
Clinical Trial," Drug and Alcohol Dependence, Vol.  37 (1995), pp. 
45-57. 


COMMENTS FROM THE NATIONAL
INSTITUTE ON DRUG ABUSE
========================================================= Appendix III



(See figure in printed edition.)


BIBLIOGRAPHY
=========================================================== Appendix 0

Alterman, A., M.  Droba, R.  Antelo, J.  Cornish, K.  Sweeney, G. 
Parikh, and C.  O'Brien.  "Amantadine May Facilitate Detoxification
of Cocaine Addicts." Drug and Alcohol Dependence, Vol.  31 (1992),
pp.  19-29. 

Alterman, A., C.P.  O'Brien, A.  Thomas McLellan, D.S.  August, E.C. 
Snider, M.  Droba, J.W.  Cornish, C.P.  Hall, A.H.  Raphaelson, and
F.X.  Schrade.  "Effectiveness and Costs of Inpatient Versus
Outpatient Hospital Cocaine Rehabilitation." The Journal of Nervous
and Mental Disease, Vol.  182, No.  3 (1994), pp.  157-63. 

Avants, S.  Kelly, A.  Margolin, P.  Chang, T.  Kosten, and S. 
Birch.  "Acupuncture for the Treatment of Cocaine Addiction: 
Investigation of a Needle Puncture Control." Journal of Substance
Abuse Treatment, Vol.  12, No.  3 (1995), pp.  195-205. 

Batki, S., L.  Manfredi, P.  Jacob, and R.  Jones.  "Fluoxetine for
Cocaine Dependence in Methadone Maintenance:  Quantitative Plasma and
Urine Cocaine/Benzoylecgonine Concentrations." Journal of Clinical
Psychopharmacology, Vol.  13 (1993), pp.  243-50. 

Batki, S., L.  Manfredi, Sorenson, and others.  "Fluoxetine for
Cocaine Abuse in Methadone Patients:  Preliminary Findings."
Proceedings of the Annual Meeting of the Committee on Problems of
Drug Dependence, National Institute on Drug Abuse Research Monograph
#105.  Rockville, Md.:  National Institute on Drug Abuse, 1991, pp. 
516-17. 

Brewington, V., M.  Smith, and D.  Lipton.  "Acupuncture as a
Detoxification Treatment:  An Analysis of Controlled Research."
Journal of Substance Abuse Treatment, Vol.  11, No.  4, pp.  289-307. 

Bridge, P., S.  Li, T.  Kosten, and J.  Wilkins.  "Bupropion for
Cocaine Pharmacotherapy:  Subset Analysis." Poster abstract
submission, enclosed with Dec.  28, 1994, letter from NIDA to GAO. 

Carroll, K., and C.  Nich.  Unpublished 12-month data provided to
GAO, Oct.  19, 1995. 

Carroll, K., B.  Rounsaville, and F.  Gawin.  "A Comparative Trial of
Psychotherapies for Ambulatory Cocaine Abusers:  Relapse Prevention
and Interpersonal Psychotherapy." American Journal of Drug and
Alcohol Abuse, Vol.  17, No.  3 (1991), pp.  229-47. 

Carroll, K., B.  Rounsaville, L.  Gordon, C.  Nich, P.  Jatlow, R. 
Bisighini, and F.  Gawin.  "Psychotherapy and Pharmacotherapy for
Ambulatory Cocaine Abusers." Archives of General Psychiatry, Vol.  51
(1994), pp.  177-87. 

Carroll, K., D.  Ziedonis, S.  O'Malley, E.  McCance-Katz, L. 
Gordon, and B.  Rounsaville.  "Pharmacologic Interventions for
Abusers of Alcohol and Cocaine:  Disulfiram Versus Naltrexone."
American Journal of the Addictions, Vol.  2 (1993), pp.  77-9. 

Condelli, W., J.  Fairbank, M.  Dennis, and J.V.  Rachal.  "Cocaine
Use By Clients in Methadone Programs:  Significance, Scope, and
Behavioral Interventions." Journal of Substance Abuse Treatment, Vol. 
8 (1991), pp.  203-12. 

Covi, L., J.  Hess, N.  Kreiter, and C.  Haertzen.  "Three Models for
the Analysis of a Fluoxetine Placebo Controlled Treatment in Cocaine
Dependence." Proceedings of the Annual Meeting of the College on
Problems of Drug Dependence, National Institute on Drug Abuse
Research Monograph #141.  Rockville, Md.:  National Institute on Drug
Abuse, 1994, p.  138. 

DeLeon, G.  "Cocaine Abusers in Therapeutic Community Treatment."
National Institute on Drug Abuse Research Monograph #135.  Rockville,
Md.:  National Institute on Drug Abuse, 1993, pp.  163-89. 

DeLeon, G., and others.  "Therapeutic Community Methods in Methadone
Maintenance (Passages):  An Open Clinical Trial." Drug and Alcohol
Dependence, Vol.  37 (1995), pp.  45-57. 

Drug Abuse Warning Network.  Annual Medical Examiner Data 1993. 
Statistical Series 1, No.  13-B (Rockville, Md.:  Substance Abuse and
Mental Health Services Administration, 1995), p.  21. 

U.S.  General Accounting Office.  Drug Abuse:  The Crack Cocaine
Epidemic:  Health Consequences and Treatment.  GAO/HRD-91-55FS, Jan. 
30, 1991, p.  24. 

_____.  Methadone Maintenance:  Some Treatment Programs Are Not
Effective; Greater Federal Oversight Needed.  GAO/HRD-90-104, Mar. 
22, 1990, p.  18. 

_____.  Treatment of Hardcore Cocaine Users.  GAO/HEHS-95-179R, July
31, 1995. 

Grabowski, J., H.  Rhoades, R.  Elk, J.  Schmitz, C.  Davis, D. 
Creson, and K.  Kirby.  "Fluoxetine Is Ineffective for Treatment of
Cocaine Dependence or Concurrent Opiate and Cocaine Dependence:  Two
Placebo Controlled Double-Blind Trials." Journal of Clinical
Psychopharmacology, Vol.  15 (1995), pp.  163-74. 

Havassy, B.  Unpublished inpatient/outpatient data provided to GAO,
Sept.  25, 1995. 

Higgins, S.  Unpublished 12-month data provided to GAO, June 6, 1995. 

Higgins, S., A.  Budney, W.  Bickel, J.  Hughes, F.  Foerg, and G. 
Badger.  "Achieving Cocaine Abstinence With a Behavioral Approach."
American Journal of Psychiatry, Vol.  150, No.  5 (1993), pp. 
763-69. 

Higgins, S., D.  Delaney, A.  Budney, W.  Bickel, J.  Hughes, F. 
Foerg, and J.  Fenwick.  "A Behavioral Approach to Achieving Initial
Cocaine Abstinence." American Journal of Psychiatry, Vol.  148, No. 
9 (1991), pp.  1218-24. 

Khalsa, M.  Elena, A.  Paredes, and M.  Douglas Anglin.  "A Natural
History Assessment of Cocaine Dependence:  Pre- and Post-Treatment
Behavioral Patterns." Unpublished manuscript. 

Kumor, M., M.  Sherer, and J.  Jaffe.  "Effects of Bromocriptine
Pretreatment on Subjective and Physiological Responses to IV
Cocaine." Pharmacology, Biochemistry and Behavior, Vol.  33 (1989),
pp.  829-37. 

Lipton, D., V.  Brewington, and M.  Smith.  "Acupuncture and Crack
Addicts:  A Single-Blind Placebo Test of Efficacy." Presentation made
at Advances in Cocaine Treatment, National Institute on Drug Abuse
Technical Review Meeting, Aug.  1990. 

Magura, S., A.  Rosenblum, M.  Lovejoy, L.  Handelsman, J.  Foote,
and B.  Stimmel.  "Neurobehavioral Treatment for Cocaine-Using
Methadone Patients:  A Preliminary Report." Journal of Addictive
Diseases, Vol.  13, No.  4 (1994), pp.  143-60. 

Magura, S., Q.  Siddiqi, R.  Freeman, and D.  Lipton.  "Changes in
Cocaine Use After Entry to Methadone Treatment." Journal of Addictive
Diseases, Vol.  10, No.  4 (1991), pp.  31-45. 

Margolin, A., S.  Kelly Avants, P.  Chang, and T.  Kosten. 
"Acupuncture for the Treatment of Cocaine Dependence in
Methadone-Maintained Patients." The American Journal on Addictions,
Vol.  2, No.  3 (1993), pp.  194-201. 

Margolin, A., T.  Kosten, I.  Petrakis, S.  Avants, and T.  Kosten. 
"Bupropion Reduces Cocaine Abuse in Methadone-Maintained Patients."
Archives of General Psychiatry, Vol.  48 (1991), p.  87. 

Mello, N., J.  Kamien, J.  Mendelson, and S.  Lukas.  "Effects of
Naltrexone on Cocaine Self-Administration By Rhesus Monkey." National
Institute on Drug Abuse Research Monographs, Vol.  105.  Rockville,
Md.:  National Institute on Drug Abuse, 1991, pp.  617-18. 

Moscovitz, H., D.  Brookoff, and L.  Nelson.  "A Randomized Trial of
Bromocriptine for Cocaine Users Presenting to the Emergency
Department." Journal of General Internal Medicine, Vol.  8 (1993),
pp.  1-4. 

"NIDA Media Advisory," Dec.  14, 1995. 

NIDA Notes, Vol.  10, No.  5 (Sept./Oct.  1995), pp.  10, 14. 

Preston, K., J.  Sullivan, E.  Strain, and G.  Bigelow.  "Effects of
Cocaine Alone and in Combination with Bromocriptine in Human Cocaine
Abusers." Journal of Pharmacology and Experimental Therapeutics, Vol. 
262 (1992), pp.  279-91. 

RAND.  "Treatment:  Effective (But Unpopular) Weapon Against Drugs."
RAND Research Review, Vol.  19, No.  1, Spring 1995, p.  4. 

Rawson, R., J.  Obert, M.  McCann, and W.  Ling.  "Neurobehavioral
Treatment for Cocaine Dependency:  A Preliminary Evaluation." Cocaine
Treatment:  Research and Clinical Perspectives, National Institute on
Drug Abuse Research Monograph #135.  Rockville, Md.:  National
Institute on Drug Abuse, 1993, pp.  92-115. 

Rosenblum, A., S.  Magura, J.  Foote, M.  Palij, L.  Handelsman, M. 
Lovejoy, and B.  Stimmel.  "Treatment Intensity and Reduction in Drug
Use for Cocaine-Dependent Methadone Patients:  A Dose Response
Relationship." Prior version of this paper was presented at the
American Society of Addiction Medicine Annual Conference, New York,
Apr.  1994. 

Shoptaw, S., R.  Rawson, M.  McCann, and J.  Obert.  "The Matrix
Model of Outpatient Stimulant Abuse Treatment:  Evidence of
Efficacy." Journal of Addictive Diseases, Vol.  13, No.  4 (1994),
pp.  129-41. 

Silverman, K., R.K.  Brooner, I.D.  Montoya, C.R.  Schuster, and K.L. 
Preston.  "Differential Reinforcement of Sustained Cocaine Abstinence
in Intravenous Polydrug Abusers." In L.S.  Harris, ed.  Problems of
Drug Dependence 1994:  Proceedings of the 56th Annual Scientific
Meeting, The College on Problems of Drug Dependence, National
Institute on Drug Abuse Research Monograph #153.  Rockville, Md.: 
National Institute on Drug Abuse, 1995, p.  212. 

Silverman, K., C.J.  Wong, A.  Umbricht-Schneiter, I.D.  Montoya,
C.R.  Schuster, and K.L.  Preston.  "Voucher-Based Reinforcement of
Cocaine Abstinence:  Effects of Reinforcement Schedule." In L.S. 
Harris, ed.  Problems of Drug Dependence 1995:  Proceedings of the
57th Annual Scientific Meeting, The College on Problems of Drug
Dependence, National Institute on Drug Abuse Research Monograph, in
press. 

Smith, M.  "Acupuncture Treatment for Crack:  Clinical Survey of
1,500 Patients Treated." American Journal of Acupuncture, Vol.  16
(1988), pp.  241-47. 

Vocci, F., B.  Tai, J.  Wilkins, T.  Kosten, J.  Cornish, J.  Hill,
S.  Li, H.  Kraemer, C.  Wright, and P.  Bridge.  "The Development of
Pharmacotherapy for Cocaine Addiction:  Bupropion As a Case Study."
Paper presented at the College on Problems of Drug Dependence Annual
Scientific Meeting, 1994. 

Walsh, S., J.  Sullivan, and G.  Bigelow.  "Fluoxetine Effects on
Cocaine Responses:  A Double-Blind Laboratory Assessment in Humans."
The College on Problems of Drug Dependence Annual Scientific Meeting
Abstracts, 1994. 

Washton, A., and N.  Stone-Washton.  "Outpatient Treatment of Cocaine
and Crack Addiction:  A Clinical Perspective." National Institute on
Drug Abuse Research Monographs # 135.  Rockville, Md.:  National
Institute on Drug Abuse, 1993, pp.  15-30. 

Wells, E., P.  Peterson, R.  Gainey, J.  David Hawkins, and R. 
Catalano.  "Outpatient Treatment for Cocaine Abuse:  A Controlled
Comparison of Relapse Prevention and Twelve-Step Approaches."
American Journal of Drug and Alcohol Abuse, Vol.  20, No.  1 (1994),
pp.  1-17. 


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