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?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 DesignStudy Design

Pharmacotherapy(Naltrexone)

0 mg 50 mg

Psycho-Therapy

Drug Counseling (DC)

Relapse Prevention (RP)

PharmacotherapyPharmacotherapy

NaltrexoneOpiate 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)

PsychotherapyPsychotherapy

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 AdherenceTherapy Adherence

0 1 2 3 4 5

Focus on supportEncourage 12-step

Assess gen. FunctioningFocus 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

RetentionRetention

0

20

40

60

80

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-50mg

DC-0mg

RP-50mg

RP-0mg

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

Cocaine UseCocaine 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 ur

ines

DC-50mg

DC-0mg

RP-50mg

RP-0mg

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

*

Does homework compliance predict outcome?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 90 100

Homework completed (%)

% c

oca

ine

po

sitiv

e u

rine

s

High motivation

Low motivation

ConclusionsConclusions

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 StudiesNaltrexone Studies

Naltrexone and relapse prevention treatment for cocaine-dependent patients

Naltrexone and relapse prevention treatment for cocaine-alcohol dependent patients

Study DesignStudy Design

Pharmacotherapy(Naltrexone)

0 mg 50 mg

Psycho-Therapy

Drug Counseling (DC)

Relapse Prevention (RP)

RetentionRetention

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-50mg

DC-0mg

RP-50mg

RP-0mg

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

Cocaine UseCocaine 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 ur

ines

DC-50mg

DC-0mg

RP-50mg

RP-0mg

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

ConclusionsConclusions

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

% Ne

gativ

e Urin

es

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

% Ne

gativ

e Urin

es

Placebo Naltrexone 150mg

ConclusionsConclusions 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 ConsiderationsFuture Considerations Optimal dosing

Combination pharmacotherapy

Relapse prevention vs abstinence initiation

Enhancing compliance, increasing motivation

Patients’ conceptualization of behavior therapy + medication

Treatment expectanciesTreatment expectancies

Which part of treatment do you expect will be most beneficial?

Medication

Therapy

Medication andTherapy