| The current
cocaine problem is the fifth epidemic of stimulant
abuse in our history (Gawin & Ellinwood, 1988).
The first epidemic of cocaine abuse was in the
1890s and the second in the 1920s. In the early
1950s and late 1960s, amphetamine and methamphetamine
were abused. Now, it is powder and crack cocaine.
The seriousness of the current "drug problem"
is apparent in this country in the birth of drug-affected
children and the growing numbers of young black
males in prisons, and abroad in the deaths of
combatants over drug empires. National concern
has provoked four principal responses: interdiction
of drugs from outside the United States, punishment
of drug sellers and users, treatment, and prevention
(Fraser & Kohlert, 1988). None of these responses
so far has resolved the drug problem. Social and
health services professionals tend to put faith
in the latter two approaches.
This article presents treatment models and findings
of cocaine treatment effectiveness and outcome.
Because treatments can differ from drug to drug,
this article primarily addresses what is known
about cocaine treatment efficacy. However, treatment
outcome data on other drugs are included when
appropriate. Although there are many calls for
more women-sensitive treatment approaches (Reed,
1987), treatment models that have been developed
or evaluated are not gender specific. The vast
majority of clients in these studies are male.
The extent to which findings on treatment effectiveness
apply to women is uncertain.
Treatment Perspectives
Drug treatment approaches derive from three perspectives:
the biological, the psychological, and the sociocultural.
Each perspective has generated different models.
The biological perspective has generated the medical
model. The psychological perspective inspired
the psychological and social learning models.
From the sociocultural perspective, treatment
models focus on the person and on changing the
social and physical environment (for example,
halfway houses). The biopsychosocial model integrates
the three perspectives (Institute of Medicine,
1990).
Biological Perspectives
In the medical model of treatment, addiction to
drugs or alcohol has been described as a progressive
disease requiring treatment and supervision by
a physician. In this model, the person is not
responsible for such physical vulnerabilities
as craving, but rather is responsible for seeking
treatment and preventing relapse. Drug treatment
programs that include methadone or other medications
(for example, antidepressants) are medical model
programs. Clients in outpatient clinics may also
receive counseling (Hubbard et al., 1989). Generally,
the staff employed in methadone clinics are doctors,
nurses, social workers, and counselors. Blockers
such as naltrexone hydrochloride may be used to
reduce craving for opiates.
For cocaine treatment, the medical treatment may
include medications like tricyclic antidepressants
and bromocriptine mesylate (a blocker). Antidepressants
may assist the powder-cocaine or crack-cocaine
user during the period of neurotransmitter depletion.
Thus far, however, there are no effective blockers
for cocaine users that are equivalent to methadone
for heroin users.
Psychological Perspectives
Under the psychological perspective, drug or alcohol
problems originate from motivational, learning,
or emotional dysfunctions. Within the psychological
perspective, addiction problems may be symptoms
of psychopathology (intrapsychic conflicts) or
social learning (the behavioral model). For example,
Khantzian (1985) argued that addicts do not choose
drugs randomly, but that their choice of drugs
is the result of the way the drug reduces their
personal distress. Cocaine has appeal because
of its ability to relieve distress associated
with depression, hyperactivity and restlessness,
and bipolar illness.
Social learning-based models most closely follow
from the psychological perspective. People are
considered to have deficits in social and cognitive
coping skills that lead to an inability to manage
everyday stress and that make them vulnerable
to using substances to function. The social learning
model may draw on individual psychotherapeutic
relationships, adjunctive psychotherapies (for
example, group therapy), and behavior therapy
techniques (for example, the social learning model)
(Institute of Medicine, 1990; Marlatt & Gordon,
1980).
Socio-Cultural Perspectives
In the sociocultural perspective, addiction problems
result from lifelong socialization processes in
social and cultural environments. The treatment
strategy may include environmental restructuring
that provides alternative living arrangements
and involvement with self-help groups. Social
groups such as family, church, Narcotics Anonymous,
and Alcoholics Anonymous are considered important
influences on the person's drug-using and drinking
behavior and response to treatment and key inpreventing
relapse.
Bio-Psychological Integrative Model
The biopsychosocial model integrates biological,
psychological, and social factors in the assessment
and treatment of drug problems. This approach
recognizes that problems are determined by multiple
factors and involve different causes. This model
also recognizes that one or a combination of these
factors may determine individual outcomes (Institute
of Medicine, 1990).
Even though treatment may be individualized
in some places, programs that mix treatment models
are uncommon. Treatment strategies are generally
not individualized, given that it is practically
impossible to operate a completely individualized
program given the current treatment system and
its funding. Within the same physical clinic,
social model programs may operate alongside medical
approaches without any integration of methods.
Typically, clients have had to fit the program
rather than the program fit the client. The most
individualized drug treatment components are psychotherapeutic
and pharmacologic treatments that address unique
client characteristics and personal triggers to
drug use.
Until recently, treatment methodology was the
same regardless of the drug used. The primary
focus during treatment has been on the problem
of addiction (Schnoll et al., 1985). The treatment
community is increasingly endeavoring to apply
treatment models and approaches specific to the
type of drug used (A. Stalcup, medical director
of detox, Haight Asbury Free Clinic, personal
communication, October 30, 1989).
Recommended Treatment Approaches
Comprehensive drug treatment approaches are more
frequently described than offered. Outpatient
programs should include multiple weekly contacts
with peer-support groups; family or couples therapy;
and treatment contracts with corresponding contingencies
for completing activities related to abstinence,
urine monitoring, education sessions, and individual
psychotherapy.
The first goal of cocaine abuse treatment is for
the client to withdraw from the stimulant. Measures
to achieve this goal are often added to conventional
detoxification approaches (Gawin & Ellinwood,
1988) and include a range of ways to help clients
avoid environmental triggers for drug-using behavior,
including providing an alternative residence,
altering the client's access to money, curtailing
the client's social activities, and changing the
client's phone number. Involving significant others
who are drug free in the treatment plans of patients
allows significant others to provide support,
monitor behavior, and provide alternative activities
to drug use.
The second goal of treatment is to prevent relapse.
Well-accepted techniques for enhancing resilience
to relapse include predicting situations in which
relapse risk is high; rehearsing avoidance strategies;
changing lifestyle; developing a drug-free network
of social contacts; and developing memories of
the negative consequences of abuse to counteract
memories of drug euphoria, conditioned cues, and
external stress reduction. Although such approaches
appear to promote some control over other substances
(Marlatt & Gordon, 1980; Schottenfeld, 1991),
their ultimate efficacy with crack cocaine is
unknown. Given the apparently high rate of cocaine
relapse, using medication to reduce intense craving
in the early weeks of treatment may yield greater
effectiveness (A. Stalcup, medical director of
detox, Haight Asbury Free Clinic, personal communication,
October 30, 1989).
Today, treatment models that incorporate a variety
of adult rehabilitative services in their programs
before returning clients to the communities make
sense. According to Salvatore di Menza, special
assistant to the director of the National Institute
on Drug Abuse,
It may be more satisfying to think mainly of residential
programs because the addict is put away somewhere
safe. But we're going to need a range of strategies.
For many addicts, for instance, it's not rehabilitation;
it's habilitation. They don't know how to read
or look for work, let alone beat their addiction.
(Malcolm, 1989, p.23)
Clientst psychosocial functioning may not be
adequate to avoid relapse if they lack skills
for successful employment, parent training, general
life skills training in self-esteem and coping,
and other educational training. Although drug
taking may be statistically independent from environmental
causes, it is highly interrelated with job productivity,
life satisfaction, and life circumstances (Hubbard
et al., 1989; Malcolm, 1989; Reed, 1987; Sutker,
1987). Drug treatment programs need to be coordinated
through various community agencies to provide
services and must be tailored to individual needs.
Coordination of services across agencies has been
a problem identified in social services for many
years (Richmond, 1901). Strategies for coordinating
social services, employment services, health,
child care, and drug treatment continue to need
exploration and evaluation.
Drug treatment programs are typically just one
of the service pieces that a drug user needs.
However, drug treatment programs have long existed
independent of conventional agencies.
Social workers in a range of settings have gradually
learned to refer clients to drug programs, but
many drug programs lack social workers to refer
clients to allied services. Social workers must
work to improve their linkages to drug treatment
programs and to facilitate referrals. A variety
of service components may be needed to assist
clients in remaining drug free after treatment.
These services may include education, vocational
training, medical services, assistance with access
to other social services such as Aid to Families
with Dependent Children or food programs, social
support, parenting skills, social skills training,
and counseling.
Even when drug treatment has been effective, clients
have often not been integrated into the social
and economic mainstream of society. This challenge
is becoming still greater as businesses establish
screening procedures and sanctions against substance
users. Restructured programs need to include greater
attention to the family and employment needs of
the client. The progress of clients could be monitored
during their participation in the different services
to ensure attainment of goals and objectives.
Thus far, conventional programs that offer one
month of residential treatment for drug users
without follow-up services have not shown promising
results, perhaps because they lack these links.
Most long-term residential programs (between three
and 18 months) do not include the necessary range
of habilitative services. A better mix of short-
and long-term programs are needed.
For instance, 30-day hospital-based programs may
incorporate habilitative services such as education
or vocational training and follow-up case management.
Similarly, long-term residential programs may
also include a range of services (treatment and
habilitation) according to the needs of their
clientele. Although group care arrangements for
families in recovery are beginning to develop,
they are not as affordable or flexible as foster
homes that accept mother and child; these programs
need development and evaluation (Barth, 1993).
Under the current social conditions and economic
structure, alternatives that extend treatment
and provide education and employment opportunities
seem to be one way to empower those who have drug
problems and who are also poor or unskilled.
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