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Center for Substance Abuse Treatment. Treatment for Stimulant Use Disorders. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1999. (Treatment Improvement Protocol (TIP) Series, No. 33.)

  • This publication is provided for historical reference only and the information may be out of date.

This publication is provided for historical reference only and the information may be out of date.

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Treatment for Stimulant Use Disorders.

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Chapter 3—Approaches to Treatment

As large numbers of people with substance use disorders began to seek treatment in the early and mid-1980s, "treatment" for stimulant abuse and dependence was invented. The treatment system that responded most quickly was the 28-day Minnesota Model hospital industry. The number of these 28-day, for-profit treatment units grew at an astonishing rate. Tens of thousands of cocaine users were treated in these programs with strategies adapted from the treatment of alcoholics. Today, there is little empirical evidence to assess the efficacy of these efforts.

During this same period, all sorts of unconventional remedies, including health foods, amino acids, hot tubs, electronic brain tuners, and other "New Age" treatments emerged and disappeared. Research efforts to develop scientifically based treatments began during this period with behavioral techniques like contingency contracting (Anker and Crowley, 1982) and medication evaluations including the use of desipramine (Norpramine) (Tennant and Rawson, 1983; Gawin and Kleber, 1984). Over the 15-year period since these early efforts, an entire stimulant use disorder treatment literature has developed.

This chapter reviews the current state of knowledge on the treatment of stimulant use disorders, beginning with the approaches that have the most rigorous empirical support. Other approaches with less support in the scientific literature are presented later in the chapter. At the end of the chapter is a review of the current state of medications research in the treatment of stimulant use disorders. Although at the time of this writing there were no medications with demonstrated clinical efficacy, the ongoing program of research sponsored by the National Institute on Drug Abuse (NIDA) holds great promise for important treatment advances. For this reason, the current state of this research effort will be reviewed.

Documented Treatment Approaches

How To Measure Effectiveness

This chapter reviews what is scientifically known about effective treatments for stimulant use disorders. To be judged effective, a treatment must have been tested and demonstrated to be effective in a randomized clinical trial. Many psychosocial and pharmacological treatments have been investigated in such trials. Several psychosocial treatments for stimulant abuse and dependence have been found to be effective, but to date, no reliably effective pharmacological treatments have been found. What has been learned so far about the use of psychosocial and pharmacological treatments for stimulant use is summarized below. Almost all of the information has been gleaned from studies conducted with cocaine users. Similar studies with methamphetamine (MA) users have not been reported. However, evidence from at least one study indicates that cocaine and MA users respond similarly to psychosocial interventions, suggesting that what has been learned from cocaine users may be applicable to MA users (Huber et al., 1997).

Randomized clinical trials are the best available method for determining whether an intervention improves health. A randomized clinical trial is a prospective study comparing the effect of some intervention against a control intervention in groups of clients who are assigned randomly to the respective treatment groups (see Friedman et al., 1983). In such trials, clients from a particular population sample (e.g., all admissions to clinic X during 1998 meeting a particular list of inclusion and exclusion criteria) are randomly assigned to the intervention under study or to a control condition. Random assignment ensures against possible bias in assigning particular kinds of clients to the respective groups and helps to distribute evenly between the groups any subject characteristics that might influence outcomes.

Prospective means that clients in the groups are studied from the start of the intervention as opposed to retrospectively compiling the information after the intervention is completed. Retrospective observations tend to be less accurate because of relevant information not being collected, getting lost, or being distorted through reliance on people's recall. Having a comparison or control group is essential because most problems have some level of variability (i.e., they wax and wane over time) and because many health problems resolve over time without any formal treatment. The most effective way to determine whether any observed changes are due to the treatment being investigated rather than natural variability is by comparing against a similar group of clients who either received no treatment or received a standard treatment.

Some of the alternatives to randomized clinical trials common in the substance use disorder treatment field can provide useful information but have serious limitations that must be recognized. For example, following a group of clients who received a particular treatment in the absence of a comparison group can be informative in terms of characterizing what has happened to them (e.g., percentage relapsed, percentage who received additional treatment, amount of change from pre- to posttreatment), but such observations do not permit any scientifically valid inferences regarding the role of the treatment provided to any of the changes observed during followup. For that purpose, a comparison group is necessary. Any changes observed might have occurred in the absence of treatment. Without a comparison group there simply is no way to rule out that possibility. Similarly, when clients themselves select group membership, as opposed to being assigned by the researcher, one cannot make valid inferences about the role of treatment to outcome. For example, comparing treatment completers to dropouts is common and may be informative in terms of characterizing how the groups fared, but it is not scientifically valid to infer that any differences observed between them were due to the different amounts of treatment received. It very well could be that some other factor (e.g., differences in the amount of other demands on their time) was responsible both for the differential retention rates and for the subsequent differences observed at followup.

Psychosocial Treatment Approaches

The psychosocial interventions demonstrated thus far to be efficacious in randomized clinical trials with stimulant users share a common feature of incorporating well established psychological principles of learning.

It is impossible to quantify all aspects of psychosocial treatment. Often therapists working in the same clinic and using the same treatment approach differ greatly in terms of the progress their clients make. Put simply, some therapists appear to be very effective and others relatively ineffective. The use of carefully prepared treatment manuals reduces such between-therapist differences. Treatment manuals increase the likelihood that therapists will deliver a uniform set of services to their clients. That does not come at the cost of eliminating therapists' clinical judgment or flexibility. A carefully prepared manual recognizes the importance of clinical judgment and flexibility in addressing the individual needs of clients and incorporates those features into the manual. Considering that effective treatments and associated manuals are available, using them is prudent and will help ensure that clients receive the services that research has shown to be effective.

Community-Reinforcement-Plus-Vouchers Approach

Community reinforcement is an individualized treatment designed to promote lifestyle changes in several key areas that are conducive to successful recovery (see Meyers and Smith, 1995; Sisson and Azrin, 1989). First, clients with spouses who are not themselves users are offered marital therapy to improve the quality of their relationships in a reciprocal and rewarding manner. Second, clients who are unemployed, employed in jobs that are high-risk for substance abuse, or need vocational assistance for some other reason receive help in that domain. Third, clients are counseled and assisted in developing new social networks and recreational practices that promote and support recovery. Self-help participation is not mandatory but is often used as an effective means of developing a new social network. Fourth, various types of skills training are provided depending on individualized client needs, including substance refusal and associated skills, social skills, time management, and mood regulation training. Finally, clients with alcohol use disorders and no medical contraindications are offered a program of disulfiram (Antabuse) therapy coupled with strategies to support medication compliance.

Voucher-based incentive programs are designed to facilitate retention in treatment and to promote initial abstinence from stimulants. Such incentive programs are known as contingency management interventions, which are discussed further below. In this treatment, clients earn vouchers that are exchangeable for retail items contingent on stimulant-free urinalysis results during the initial 12 weeks of the 24-week treatment. Urinalysis monitoring is conducted thrice weekly during that period. The voucher system used in studies evaluating this treatment included incentives worth a maximum of approximately $980 across the course of treatment. Since those studies were completed, others have reported effective voucher programs using lower cost incentives (Tusel et al., 1995); another program obtained all its incentives via donations from community businesses (Amass, 1997), although the efficacy of this program was not evaluated. How valuable the incentives must be to significantly improve outcomes has not yet been evaluated.

The efficacy of the community-reinforcement-plus-vouchers approach, delivered as a comprehensive, stand-alone treatment, is supported by three randomized clinical trials (Higgins et al., 1993b, 1994b, 1997), with several additional trials supporting the efficacy of particular components of that approach (e.g., Silverman et al., 1996). The first trial examined the efficacy of this treatment compared with standard outpatient counseling (Higgins et al., 1993b). Treatment was 24 weeks in duration with 6 months of additional followup. The community-reinforcement-plus-vouchers treatment retained clients significantly longer and documented significantly longer periods of continuous stimulant abstinence than did standard counseling. For example, 58 percent of clients assigned to the community-reinforcement-plus-vouchers treatment completed 24 weeks of treatment compared with 11 percent of those assigned to standard counseling. Furthermore, of the clients in the community-reinforcement-plus-vouchers group, 68 percent were documented to have achieved 8 weeks of continuous cocaine abstinence, and 42 percent had 16 weeks of continuous abstinence. Of the clients in the standard counseling group, only 11 percent were documented to have achieved 8 weeks of continuous cocaine abstinence, and only 5 percent had achieved 16 weeks of continuous abstinence. Followup assessments revealed another important difference: Greater cocaine abstinence was documented--at 6, 9, and 12 months after treatment entry--in the group that received community-reinforcement-plus-vouchers treatment than in those who received standard counseling (Higgins et al., 1995).

A detailed manual (Budney and Higgins, 1998) that was designed specifically to guide clinicians in the day-to-day implementation of this approach was published recently by NIDA and is available at no cost via the NIDA Clearinghouse (1-800-729-6686) or can be downloaded from the website http://www.nida.nih.gov/TXManuals/CRA/CRA1.html

Contingency Management

The voucher system mentioned above is a contingency management intervention (also referred to as contingency contracting). Contingency management is a well-known behavioral intervention that is designed to increase or decrease desired behaviors by providing immediate reinforcing or punishing consequences when the target behavior occurs. Contingency management has been used with considerable effectiveness in the treatment of a variety of types of substance use disorders and is very useful for treatment planning because it sets concrete short-term and long-term goals and emphasizes positive behavioral changes (Stitzer and Higgins, 1995). However, relying exclusively on punitive consequences in contingency management interventions is not recommended because doing so can promote early treatment dropout (Stitzer et al., 1986).

The voucher program has been demonstrated to be efficacious when delivered apart from the community reinforcement treatment. Silverman and colleagues, for example, demonstrated that vouchers contingent on cocaine-negative urinalysis results increase cocaine abstinence in methadone maintenance clients who abuse cocaine (Silverman et al., 1996). Tusel and colleagues demonstrated reductions in all illicit substance abuse with contingent vouchers (Tusel et al., 1995).

Although vouchers are a well-supported contingency management intervention for increasing abstinence in stimulant users, other methods are also effective. Examples among methadone maintenance clients are take-home methadone doses (which eliminate the need for methadone clients to visit the clinic daily to consume their medication under staff supervision) (Stitzer et al., 1992), continuance of methadone maintenance treatment contingent on abstinence from cocaine (Kidorf and Stitzer, 1993), and even a simple system wherein publicly displayed gold stars and inexpensive gifts (e.g., coffee cups, gasoline coupons) are earned for substance abstinence and counseling attendance (Rowan-Szal et al., 1994).

Contingent methadone take-home doses have been used effectively when coupled with other treatment services. An excellent example of this was provided by McLellan and colleagues (McLellan et al., 1993). Methadone maintenance clients were randomly assigned to one of three conditions that provided increasing levels of services. Two of the three groups received methadone take-home doses contingent on negative urinalysis results and proof of current employment. These groups also received additional services not provided to the minimal-service group. The two groups given the opportunity to earn contingent take-home methadone doses achieved higher rates of cocaine and opiate abstinence than did clients receiving noncontingent take-home doses.

Iguchi and colleagues investigated whether cocaine abstinence could be increased through contingent reinforcement of compliance with individualized treatment plans rather than negative urinalysis results (Iguchi et al., 1997). Newly admitted methadone maintenance clients were assigned to one of three groups: (1) a control group receiving standard treatment at the methadone clinic (the standard group); (2) a group receiving standard treatment plus monetary vouchers contingent on the submission of substance-free urine specimens (urinalysis-contingent group), or (3) a group receiving standard treatment plus the same monetary vouchers but contingent on completing treatment plan tasks (treatment plan group). The third group demonstrated significantly greater reductions in illicit substance use than did the other two groups.

Contingency management can be effective with more-difficult-to-treat subgroups of stimulant users. For example, a contingency management approach that was efficacious in homeless stimulant users combined nonhospital day treatment with access to work therapy and housing contingent on substance abstinence (Milby et al., 1996). Nearly three-fourths of the subjects in this study were primarily crack cocaine users. They were randomly assigned to receive either enhanced or usual care. Enhanced care consisted of 2 months of clinic attendance for 5.5 hours each weekday, transportation to and from the clinic, lunch, psychoeducational groups, and individualized counseling.

During the last 4 months of the trial, the intensity of day treatment was reduced to allow subjects to participate in a work-therapy program refurbishing condemned houses in which they could live for a modest rental fee. Participation in the work program and housing were contingent on the provision of weekly random urinalysis testing. Drug-positive results precluded subjects from working in the program and required them to vacate the housing within 2 weeks. The work and living arrangements could be resumed on submission of two consecutive substance-free urine specimens. Usual care consisted of twice-weekly, 12-Step-oriented group and individual counseling, medical evaluation and treatment or referral, and referrals to community agencies for housing and vocational services. Enhanced care increased cocaine abstinence significantly at the 2-month assessment, although not at the 6- or 12-month assessments. Enhanced care also produced greater reductions in alcohol use at each assessment and significantly fewer days homeless at the 6- and 12-month assessments.

Pregnant women are another important subgroup with whom contingency management has been evaluated, although only in the form of preliminary studies. In two pilot studies, pregnant women were offered incentives for attendance at prenatal clinics and/or maintaining cocaine abstinence (Elk, in press). Monetary vouchers of increasing value were awarded for each successive substance-free urine specimen and for increased or consistent attendance at prenatal and substance use disorder treatment clinics. Abstinence, retention rates, and compliance with prenatal care visits were generally higher in the contingency groups. In another study, pregnant clients were randomly assigned to receive standard or enhanced methadone maintenance treatment (Carroll et al., 1995a). Standard treatment consisted of daily methadone, weekly group counseling, and thrice-weekly urine testing. Enhanced treatment consisted of weekly prenatal care, weekly relapse prevention groups, and monetary vouchers for every three consecutive substance-free urine samples. Treatment retention was similar in the two groups, and there were no significant differences in the percentage of cocaine-positive urine samples provided by the two groups.

This treatment approach with pregnant women with stimulant use disorders is very preliminary and needs more thorough evaluation. However, these efforts further illustrate the potential utility of contingency management for addressing some of the more daunting clinical challenges in treating stimulant abuse. Other important examples are recent pilot studies (Roll et al., 1998; Shaner et al., 1997) suggesting that contingent monetary reinforcement can reduce cigarette and cocaine use in adult schizophrenic clients and providing evidence that contingent monetary reinforcement can be used to increase medication compliance in tuberculosis-infected stimulant users (Elk, in press).

When considered as a group, contingency management interventions have by far the greatest amount of empirical support for their efficacy in promoting therapeutic behavioral change among stimulant users. Stimulant users are sensitive to systematically applied contingency management interventions. Presently, there is no other treatment strategy about which one can make an equally strong positive statement.

Relapse Prevention

Relapse prevention (RP) systematically teaches clients (1) how to cope with substance craving, (2) substance refusal and assertiveness skills, (3) how seemingly irrelevant decisions can affect the probability of later substance use, (4) general coping and problem solving skills, and (5) how to apply strategies to prevent a full-blown relapse should an episode of substance use occur (Marlatt and Gordon, 1985).

Carroll and colleagues have adapted and demonstrated the efficacy of this treatment approach with cocaine users (Carroll et al., 1991a, 1991b, 1994a, 1994b). In an initial study, RP was compared with interpersonal psychotherapy (IP), which teaches strategies for improving social and interpersonal problems (Carroll et al., 1991a). Retention was better with RP than IP, and trends suggested cocaine abstinence may have been as well, but that difference was not significant.

A subsequent study compared RP and case management (Carroll et al., 1994a); the clients in this study also received either desipramine or placebo. A total of 139 clients were randomized to one of four treatment groups. Case management was designed to provide a nonspecific therapeutic relationship and an opportunity to monitor clients' clinical status. Both treatments were delivered in weekly therapy sessions during 12 weeks of treatment. All clients also received weekly urinalysis testing and other clinical monitoring. All treatment groups improved from pre- to posttreatment on measures of cocaine use and the Addiction Severity Index (ASI) drug, alcohol, family/social, and psychiatric composite scales, but there were no significant main effects for psychosocial (RP vs. case management) or drug treatment (desipramine vs. placebo). At 1-year followup, those clients who received RP reported significantly higher levels of cocaine abstinence than did clients who received case management (Carroll et al., 1994b). Considering RP's focus on teaching skills to prevent a lapse from becoming a full-blown relapse, these delayed effects might be expected. Indeed, similar delayed effects of RP have been reported in studies on treatment of other types of substance use disorders (see Carroll, 1996).

Not all studies with RP have been positive. For example, Wells and colleagues reported negative results in a comparison of RP and 12-Step-based counseling (Wells et al., 1994). No significant differences between the two groups were discerned in retention or cocaine use during the 24-week outpatient trial or at a 6-month followup evaluation.

Treatment Approaches With Supportive Research

The Matrix Model

The Matrix model (originally referred to as the neurobehavioral model) is an outpatient treatment approach that was developed during the mid-1980s for the treatment of individuals with cocaine and MA use disorders (Rawson et al., 1990). The model integrates treatment elements from a number of specific strategies, including relapse prevention, motivational interviewing, psychoeducation, family therapy, and 12-Step program involvement. The basic elements of the approach consist of a collection of group sessions (early recovery skills, relapse prevention, family education, and social support) and 20 individual sessions, along with encouragement to participate in 12-Step activities, delivered over a 24-week intensive treatment period (Rawson et al., 1989).

This treatment model serves as the primary treatment protocol for a network of outpatient treatment offices in Southern California (Matrix Center). In this network of clinics, more than 8,000 people with cocaine and MA use disorders have been treated with this approach since 1985. The client population ranges from professionals and executives to inner-city crack users and indigent rural MA users. In order to adapt to the financial realities imposed by the emergence of managed care, 2-month and 4-month versions of the model have been developed and are currently being evaluated. As the model was developed and refined, an extensive set of data on the value of the treatment approach was collected. The research studies evaluating this treatment approach do not include a randomized clinical trial. However, in seven research projects evaluating the treatment model, application of the model has been shown to be associated with significant reductions in cocaine, MA, and other substance use (Rawson et al., 1993, 1996; Shoptaw et al., 1994). In a project comparing the treatment outcome of 224 cocaine and 500 MA users to the Matrix approach, all indicators suggested a comparable treatment response (Rawson et al., 1996; Huber et al., 1997). Along with a reduction of stimulant and other substance use, treatment participation in the Matrix model has been demonstrated to be associated with a significant reduction in HIV-risky sexual behavior (Shoptaw et al., 1997). See Figure 3-1 for an evaluation of Matrix Center protocols for the treatment of MA abuse and dependence.

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Figure 3-1: Evaluating the Matrix Model. The Center for Substance Abuse Treatment has recently solicited applications to replicate and evaluate the Matrix 8- and 16-week protocols for the treatment of MA use disorders. This project will represent (more...)

Behavioral Family/Couples Therapy

People with substance use disorders often have extensive marital, relationship, and family problems. Stable marital and family adjustment is associated with better treatment outcomes. Inclusion of family members in treatment is based on the view that they can provide important support for the client's efforts to change and provide additional information about the client's substance use and other behavior. Interventions directed at improving marital and family adjustment have therefore been judged to have the potential to improve treatment outcome. Studies with alcoholics have supported this hypothesis, at least in part. Few studies have been attempted with stimulant users, however.

One randomized trial conducted with a heterogeneous group of substance users, many of whom were cocaine users, supported marital/family therapy as a means to improve treatment outcome (Fals-Stewart et al., 1996). Subjects were male substance users under current criminal justice supervision, who were living with a spouse during the past year, and who expressed a commitment to sustained substance abstinence. These individuals were randomly assigned to two treatment groups that received an equal number of therapy sessions across 24 weeks of treatment. For one group, those sessions focused exclusively on coping skills. For the other group, sessions consisted of coping-skills training plus behavioral marital therapy. The group that received marital therapy had better relationship outcomes (in terms of more positive dyadic adjustment and less time separated) than did the comparison group, and reported fewer days of substance use, longer periods of abstinence, fewer substance-related arrests, and fewer hospitalizations during the year after treatment. As might be expected, some of those differences dissipated over the course of the followup period, but this study illustrates an important role for behavioral marital therapy for stimulant users who have a relatively stable romantic relationship and who express a commitment to substance abstinence at the initiation of treatment.

Other Interventions With Supportive Research

Some additional interventions merit mention. Permitting women entering residential treatment to be accompanied by some or all of their children appears to improve retention. In a published controlled study on this topic (Hughes et al., 1995), women entering residential treatment for cocaine use who were permitted to have one or two of their children reside with them were retained significantly longer than women whose children were placed with the best available caretaker (300.4 vs. 101.9 mean days of retention). No other measures of outcome were reported.

Another study described procedures for improving treatment participation (Hall et al., 1994). Clients were cocaine-dependent male veterans. All clients began treatment as inpatients, typically for 2 weeks, and were then encouraged to continue therapy in the outpatient center of the same medical complex. Therapy consisted of individual and group therapy sessions. Participation in the outpatient regimen began either during the inpatient stay, in which case clients kept the same individual and group therapists throughout the inpatient and outpatient phases, or it began after the inpatient stay and subjects were assigned new individual and group therapists on entering the outpatient phase. Having participation in outpatient care begin during the inpatient stay resulted in somewhat better participation after hospital discharge, and significantly better initial (3 weeks) but not later cocaine abstinence.

Woody and colleagues reported that supportive-expressive psychotherapy may help the subset of clients interested in receiving such therapy to reduce their cocaine use (Woody et al., 1995). They studied a subset of newly admitted methadone clients who indicated an interest in receiving psychotherapy and were compliant with attending counseling sessions (less than half the clients admitted). These individuals were randomized to receive supportive-expressive psychotherapy plus substance use counseling or only substance use counseling. Supportive-expressive psychotherapy focused on exploring the role that substances played in relationship problems, troubling feelings, and other problems. Those who received psychotherapy used significantly less cocaine during the 24-week study than those who received only substance use counseling.

Finally, an intervention called "node-link mapping" may be helpful in reducing cocaine abuse (Czuchry et al., 1995; Dansereau et al., 1995; Joe et al., 1994). This intervention uses flowcharts and other methods to diagram relationships between clients' thoughts, actions, feelings, and substance use. Clients were individuals enrolled in methadone treatment who were randomized to receive standard counseling or node-link enhanced counseling. Those who received the node-link mapping appeared to reduce their cocaine use more during 6 months of treatment than those who received standard care, but the effect was not compelling. The node-link-mapping group was using more cocaine at the start of treatment. Although the node-link-mapping group showed a greater reduction from the start to the end of treatment than did the standard group, the absolute amount of cocaine use at the end of treatment was not significantly different. Further studies are needed in which these results are replicated in groups that start treatment with the same level of cocaine use or finish treatment with the node-link-mapping group using significantly less cocaine.

Other Models of Psychosocial Treatment

A number of other psychosocial models and approaches have been described, and some used quite widely, for the treatment of stimulant use disorders.

Network Therapy

Network therapy is based on the rationale that people can recover from substance use disorders if they have a stable social network to support them in psychotherapeutic treatment. In this model, clients receiving individual psychotherapy develop a network of stable, nonsubstance-using support persons, such as family, partners, and close friends. These support persons learn strategies from the therapist to support the therapeutic process for the individual being treated. They may interact regularly with the therapist, participate in treatment sessions with the client, and be involved in setting up treatment plans for the client.

Empirical evidence for network psychotherapy is scarce. Controlled trials of network therapy for cocaine or other substance use have not yet been published.

Acupuncture

Acupuncture is an ancient Chinese therapy in which thin needles are inserted subcutaneously at various points on the body. The technique is based on the belief that the body's normal functioning depends on a balance of two opposite polar energies that flow along lines of the body called meridians. Approximately 1,000 acupuncture points are aligned along these meridians, and their stimulation by the thin needles is believed to correct energy imbalances and enhance the body's natural capacity to heal itself. No controlled outcome studies have been reported supporting the efficacy of acupuncture for the treatment of cocaine or other stimulant use disorders (TIP 10, Assessment and Treatment of Cocaine-Abusing Methadone-Maintained Patients [CSAT, 1994b]).

Inpatient Treatment

Inpatient treatment has traditionally consisted of a 28-day stay in a hospital or residential treatment facility, during which daily activities such as self-help groups, group psychotherapy, and relaxation techniques were provided in a structured format. Generally supportive and sometimes confrontational in nature, inpatient treatment was aimed at combating clients' denial and initiating participation in the 12 steps of recovery originally delineated by Alcoholics Anonymous (AA). The major goals of most inpatient treatment programs are detoxification from the influence of chronic substance use and beginning the process of engaging with self-help programs such as AA and Narcotics Anonymous (NA). Treatment components include didactic learning about the processes of addiction and recovery as well as experiential techniques. Often the client's family is involved in special "Family Days" to acquaint them with these issues.

Originally developed for the treatment of alcoholism, the 28-day standard hospital treatment regimen was used especially in the early 1980s, when the numbers of clients seeking treatment for cocaine use disorders began to rise dramatically. This trend peaked in the mid-1980s, when more than half of clients in many private programs were being treated for cocaine abuse and dependence (Rawson, 1986). Most of these inpatient programs were adapted to treat cocaine users with few or no modifications from the alcohol regimens. In the mid-1980s, when cocaine use among middle-class Americans reached epidemic proportions, the standard 28-day inpatient treatment program was the most widely used treatment modality for this population (Rawson et al., 1991a).

Several hospital/residential treatment organizations did attempt to evaluate the effectiveness of their treatment programming for cocaine users. For example, Sierra Tucson, in Tucson, Arizona, conducted a program of outcome research during the 1980s designed to evaluate and improve the efficacy of its treatment efforts for cocaine users. The Hazelden treatment organization compiled an extensive database on the effectiveness of its treatment services with cocaine and other substance users. The Carrier organization has published a series of studies designed to evaluate the effectiveness of their treatment programs (Pettinati, 1991). Although the evaluations were not randomized clinical trials, the information collected in the reports supported the value of the treatment services.

The traditional 28-day inpatient treatment regimen was developed with little input from empirically based research. In the past several years, the use of such inpatient programs has been called into question by insurance providers, and subsequently their use has been steadily declining. As insurance coverage for inpatient treatment likewise began to dwindle, these programs became variable in length. Many programs closed, and others were forced to scale back on the services they provided. Currently, in many cases clients are covered for brief inpatient stays (up to 7 days) for detoxification purposes only, and psychosocial services have been limited. Inpatient treatment programs are widely variable in the credentialing of their staff, but nearly all employ some staff members who are themselves in recovery.

Long-Term Residential Treatment

Long-term residential treatment is used for substance users who are deemed to be in need of a structured support system for a sustained period. The structure provided by long-term residential treatment is designed to allow positive changes and stabilization in the client's attitudes and lifestyle. The durations of residential treatment programs vary; at one time, most programs were at least 1 year in duration, but today most are about 6 months, or even only 90 days. Most residential programs, both long-term and halfway houses, are staffed at least in part by people who are themselves in recovery.

Therapeutic communities (TCs), the most common type of long-term residential treatment, are residential treatment programs that usually use group activities directed toward effecting significant changes in the residents' lifestyles, attitudes, and values. They emphasize prosocial behavior and the assumption of responsibility for one's actions. Many referrals to TCs take place through the court system. In fact, TCs originally were designed for heroin-addicted clients with deprived socioeconomic backgrounds and long-term histories of criminal involvement.

Halfway houses are residential treatment programs providing transitional support for individuals who are usually progressing from a more restrictive environment, such as a TC, but who are not yet ready to function independently in the community. These individuals may not need the intensive structured environment of a TC but may not yet be ready for independent living. Requirements of halfway-house programs usually include specified community involvement, such as employment or enrollment in school, and abstinence from mood-altering substances. Evening group activities are structured around residents' work schedules.

Although relatively little empirical evidence exists supporting the efficacy of long-term residential treatment for stimulant use disorders, there is at least some reason to believe that it can be effective (Gerstein et al., 1994; Mueller and Wyman, 1997). Although clinical experience suggests that TCs are effective with a subset of cocaine users, to the Consensus Panel's knowledge no controlled clinical trials have been published supporting their efficacy in the treatment of cocaine-dependent individuals.

Pharmacological Treatments for Stimulant Abuse and Dependence

There is not yet an effective pharmacotherapy for cocaine use disorders, but this topic is being researched intensively. Because of differences in the neurochemistry of cocaine and MA, there is sound reason to believe that different pharmacotherapies may be needed to treat those two forms of stimulant use (Ling and Shoptaw, 1997). However, because both drugs produce similar effects on the brain's dopamine levels, promising medications for the treatment of cocaine use disorders are also being examined for the treatment of methamphetamine use.

Clinical research on pharmacotherapies for MA use disorders is just getting under way. Medications are being sought to address a range of indications. There is interest in developing agents that can alleviate the medical/psychiatric symptoms caused by MA intoxication and withdrawal. For example, antidepressant medications have been found useful in the treatment of individuals who have discontinued their use of MA (NIDA, 1998c). Also, there is interest in developing medications to treat MA abuse and dependence. Ongoing trials are currently assessing dopaminergic (i.e., dopamine-mediated), serotonergic (i.e., serotonin-mediated), and other compounds (CSAT, 1997).

Pharmacotherapy research for cocaine use disorders was spurred initially by an open-label trial followed by a double-blind, randomized trial supporting the efficacy of desipramine, a tricyclic antidepressant, in producing short-term reductions in cocaine use and craving in outpatients (Gawin and Kleber, 1984; Gawin et al., 1989). In the randomized trial, 59 percent of cocaine-dependent clients treated for 6 weeks with desipramine achieved 3 or more weeks of continuous cocaine abstinence compared with 25 percent of those treated with lithium and 17 percent of those who received placebo (Gawin et al., 1989). Unfortunately, those promising results have not been replicated in subsequent controlled trials with desipramine (e.g., Carroll et al., 1994a; Weddington et al., 1991) or imipramine (Janimine), another tricyclic antidepressant (Nunes et al., 1995). Evidence that clients with less severe cocaine dependence may benefit from treatment with desipramine and imipramine was presented in at least two reports and merits further study (Carroll et al., 1994a; Nunes et al., 1995).

Other antidepressants that have been investigated in primary cocaine users include fluoxetine (Prozac) (Grabowski et al., 1995), maprotiline (Ludiomil) (Brotman et al., 1988), and gepirone (Jenkins et al., 1992). Studies are still in progress with some of these compounds, but none has demonstrated reliable efficacy in reducing cocaine craving or use in controlled trials. Because of cocaine's very pronounced effects in the dopamine system, a variety of different dopaminergic compounds has been investigated, including amantadine, bromocriptine, bupropion, flupenthixol, carbidopa-l-dopa, mazindol, methylphenidate, and tyrosine (see reviews by Gorelick, 1994; Kleber, 1995; Mendelson and Mello, 1996). Open-trial data have sometimes looked promising, but no reliable positive effects have been observed with any of these compounds in randomized trials. The same is true for the anticonvulsant carbamazepine (Kranzler et al., 1995).

Buprenorphine is an opioid drug that is currently being evaluated as a treatment for opiate dependence in the same manner as methadone is used. In the course of this work, observations by several researchers suggested that buprenorphine might be an effective treatment for cocaine use disorders in the population that uses both opiates and cocaine (e.g., Kosten et al., 1992; Schottenfeld et al., 1993). However, other more rigorous clinical studies have failed to find that buprenorphine has efficacy in suppressing cocaine abuse (e.g., Johnson et al., 1995). Research continues on this topic. Currently, there is no convincing evidence showing that buprenorphine causes decreases in cocaine use or is associated with greater reductions in cocaine use than when methadone is used to treat clients who abuse opiates and cocaine (see Silverman et al., 1998).

Use of disulfiram therapy for clients who use both cocaine and alcohol looks promising. The majority of stimulant users meet medical criteria for alcohol dependence, and more than 90 percent are current alcohol users (Grant and Harford, 1990; Higgins et al., 1994a). Disulfiram therapy with social monitoring to ensure medication compliance was used as a standard component in the community-reinforcement-plus-vouchers treatment approach described above. A chart review was conducted on 16 cocaine-dependent individuals who received that treatment (Higgins et al., 1993a). Carroll and colleagues reported results consistent with these findings in a pilot randomized trial (Carroll et al., 1993b). In that study, disulfiram therapy was compared with naltrexone therapy in a population of 18 outpatients who abused cocaine and alcohol. Disulfiram therapy resulted in significantly greater reductions in drinking and cocaine use than naltrexone therapy. Finally, a larger randomized trial on the efficacy of disulfiram therapy was completed recently, and again cocaine use was significantly reduced by disulfiram therapy (Carroll, 1996). A detailed protocol for use of disulfiram therapy with cocaine users is provided in the NIDA manual on community reinforcement plus vouchers mentioned above (Budney and Higgins, 1998).

Finally, an exciting area of research currently being pursued in the basic-science laboratory using nonhuman subjects focuses on the development of potential vaccines against

cocaine use disorders in the form of enzymes or catalytic antibodies. These novel approaches may hold greater promise than more conventional approaches (Ling and Shoptaw, 1997).

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