Clinical Textbook of Addictive Disorders 3rd ed - R. Frances, S. Miller, A. Mack (Guilford, 2005) WW

9. Cocaine and Stimulants 203Cognitive, Behavioral, and Nonpharmacological TreatmentsCocaine disorders have proven to be refractory to both psychological and pharmacologicaltreatment. Consequently, considerable energy has been directedtoward developing and testing the efficacy of new psychotherapeutic approachesin the treatment of cocaine use disorders. Many of these therapieshave been adapted from ones originally developed to treat alcoholism. Oneapproach that has received attention is cognitive-behavioral relapse prevention(Marlatt & Gordon, 1985). Relapse prevention strives to teach the addict howto recognize high-risk situations and deal with these using cognitive strategiesthat have been well rehearsed. Relapse prevention recognizes that with achronic disorder such as addiction, relapses and remissions are expected. Whena relapse occurs, more intense treatment and cognitive restructuring are necessaryto help prevent a “slip” from escalating. Reminding patients of their priorprogress, focusing on making the “slip” an isolated event, and maximizing thelearning value of this experience are constructive ways of handling the situation.The literature on efficacy of relapse prevention in the treatment ofcocaine dependence is mixed. In a review of 24 randomized clinical trials ofrelapse prevention for drug abuse (including cocaine), Carroll (1996) concludedthat relapse prevention is superior to no treatment, although superiorityto other active therapies is less evident.Cognitive behavioral therapy (CBT) is also an effective treatment forcocaine addiction, and improves comorbid psychosocial problems (Carroll,2000). In addition, CBT has demonstrated higher retention rates and improvedcompliance compared to other forms of individual and group therapy (Crits-Christoph et al., 1999). However, recent findings indicate that patients withcognitive impairments are more likely to drop out of CBT (Aharonovich,Nunes, & Hasin, 2003).A somewhat different approach has been taken by researchers studying therole of conditioned cues or “reminders” of cocaine use (O’Brien, Childress,Arndt, & McLellan, 1988); this approach attempts to extinguish conditionedresponses to these cocaine cues, thereby reducing the chances for relapse.Desensitization training requires that patients be repeatedly exposed to drugstimuli, then given the opportunity to deal with them in real-life situations.Behavioral rehearsal is key to being prepared to deal with the drug-laden situationsthat exist outside the protection of the treatment center. In one study(O’Brien, Childress, McLellan, & Ehrman, 1990), 30 drug-free cocaine addictswere repeatedly exposed to cocaine cues within a controlled setting. Subjectsreported experiencing strong physiological arousal, including cocaine craving,highs, and withdrawal in response to exposure. However, by the sixth hour ofextinction (repeated nonreinforced exposure to cocaine cues), highs and withdrawalwere no longer reported and, by the 15th hour, craving was no longer