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

9. Cocaine and Stimulants 205tity is considered unimportant, patients are less likely to manifest overt resistance.Rather than emphasize powerlessness, this approach assumes that peoplehave within themselves the capacity to change. Although the efficacy of MET/MI for cocaine abusers has yet to be proven, it would appear that its uniquefocus on readiness should, at minimum, help patients to engage in other formsof therapy. In addition, a few studies have begun to support the use of MET/MIfor treatment of cocaine abuse and dependence. In a small study examining 27female workers with concurrent cocaine or heroin dependence, MI significantlyreduced the women’s cocaine use (Yahne, Miller, Irvin-Vitela, & Tonigan,2002). Similarly, compared to patients who only underwent a detoxificationprogram, patients who also received MI were more likely to be abstinentfrom cocaine following detoxification and demonstrated higher abstinencerates throughout the following relapse prevention treatment. Inaddition, MI was more effective for those patients with lower initial motivation(Stotts, Schmitz, Rhoades, & Grabowski, 2001). Finally, Brown and colleagues(1998) showed that, compared to patients who received meditation/relaxation,patients who received MI had better retention in treatment, though no differenceswere found in overall cocaine use. The researchers also found that MIpatients who initially reported less motivation for change had higher rates ofabstinence at follow-up than did MI patients reporting more motivation forchange at baseline. These findings suggest that MET/MI strategies may be mosteffective for patients who come into drug treatment with low motivation.The approaches described (i.e., relapse prevention, cue exposure/desensitization,contingency management, and motivational interviewing) are somewhattechnical and require specific training and supervision. Research-basedinterventions such as these appear to be the wave of the future, and most can beadapted for use in community-based programs. Frequently, treatment of cocainedependence takes place within the context of a comprehensive drug treatmentprogram. Although therapeutic modalities may be the same as for other drugabusers (e.g., education, and individual and group therapy), the intensity oftreatment must be greater. Emphasis must be placed on the acquisition of skillsthat will enable the cocaine abuser to have more internal control, greater selfefficacy,and reduced likelihood of relapse. This means that treatment musthave multiple “practical” components.The first goal of treatment is to interrupt recurrent binges or daily use ofcocaine and overcome drug craving. For patients who do not have serious psychiatriccomorbidity, a structured outpatient program can be attempted prior tophysically removing the person from the drug-using environment for treatmentin a residential setting. While attempting to initiate abstinence, treatmentshould include daily or multiple weekly contacts and urine monitoring, with asmany external controls as possible. Explicit practical measures to limit exposureto stimulants and high-risk situations should be individualized but mightinclude monitoring and support by drug-free “significant others,” discarding