Editor’s note: The Collaborative Cocaine Treatment Study is the largest trial comparing different outpatient treatments for cocaine addiction to date. Funded by NIDA, the study involved 487 clients and the efforts of dozens of researchers at five clinical sites.

Clinicians treating addictions often feel that cocaine dependence is difficult to treat, relative to other chemical dependencies. Many factors contribute to the challenge of treating cocaine addiction. First, "crack," the fast-food version of cocaine is relatively inexpensive and easily accessible, at least in urban areas, which has led to an increase in cocaine addicts. Second, addicts who enter treatment usually attend sessions sporadically because of their intense psychological craving and resulting impulsive and compulsive drug-using behavior. Often a rapid progression of the addiction and consequently a rapid loss of the healthier supports which anchor their lives leave them few resources to aid their recovery. Also, cocaine is highly psychotoxic and often causes substance-related depression. This can work in the clinician's favor if the patient recognizes how low they feel and decides that they want to stop using drugs. Frequently, however, addicts use the depression as a sort of "smokescreen," viewing the depression as the "real" problem and denying the magnitude of the cocaine problem. Clients may try to "fix" this depression by using more cocaine, which leads to a vicious cycle of using drugs to escape from the pain of using drugs.

Research into cocaine addiction can help clinicians better meet the challenge of treating it. Findings from the latest study offer a lot of valuable clinical information for those in the field treating cocaine addiction.

Within the last year, results were published of a large multicenter investigation, the Collaborative Cocaine Treatment Study (CCTS) (Crits-Cristoph, Siqueland, Blaine, et al., 1997; Crits-Cristoph, Siqueland, Blaine, et al., 1999). This study, the largest clinical trial comparing different treatments for cocaine addiction to date, examined the efficacy of four psychosocial (non-pharmacological) treatments for cocaine dependence. The research was methodologically rigorous and thoughtfully undertaken.

The National Institute on Drug Abuse (NIDA) supported study involved a patient sample of 487 adult, male and female, white and minority patients at five clinical sites. Patients were recruited from 1994 through 1996.

• The University of Pennsylvania Medical School, Philadelphia, Pennsylvania
• Western Psychiatric Institute and Clinic at the University of Pittsburgh Medical Center,Pittsburgh, Pennsylvania
• Massachusetts General Hospital, Boston
• McLean Hospital, Belmont, Massachusetts
• Brookside Hospital, Nashua, New Hampshire

The 487 clients were randomly assigned to one of four manual-guided treatments:

• individual drug counseling (IDC) plus group drug counseling (GDC)
• cognitive therapy (CT) plus GDC
• supportive-expressive (SE) therapy plus GDC
• GDC alone

The duration of the treatment was six months, with follow-up booster sessions for three additional months. Individual sessions of 45 minutes were offered twice a week for the first three months decreasing to once a week for the second three months of the program. Group sessions of 1 1/2 hours were provided once a week throughout the six-month program. Observed urine samples were obtained weekly, for both clinical and research purposes, although limited patient compliance with this aspect of the program made it a less valuable intervention than it was intended to be.

Participants were recruited from advertisements in newspapers, fliers, or on local cable TV; referrals from substance-abuse treatment centers, mental health centers, and private mental health providers; and referrals by a friend or acquaintance. The inclusion criteria were a principal diagnosis of DSM-IV cocaine dependence (current or in early partial remission), having used cocaine within the last 30 days, and aged 18 to 60 years.

Participants in our sample were:

• 76.8 percent male
• 57.9 percent Caucasian
• 39.8 percent African-American
• 2.2 percent Hispanic

The average age was 33.9 years old. Most patients (69.9 percent) lived alone and 60.4 percent were employed. The average level of education was 13 years. There were demographic differences from site to site that corresponded to the population demographics of the area.

The most common mode of cocaine ingestion was smoking crack (79.0 percent), with 18.9 percent using intranasally and 2.1 percent using intravenously. At treatment entry the clients used cocaine an average of 10.4 days a month and had been using for an average of 6.9 years. Alcohol and marijuana use were also prevalent. Thirty-three percent of patients were alcohol dependent and 17 percent abused marijuana. In instances where the patient had two or more drug addictions, they were included only if cocaine was considered to be the primary addiction. Our thinking was that if someone's primary addiction were to alcohol, for example, they would be more appropriately treated in a program that focused on this drug. Individuals who were concurrently opiate dependent were excluded from this study, the rationale being that they required a program that could offer opiate detoxification and/or methadone maintenance in addition to cocaine treatment.

In general, the sample had low levels of psychiatric symptoms. This is probably due in part to the study criteria that excluded patients with psychotic or bipolar disorders, or who needed antidepressant medication. Also, since the study offered outpatient treatment, those patients whose psychiatric symptoms were severe enough that it appeared they would be better treated in the hospital often tended to choose to leave our program. When this happened, study staff helped them to find treatment that was more appropriate for their needs.

The low level of psychiatric symptoms is consistent with what is found in outpatient cocaine treatment generally, but it may have made it impossible for us to examine whether patients with higher psychiatric severity would benefit more from psychotherapy than just drug counseling in addition to group drug counseling.

Individual Drug Counseling
(Mercer and Woody, 1999)

This modality is based on a widely used approach to the treatment of drug addiction. Originally, the intention in developing this model was to develop a treatment that was representative of what is used in the field of addiction treatment in community programs. Consequently, IDC relies heavily on 12-step philosophy, and encourages self-help participation. It is fairly similar to the Minnesota Model, which is based on traditional addiction counseling, but guided by a treatment manual. In this treatment research program, the IDC was limited to six months. It focuses primarily and directly on helping clients to achieve and maintain abstinence through encouraging behavioral changes and promoting 12-step ideology and participation.

Group Drug Counseling
(Daley, Mercer and Carpenter, in press)

Group counseling was very similar to individual addiction counseling in content, but delivered in a structured group format. Basically the treatment was designed to educate clients about the important concepts in addiction recovery, to strongly encourage participation in 12-step programs, and to provide a supportive group atmosphere in which members were encouraged to express feelings, discuss problems and learn to draw strength from one another. Group treatment was progressive. The first three-month phase was psychoeducational and topic-focused (e.g., understanding addiction and recovery, resisting social pressures to use substances, managing cravings and identifying relapse warning signs, etc.). The second three-month phase consisted of less structured discussion and problem solving of current issues or unique problems in recovery identified by the group members.

Supportive-Expressive
Psychodynamic Therapy
(Luborsky, 1984; Mark & Luborsky, 1992)

This is a psychodynamically oriented model of psychotherapy that has been used for general psychiatric problems and for opiate dependence (combined with drug counseling and methadone). For this study, it was modified specifically to treat cocaine dependence. In SE therapy for cocaine dependence the problems associated with cocaine use and its cessation are viewed in the context of an understanding of the patient's interpersonal and intrapsychic functioning. The core conflictual relationship theme provides the framework for this understanding. The patient's core conflictual relationship theme, defenses and views of self influence impede the patient in stopping drug use and dealing with the related problems. The therapist makes supportive and interpretive interventions to create new insights into these issues that interfere with the patient's recovery and other goals.

Cognitive Therapy
(Beck, Wright, Newman, & Liese, 1993).

Cognitive therapy for substance abuse is based on the assumption that substance-use disorders are related to individuals' maladaptive beliefs and related thought processes.

Cognitive therapy for substance abuse consists of five components:

1. collaboration
2. case conceptualization
3. structure
4. socialization to the cognitive model
5. the use of cognitive and behavioral techniques.

Among techniques used are Socratic questioning, advantages-disadvantages analysis, monitoring of drug-related beliefs, activity monitoring and scheduling, behavioral experiments and role-playing.

Family Educational Workshop

Although this was a study comparing individual treatments, we included a single multi-group family education program of two hours duration during the first month of treatment. This program encouraged family members to support the addict's participation in ongoing treatment, provided information about cocaine addiction, recovery, professional treatment, and self-help resources (for client and family).

Training and Supervision

Extensive attention was paid to the selection, training and ongoing supervision of the therapists and counselors in the project. First, therapists and counselors came to the project already having considerable experience in their areas of expertise. The individual and group drug counselors already had extensive experience treating substance abusers, and some experience specifically with cocaine users. The SE and CT therapists had significant experience in their therapeutic approaches, but not necessarily extensive experience in treating chemical dependency.

Each treatment was guided by a manual. Therapists and counselors participated in four weekend training workshops and had four cases in the training phase of the study, which occurred during several years preceding the actual clinical trial. Therapists and counselors were evaluated on their adherence to the model and their competence with the approach, and only those who were rated highly were allowed to continue in the main study. Several therapists were asked to leave the study due to their inability to achieve the desired level of competence required. Throughout the study, therapists and counselors received ongoing supervision of their audiotaped (videotaped for group) sessions. The purpose of such careful training and ongoing supervision is to ensure that the treatments are implemented as intended (so that one is really studying the treatments one wants to study) and that the treatments are clearly differentiable from each other (which they were). The use of treatment manuals, extensive training and supervision reduces the differences between individual therapists, which are a problem when your goal is to compare different models of treatment — not different therapists.

The primary aim of this study was to compare short and long-term efficacy and client acceptance of treatment for cocaine dependence. The main outcome or dependent variable was cocaine use, which was assessed from results of urine drug tests and data gathered from the Addiction Severity Index interview (ASI) and a weekly cocaine inventory. The ASI is a structured interview assessing past and current (past 30 days) drug and alcohol use, medical status, employment status, legal status, psychiatric status, and family/social relationships related to substance use (McLellan et al. 1992). The weekly cocaine use inventory gathered information on how many times cocaine or other drugs were used the past week, how much money the addict spent on cocaine during the last week, and the method of administration of drug use.

Outcome data showed that all four study treatments (IDC+GDC, CT+GDC, SE+GDC, or GDC) significantly decreased drug use from baseline to 12 month follow-up. Cocaine use in the past 30 days improved from a mean of 10.4 days (out of 30) to 3.4 days (out of 30), which is a 67.3 percent reduction in cocaine use. Statistical analyses of all the study data found that the combination of IDC+GDC was significantly better than the other study treatments. Statistical analyses also found that there were no significant differences between CT+GDC, SE+GDC, or GDC alone. Clients receiving IDC+GDC had the best outcomes in terms of percent of clients with consecutive clean urines and percent who were abstinent at the 12-month follow-up period. Results also showed that clients who completed treatment did better than those who dropped out early.

• Cocaine use at six and 12 months:
   Sixty percent of clients who received IDC+GDC were abstinent from cocaine at the six- and 12-month follow-up period. This compares favorably to six- and 12-month abstinence rates for clients receiving CT+GDC (42 percent and 54 percent), GDC alone (48 percent and 53 percent), or SE+GDC (50 percent and 52 percent).
• Consecutive clean urines for one and four months:
   Seventy percent of IDC clients from the entire treatment sample, including those who dropped out of treatment or received very few sessions, had at least one month, and 24 percent had at least four months of consecutive clean urines. This compares favorably to the other treatments whose consecutive clean urines for one and four months were as follows: SE 60 percent (one month) and 12 percent (four months); GDC 57 percent (one month) and 21 percent (four months), and CT 53 percent (one month) and 16 percent (four months).
• Alcohol use:
   Outcome data showed significant reductions in alcohol use as well among all four treatment conditions. Six-month follow-up data indicates that both GDC and CT clients' ASI alcohol composite score decreased by 66.7 percent, SE clients' score decreased by 61 percent and IDC clientsÕ score decreased by 59.5 percent. This is an important finding given the high rate of alcohol abuse and dependence among clients who have cocaine problems.
• Other outcome variables:
   Although substance use is the primary outcome in studies such as this one, other outcomes of interest include adherence to treatment, treatment completion, psychiatric symptoms and other areas of psychosocial functioning. This study examined many other variables in addition to cocaine and other substance use.
   Attendance at treatment sessions and retention in treatment have been identified as important factors contributing to positive outcome in the treatment of drug dependence (Onken, Blaine & Boren, 1997), alcoholism (Carroll, 1997), and substance abuse combined with psychiatric disorders (Daley & Zuckoff, 1999). In the sections that follow, we discuss study findings related to session attendance, retention and dropout.
• Treatment session attendance:
   While IDC showed better results in terms of reduction of cocaine use at six- and 12-month follow-up, clients receiving CT or SE attended significant more individual and total treatment sessions during the active study period. IDC clients averaged 20.5 total sessions (11.9 individual + 8.6 group) sessions compared to 24.5 for CT (15.5 individual + 9.5 group) and 23.5 for SE (15.7 individual + 8.8 group) for SE clients. Clients assigned to the GDC alone treatment condition attended an average of 8.6 sessions. Overall, clients attended about one-third or slightly more of the total possible sessions offered.
• Treatment drop-out:
   CT and SE retained clients in the study better than IDC, both in terms of length of time spent in treatment and total number of sessions attended. The average time until 50 percent of clients dropped out of treatment was 46 days for IDC, 56 days for GDC, 72 days for SE and 77 days for CT.
• Reasons for early termination of treatment:
   Interviews were conducted with clients who did not complete treatment in an effort to find out specific reasons for their early termination. The "Reasons for Early Termination" form was used to interview clients about 19 specific reasons for ending treatment as well as elicit other reasons for quitting. In addition, clients were asked the relative degree of influence of each of these reasons on their decision to quit treatment. An overall review of responses of 272 clients who ended treatment early found the following reasons for drop out (clients could identify more than one reason for early termination). In percentages:
  
  • 47.8 time problems
  • 29.8 using drugs again and wanting to continue using
  • 21.3 group sessions were of no help
  • 20.6 problems improved
  • 18.8 wanted a different treatment
  • 17.3 unwilling to participate in treatment
  • 16.9 transportation problems
  • 12.5 individual treatment sessions were of no help
  • 12.1 needed hospitalization
  • 11.0 research forms were a bother
  • 10.3 didn't like group treatment
  • 8.5 moved from the area
  • 8.1 babysitter problems
  • 7.4 individual treatment was different that what they hoped for
  • 6.3 individual therapist bothered the client
  • 5.1 group therapist bothered the client

As this list shows, there are a multiplicity of factors related to the client's motivation (e.g. unwilling to participate in treatment), relationship with individual or group therapist (e.g., bothered by the therapist), type of therapy received (e.g., don't like their therapy or prefer another type of treatment), clinical status (e.g., relapse or need for hospitalization), and practical problems (e.g., transportation or babysitting) that impact on early treatment dropout. In addition, some clients dropped out because they improved and felt they no longer needed treatment. The drug abuse literature generally shows that three months or more in outpatient treatment is needed for any positive effect (Onken & Blaine, 1990; Daley & Zuckoff, 1999). Our findings suggest there may be a small subgroup of clients who benefit from short-term involvement in ambulatory treatment. However, at this point we would not recommend a course of outpatient drug-abuse treatment for less than a minimum of three months.

Group treatments are commonly used in outpatient and aftercare settings to treat drug dependence. While our study found that group treatment does help clients improve in terms of substance use and other symptoms or problems, it also shows that a sizable minority of clients do not like group treatments or find them of little or no help. As group supervisors, we viewed and rated hundreds of group treatment sessions and had numerous supervisory sessions with group therapists. While we strongly believe group is an important component of treatment for addiction, we think that many clients need more than group and benefit from individual sessions as well. One of the authors has talked with over a thousand clients with substance-use disorders and consulted with several treatment programs around the country which involved interviewing clients as well as staff as part of quality improvement efforts. One consistent complaint of a substantial percentage of these clients was that treatment programs (inpatient, partial hospital, outpatient and aftercare) relied too heavily on group treatments and did not provide any, or provided insufficient, individual treatment. The results of this current study show that clients receiving the combination of IDC+GDC do better than those receiving group alone. Clearly, individual treatment is both beneficial and necessary for many cocaine addicted clients.

Clients receiving IDC were much less likely to drop out of treatment if they relapsed or wanted to use again compared to those in other treatments. While only 16.4 percent of IDC clients identified relapse as a reason they quit treatment, 30.7 percent of GDC clients, 31.3 percent of CT clients, and 44.1 percent of SE clients identified relapse as a reason for early termination from treatment. Stated another way, SE clients who used again or wanted to use again were 2.7 times more likely to drop out early from treatment compared to IDC clients. This suggests that IDC helps clients who have relapsed or are struggling with strong desires to use drugs remain in treatment. Second, 25.4 percent of IDC clients identified "problems improved" as a reason for early termination. This compares to 16.4 percent of CT clients and 18.7 percent of GDC clients. This suggests that some clients feel they need much less treatment than what is actually offered in a treatment program. Third, only 6 percent of IDC clients identified the need for hospitalization as a reason for dropping out of treatment compared to 17.9 percent of CT clients. Fourth, only 16.4 percent of clients receiving IDC identified group sessions as not being helpful as a reason for dropping out of treatment, compared to 22.4 percent of clients receiving CT and 29.3 percent receiving GDC alone. This suggests that group treatment alone, which often is the treatment of choice in many outpatient and aftercare treatment programs, does not meet the needs of a significant minority of clients, and that those clients who only receive group are at higher risk for early termination from treatment.

• Psychiatric symptoms and psychosocial functioning:
   The Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Hamilton Depression Scale (HAM-D), Inventory of Interpersonal Problems (IIP), and the Addiction Severity Index (ASI) were used regularly to gather data. Follow-up data was compared to baseline data among all subjects, including those who did not start or complete treatment (an intent-to-treat analysis was used that included all study subjects, regardless of the amount of treatment that they actually received; this strategy prevents study results from being inflated, which can occur when dropouts are not included in the analysis of study data). These instruments helped to ascertain changes in symptoms and functioning over time. Results of the BAI, BDI, HAM-D, IIP, and the ASI psychiatric composite score all showed improvements from baseline to 6 month follow-up among all four treatment conditions. The average BAI scores decreased from 33 percent (SE) to 49.8 percent (GDC only), BDI scores decreased from 28.6 percent (CT) to 56.9 percent (IDC), HAM-D scores decreased from 18.4 percent (GDC alone) to 30.2 percent (IDC), IIP scores decreased from 22.7 percent (GDC alone) to 28.4 percent (CT), and ASI psychiatric composite scores decreased from 16.7 percent (GDC alone) to 45 percent (CT). These findings suggest that therapies designed specifically for cocaine dependence also reduce general psychiatric symptoms, including specific symptoms of depression and anxiety. Of all the study treatments, IDC appears to have the largest impact on reduction of depressive symptoms. This may be because IDC patients had greater success in reducing their drug use and patients who abstain from substances or reduce their use generally show improved mood as well. In addition, patients often have a sense of achievement associated with reducing or eliminating their drug use and generally feel good about this.
   Our study population generally had low levels of psychiatric severity so it is possible that more severely depressed or anxious clients would not benefit similarly from these kinds of addiction treatments and would probably need other treatment as well (e.g., pharmacotherapy and/or psychotherapy that is integrated and addresses both addiction and psychiatric problems).
• Therapeutic Alliance:
   The working alliance the client has with the therapist or counselor is often thought to be an important factor in treatment that significantly influences the success of the treatment. Some research has shown that patients in treatment for depression who feel they have a more positive therapeutic alliance early in therapy (around session 2 or 3) tend to have better treatment outcomes. In the present study, therapeutic alliance was assessed by the California Psychotherapy Alliance Scale and the Helping Alliance Questionnaire. Administered at session 2, these instruments revealed equally high ratings across the three individual conditions and no differences between the conditions. It was not surprising that these highly skilled therapists and counselors were good at establishing a positive therapeutic alliance with their clients. We wondered whether if the therapist-client similarities that clients sometimes believe are important really impacted on their experience of the alliance with their therapist or on drug use outcome. Interestingly, we found no evidence that for the IDC condition, minority counselors had better outcomes with minority clients or that recovering counselors had better outcomes. There were also no differences in the clients' ratings of therapeutic alliance for recovering counselors or racially similar counselors. Our ability to examine this issue was limited because only the individual and group drug counseling conditions had a significant number of minority and recovering counselors.

The results of the present study suggest a number of conclusions that may be of use to practitioners in the field and particularly those designing addiction treatment programs.

1. Although many scientists and practitioners would like to have an effective pharmacological treatment for cocaine dependence, we should recognize that psychosocial treatments such as IDC and GDC are reasonably successful. Psycho-social treatments have a critical role in addiction treatment and they probably will continue to do so, even if an effective medication is developed that can be used in combination with counseling.
2. A combination of group and individual treatment may be optimal for many clients. Our study showed that individual and group was superior to group alone. This is important because group is the primary and often sole modality for treatment in many substance-abuse programs.
3. Addiction counseling, employing both group and individual modalities together, may be the most effective approach for many people. In this study, it was found to be superior to cognitive therapy and psychodynamically oriented therapy for reduction of drug use and it was less expensive to provide, as well.
4. One reason we think drug counseling was more successful than the other models is that a direct, behavioral approach is particularly helpful at least in the early stages of addiction recovery. Drug addiction is, a problem that involves many destructive behaviors. It is possible that other types of therapy could be beneficial in later stages of recovery, after the addict has established abstinence and made lifestyle changes needed to support this abstinence.
5. We further hypothesize that 12-step philosophy and participation is an important component in recovery for many people. We think that 12-step ideas and participation were more integrated into and encouraged by the drug counseling (both individual and group) than the cognitive or psychodynamic psychotherapies. Also, addicts tend to gain more from AA, NA or CA when they "participate" actively rather than simply attend meetings.
6. We continue to think that a positive therapeutic alliance is an important factor in addiction treatment, although this study did not provide much evidence for this. In this study, there was not enough range in the quality of therapeutic alliance to observe this because all the counselors and therapists established and maintained good therapeutic alliances with their clients. We assume this was because they were carefully selected, highly experienced, further trained and received ongoing supervision which stands in contrast to what really occurs in the field.
7. Related to the above point, we believe all the careful training and ongoing supervision that was part of this study enhanced the quality of the drug counseling. It may be that traditional drug counseling can be very effective, but only when supported by good clinical supervision and opportunities for ongoing education.
8. We must remember that addiction is a debilitating, chronic and relapsing disease, causing many problems for the individual, family and society. Similar to other chronic diseases or disorders, it requires ongoing management by the affected individual. Professional treatment is one way of starting this process. We continue to believe that combining treatment with self-help programs is the best approach for addicts in recovery.

Dennis C. Daley, MSW, is Associate Professor of Psychiatry
and Chief of Alcohol and Drug Services at the University of Pittsburgh Medical Center Pittsburgh, PA. Delinda Mercer, PhD, is Instructor in Psychiatry at the Center for Psychotherapy Research and Veterans Administration Medical Center, Philadelphia, PA.

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