1. Cognitive Behavioral Therapy and Naltrexone for Cocaine Dependence Joy M. Schmitz, Ph.D. Substance Abuse Research Center University of Texas Medical School Houston Supported by NIDA (DA-09262, DA-6143, DA-15801) APA 2004

2. Why Combine Behavior Therapy and Medication?  For the treatment of cocaine dependence, little benefit from pharmacotherapy or psychotherapy alone  Each form of treatment may address distinct symptom areas, providing broader coverage  Offset the potential drawbacks associated with either treatment  Patient heterogeneity leads to differential response to treatment

4. Study Design Pharmacotherapy (Naltrexone) 0 mg 50 mg Psycho- Therapy Drug Counseling (DC) Relapse Prevention (RP)

5. Pharmacotherapy  Naltrexone Opiate antagonists attenuate cocaine's euphoric effects (Bain & Kornetsky, 1986; Kosten et al., 1992; Hubbell & Reid, 1995; Reid et al., 1993; 1996) Opiate antagonists decrease cocaine self-administration (DeVry et al., 1989; Mello et al., 1990; Ramsey & vanRee, 1991; Corrigall & Coen, 1991; Reid et al., 1995; 1996; 1997) Opiate antagonist treatment associated with lower rates of cocaine use (Kosten et al., 1989; Rosen & Kosten, 1991)

6. Psychotherapy  Relapse Prevention (RP) Coping Skills Relapse Prevention Theory (Marlatt & Gordon, 1985) Components include functional analysis of situational factors associated with craving or drug use, self- monitoring and specific home practice exercises, general lifestyle modifications, handling a lapse training.  Drug Counseling (DC) General education, nondirective support, encouragement for abstinence-oriented behaviors (Woody et al., 1983; Luborsky et al., 1982) Components include assessment of problem areas (e.g., health, family, vocation), education about recovery, crisis management.

7. Therapy Adherence

9. Retention Log Rank Statistic = 1.72, df = 3, p =.63.

10. Cocaine Use Therapy x Medication x Time: F (2, 60) = 3.69, p < 0.03. *

11. Does homework compliance predict outcome?  Cognitive-behavioral psychotherapies are based on the premise that clients are more likely to improve if they apply skills learned in treatment to situations outside treatment (i.e., homework).  The relationship between homework compliance and treatment outcome is reliable and robust across different client problems (Kazantzis et al., 2002).

12. CBT Homework Examples:  Self-monitoring  Trigger sheet  Recognizing assertiveness  Goal setting  Coping records  Awareness of problem thinking

13. Motivation and homework completion on cocaine use during treatment High motivation Low motivation

14. Conclusions  In cocaine-dependent patients, the combination of naltrexone 50 mg and Relapse Prevention therapy was effective in reducing cocaine use.  Treatment integrity measures showed evidence of therapy adherence and discriminability.  For CBT, a positive relationship between homework compliance and cocaine outcome was found. Motivation to change affected the direction of this relationship.  Need to replicate and extend to determine the robustness of this treatment.

15. Naltrexone Studies  Naltrexone and relapse prevention treatment for cocaine-dependent patients  Naltrexone and relapse prevention treatment for cocaine-alcohol dependent patients

16. Study Design Pharmacotherapy (Naltrexone) 0 mg 50 mg Psycho- Therapy Drug Counseling (DC) Relapse Prevention (RP)

17. TABLE 1 Characteristics of Participants in Each Treatment Group a Attended at least six weeks of treatment.

18. Retention Log Rank (df = 3) = 3.62, ns.

19. Cocaine Use Time x Therapy F (11, 332) = 2.09, p < 0.02.

20. Conclusions  Naltrexone did not reduce cocaine or alcohol use in this sample of dually-dependent patients.  Patients receiving Drug Counseling used less cocaine over time than those receiving Relapse Prevention.  Naltrexone’s lack of efficacy in treating this type of comorbidity, also reported by Hersh et al., 1998, may be due to greater impairment in this population.

21. Combined Treatment for Cocaine-Alcohol Dependence R01 DA15801 Pharmacotherapy (Naltrexone) 0 mg 100 mg Behavior Therapy Relapse Prevention (RP) RP + Conting. Manag. Proc

22. Results: % cocaine abstinent Ss Pettinati et al, 2004 Men Women

23. Conclusions  Among cocaine dependent patients: Naltrexone 50mg reduced cocaine use was well tolerated worked best with CBT  Among cocaine-alcohol dependent patients: Naltrexone 50 mg ineffective with/without CBT

24. Future Considerations  Optimal dosing  Combination pharmacotherapy  Relapse prevention vs abstinence initiation  Enhancing compliance, increasing motivation  Patients’ conceptualization of behavior therapy + medication

25. Treatment expectancies