Pharmacological Adjuncts for Use in Smoking Cessation

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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
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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

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

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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.

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Therapy Adherence
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Retention
Log Rank Statistic 1.72, df 3, p .63.
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Cocaine Use

Therapy x Medication x Time F (2, 60) 3.69, p
lt 0.03.
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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).

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CBT Homework

• Examples
• Self-monitoring
• Trigger sheet
• Recognizing assertiveness
• Goal setting
• Coping records
• Awareness of problem thinking

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Motivation and homework completion on cocaine use
during treatment
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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.

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Naltrexone Studies

• Naltrexone and relapse prevention treatment for
  cocaine-dependent patients
• Naltrexone and relapse prevention treatment for
  cocaine-alcohol dependent patients

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Study Design
Pharmacotherapy (Naltrexone)
50 mg
0 mg
Drug Counseling (DC)
Psycho- Therapy
Relapse Prevention (RP)
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TABLE 1 Characteristics of Participants in Each
Treatment Group  
  a Attended at least six weeks of treatment.
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Retention
Log Rank (df 3) 3.62, ns.
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Cocaine Use
Time x Therapy F (11, 332) 2.09, p lt 0.02.
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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.
• Naltrexones 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.

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Combined Treatment for Cocaine-Alcohol
Dependence R01 DA15801
Pharmacotherapy (Naltrexone)
100 mg
0 mg
Relapse Prevention (RP)
Behavior Therapy
RP Conting. Manag. Proc
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Results cocaine abstinent Ss
Pettinati et al, 2004
Men
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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

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Future Considerations

• Optimal dosing
• Combination pharmacotherapy
• Relapse prevention vs abstinence initiation
• Enhancing compliance, increasing motivation
• Patients conceptualization of behavior therapy
  medication

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Treatment expectancies