Chapter 6
Treatment and Recovery

Cocaine treatment and recovery is a controversial issue for several reasons, all of which focus on the validity and effectiveness of various methods. The debate centers on questions such as whether addicts can really break their dependency on cocaine and whether any of the current therapies available to addicts has a high enough success rate to justify the $3.2 billion that the federal government annually spends on a variety of therapies.

Still, most American political and community leaders agree that cocaine and crack addicts who seek help should get it. The debate centers on determining the best strategy for curing the addict. This debate prompted the General Accounting Office (GAO) of the federal government to investigate the effectiveness of various therapies. In 1996 the GAO published the results of a lengthy study focused on cocaine that concluded that no one was sure exactly how much good therapy was doing:

Although studies conducted over nearly 3 decades consistently show that treatment reduces drug use and crime, current data collection techniques do not allow accurate measurement of the extent to which treatment reduces the use of illicit drugs. Furthermore, research literature has not yet yielded definitive evidence to identify which approaches work best for specific groups of drug abusers.³⁶

The conclusion of the GAO report that the best therapeutic approaches have not yet been identified prompted many specialists working in the field of drug rehabilitation to argue that no single therapy can be identified as being the best for all addicts and that the best strategy is for the addict and his or her therapist to explore several therapies. Experts have also concluded that whichever therapies are applied, the addict must understand that there are no short-term solutions to the complexities of addiction.

Recovery Is a Long-Term Commitment

Not only is there little agreement on which therapies work best, but even the goal of therapy is open to debate. One of the early lessons learned by therapists was that recovery from cocaine and crack addiction is more complicated than simple abstinence. Recovery, many experts say, is often a long-term process characterized by alternating periods of abstinence and use. In many cases, addicts may reduce cocaine consumption but never achieve complete abstinence.

How much therapy is needed has also been questioned. The initial belief that permanent recovery would quickly follow a week or two of abstinence proved incorrect. Studies have consistently shown that the minimum amount of time required to gain even minimal control over cocaine addiction is three months. Any period of therapy that lasted less than three months met with negligible success. The same studies have also confirmed that as treatment time increases, success rates also increase.

Harm Reduction

A growing number of health-care professionals, after many years of experience, have adopted the view that some cocaine and crack users cannot be expected to end their drug use. Although this view is in conflict with principles of recovery therapy that assert that addicts can recover given enough time and different types of therapy, the popularity of the policy of harm reduction is growing.

Harm reductionists believe that the primary goal of the war on cocaine and crack should not be to eliminate their use or to arrest all users but rather to reduce the harm that the drugs cause. The harm reductionists also believe that chronic cocaine and crack users constitute a public health problem rather than a law enforcement problem.

Harm reductionists believe that those who can be persuaded to stop using the drugs should be, and that those who cannot be stopped should be encouraged to use cocaine and crack more safely. To that end, harm reductionists favor expanding the availability of needle-exchange programs and safe crack houses for IV cocaine and crack users, and establishing maintenance programs that provide addicts with a daily dose of the drug. Harm reductionists also attempt to avoid making moral judgments about cocaine and crack users while encouraging more tolerant public attitudes.

Harm reductionists have drawn sharp criticism, accused of blindness to the tremendous harm to innocent friends and family caused by cocaine and crack addiction. There is little hard evidence that harm reduction makes life easier for the families and friends of cocaine and crack users. Critics also believe that harm reductionists make too little effort to intervene between addicts and their drugs to force them to address the personal problems that cause their addictions.

During the first three months of therapy, the primary focus is to produce initial withdrawal from cocaine as well as nutritional and emotional stabilization. Studies suggest that patients who are able to abstain from cocaine use for at least three weeks during the first three-month period improve their probability of being cocaine free one year later. Those who are able to abstain for the entire three months have a significantly better chance, although very few are able to abstain for three months.

The first three months is just a start. How long therapy must continue to achieve what can be termed success is difficult to predict. Interviews with addicts who complete therapy suggest some predictors of success. The three advantages that appear to contribute to the best results are full-time employment, education, and a stable childhood. Psychologists believe that these factors are predictors of success because each contributes to a positive and nurturing environment for the addict. Consequently, addicts who have none of the three often start and stop therapy many times over many years without ever conquering their habit.

Addicted individuals may require prolonged treatment and multiple episodes of treatment to achieve long-term abstinence and to restore their ability to function in society. Many therapists now believe that therapy must be continued on a regular basis for at least one year to achieve long-term abstinence and, for some addicts, therapy may need to continue for the remainder of their lives.

With the understanding that therapy will last a long time, the next issue for the therapist to consider is the type or types of therapies that best suit the addict.

The Cycle of Cocaine Addiction

Drug abuse therapists have identified what they believe to be a consistent and predictable cycle of cocaine addiction. The therapists at Narconon International, a drug abuse rehabilitation center in Los Angeles, specialize in cocaine and crack addiction. Their Narconon website, posts an electronic brochure that summarizes the following six steps in the cycle of addiction:

1. The life cycle of addiction begins with a problem, discomfort, or some form of emotional or physical pain a person is experiencing. The situation appears to have no healthy solution.
2. This person tries cocaine or some other drug to ease the discomfort. Initially, the cocaine appears to solve the problem and it gains value as an apparent cure.
3. The person uses it repeatedly with the same curative effect. Getting more of the drug now becomes more important than solving the problem that first prompted the cocaine use. Now the person is trapped.
4. The user now must conceal his or her use from friends and family members. Lies and self-deception about possible addiction leads to guilt and withdrawal from others and a life of isolation begins.
5. Cocaine becomes the user's only friend. Nothing has a higher priority than guaranteeing a steady supply of cocaine. Schoolwork or job performance suffers and gradually the user either quits or is dismissed. Crime commonly begins as a means to pay for drugs.
6. In addition to the embarrassment of the downhill slide and unethical behavior, the person's body now craves cocaine. The user is now obsessed with getting and using this drug, and will do anything to avoid the pain of withdrawal. The ability to get "high" decreases as the user's body adapts to the cocaine. He or she must take more and more in this downward spiral. The invisible line of addiction has been crossed and the person is now a cocaine addict.

The Strategy of Multiple Therapies

Cocaine and crack addiction is a complex problem, so it is perhaps not surprising that therapy is equally complex and requires multiple strategies. The multiple therapy approach usually begins with a form of individual therapy called psychotherapy in which addicts discuss problems from their past that may have played a role in their addiction. After a few weeks or months, cognitive therapy might begin, which focuses on teaching patients to generate positive thoughts about themselves, their personal strengths, and their ability to quit cocaine. Next, a behavioral approach might be used to improve daily function and positive activities such as finding a job, associating with drug-free friends, and avoiding old hangouts associated with drug use. Finally, several sessions of group therapy involving several people sharing their experiences with cocaine recovery might be recommended. Counselors hope that after exposure to a mix of therapies each patient will have found valuable tools to aid his or her recovery.

Dr. Jack Blaine, of NIDA's Division of Treatment Research and Development, notes in reference to the multiple-therapy strategy, "These results underline the valuable role of well-designed drug counseling in treating drug abuse. More specifically, this study demonstrates the effectiveness that combined counseling therapies can have in treating cocaine addiction."³⁷

As an individual's treatment progresses, the addict's situation must be assessed continually and treatment modified as necessary to ensure that the therapy meets the person's changing needs. For many patients, alternating from one strategy to another in a prescribed sequence assists the addict in abstaining from cocaine use. To successfully time therapy changes, the therapist looks for the moment the patient is in need of new motivation to introduce the next strategy. It is always considered better to slow down and work at a pace that is comfortable and productive for a particular individual than to change strategies too quickly.

The wide variety of cocaine treatment and recovery therapies in use today collectively produce a recovery rate of somewhere between 15 and 25 percent, depending upon which agencies are reporting the results. When they develop their strategies, therapists draw on a variety of individual therapies, group therapies, and medication therapies and create a treatment plan tailored to a particular addict's needs.

Individual Treatments

Individual treatments are, as the name implies, therapy sessions in which one therapist works with only one patient at a time. Individual therapies usually include behavioral therapies that offer people strategies for coping with their drug cravings, teaching them ways to avoid drugs, preventing relapse, and helping them deal with relapse if it occurs. The three most common approaches are psychotherapy, behavioral, and cognitive.

According to Dr. Lewis R. Wolberg, psychotherapy is

the treatment, by psychological means, of problems of an emotional nature in which a trained person deliberately establishes a professional relationship with the patient with the object of (1) removing, modifying, or retarding existing symptoms, (2) mediating disturbed patterns of behavior, and (3) promoting positive personality growth and development.³⁸

As applied to the treatment of cocaine addiction, psychotherapy typically involves an addict discussing his or her emotional and behavioral problems with the therapist. The objective is twofold: to achieve an understanding of the causes of the addiction and to change the addict's thoughts, feelings, and behavior. Generally, the patient does most of the talking and is always encouraged to discuss dreams and memories of childhood experiences.

Like psychotherapy, behavioral therapy focuses on the behavior that is causing the addiction, but unlike psychotherapy, it does not involve discussing childhood experiences. Instead, the objective of behavior therapy is to focus on observable everyday behavior and on techniques to change maladaptive habits. Change takes place within the addict by techniques such as relaxation, curing phobias that may in part be related to the addiction, and the use of aversion therapy that inflicts various forms of discomfort when the patient behaves the wrong way.

Cognitive therapy focuses on changing addicts' thoughts about themselves and their addictions. The objective is to rid them of unreasonably negative thoughts about themselves and to replace those thoughts with positive ones. Very often cocaine addicts harbor distorted or irrational thoughts that must be corrected before addiction can be cured. Examples are thinking that minor setbacks are catastrophic, that their lives are worse than any other person's, and that everyone else is smarter and happier. Once patients realize that such extreme irrational thinking is flawed, healing can take place.

The use of individual therapies has its detractors. Regardless of their record of success for some people, the cost of long-term one-on-one therapy is high. Over a long period of time, these costs are beyond the reach of most Americans, especially the poor, who have been so harmed by the crack epidemic.

Group Therapy

Typically, the recovering addict participates in group therapy in addition to individual sessions with a therapist. Most cocaine therapists believe that at times in the recovery process addicts can learn valuable lessons from other recovering addicts. Groups generally consist of from three or four up to ten or fifteen addicts who are supervised by one therapist. Within the group setting, each addict has the opportunity not only to see how others deal with problems of addiction but to receive support and encouragement from other group members.

Group therapy sessions provide addicts with an opportunity to have their assumptions and excuses for their addictions challenged by their peers. This type of confrontational dialogue forces each member to maintain a high level of honesty with other group members. Whenever members believe that someone is lying or refusing to accept responsibility for his or her failures, they collectively challenge the person's comments and defenses. When this is done in a responsible manner, the confrontation forces the person to rethink whatever he or she said. In theory, addicts in this way can reach clearer insight into their behavior.

Under certain circumstances, group therapy may involve family and friends of the addict. Called intervention therapy, this treatment is generally used to motivate a cocaine addict to seek help or to take his or her addiction more seriously by forcing a confrontation with people who have the closest emotional ties with the addict. The theory behind intervention therapy is that family and friends can often motivate an addict more effectively than strangers can. Intervention therapy also educates the addict's family and friends about the problems of addiction and how to cope with the problems an addict may encounter while in therapy, such as loss of self-confidence, difficulty with communication, and feelings of guilt.

Medications

Although not commonly prescribed, for some patients medications are more effective than behavioral therapies. Two different types of medication are available. One causes intense discomfort if mixed with cocaine, and the other is used to help reduce the painful withdrawal symptoms and cravings during the first few weeks of abstinence.

Medications that create discomfort when mixed with cocaine are intended to deter addicts from using cocaine. The most common of these aversive drugs are Naltrexone and Clonindine. By themselves the medications are benign, but in combination with cocaine they elicit intense nausea and uncontrolled vomiting. Called aversion therapy because its goal is to create in the addict an aversion to the drug, the long-term goal is for the addict to abstain from using cocaine even though the benign medication that causes the nausea is no longer in his or her system.

The success of aversion therapy depends on the patient's compliance in taking the medication as prescribed. The pitfall, not surprisingly, is that some patients who crave the rush and euphoria of cocaine will stop taking the aversion drug because they simply want to enjoy their drug. Consequently, success with aversion therapy often requires that therapists monitor patients to ensure they are regularly taking their medicine.

A second medicinal therapy uses antidepressants such as Desipramine to control the depression that accompanies withdrawal from cocaine. The object of the medication is simply to reduce the pain of withdrawal and the likelihood that the addict will relapse. When this therapy works, doctors will gradually reduce the use of the antidepressant as the withdrawal symptoms lessen until none is needed.

Hope for the Future

Researchers at the Salk Institute in San Diego, California, are developing an entirely new approach for combating cocaine addiction called immunotherapy. Although it is still in the research stages, this approach involves using compounds that immunize addicts against the effects of cocaine. Immunotherapy aims to destroy the cocaine before it has any chance of reaching the brain in the first place. In essence, these compounds would work on cocaine the way antibodies do on microorganisms, rendering them harmless before they can reach the brain.

The lead investigator at the Salk Institute, Dr. Kim D. Janda, says, "We have created a new scientific approach for potential treatment of cocaine abuse and maybe drug abuse in general. We see a great deal of promise in this immunotherapy approach to drug treatment." 39 Dr. Donald Landry of Columbia University also sees promise for immunotherapy:

Even if a cocaine blocker does not prevent every bit of the drug from reaching a user's brain, it may still act against addiction by blunting the intensity of the drug's high. The rush of smoking a large dose of crack might be reduced to the less overwhelming level of snorting a few milligrams of powdered cocaine. And that difference could be enough to start addicts on the road to recovery.⁴⁰

In addition to medical research, many educational programs in schools, religious institutions, and clinics have had success deterring youngsters from using cocaine and other drugs. Many of the educational tools used in schools to discourage teenagers from using cocaine focus on a person's willpower or character strengths. The best deterrent to cocaine addiction, they propose, is for people to make choices that avoid contact with cocaine and cocaine users. Studies indicate that high school students actively involved in school sports, student government, honor societies, and church and community programs have a dramatically lower incidence of cocaine use than students who are uninvolved. Of greater significance, studies show that students involved in many activities rarely try cocaine—they have no interest. These studies lend support to the view that avoiding cocaine and addiction is a matter of being willing to make the right choices rather that being unable to do so.

Clinical studies of reformed cocaine addicts also show that if recovering cocaine addicts have meaningful activities in their lives such as jobs, families and friends, and spiritual affiliations, their chances of recovery increase. These studies, like those of high school students, support the view that it is a willingness to make the right choices that steers people clear of cocaine.