Changes concurrent with initiation of abstinence from cocaine abuse

Spiritual Self-Schema Therapy, Drug Abuse, and HIV

This case report describes the use of Spiritual Self-Schema (3-S) therapy in the treatment of an HIV-positive inner-city drug user maintained on methadone and referred for additional treatment due to unremitting cocaine use. 3-S therapy is a manual-guided intervention based on cognitive self-schema theory. Its goal is to help the patient create, elaborate, and make accessible a cognitive schema--the "spiritual" self-schema-that is incompatible with drug use and other HIV risk behaviors. 3-S therapy facilitates a cognitive shift from the habitual activation of the "addict" self-schema, with its drug-related cognitions, scripts and action plans, to the "spiritual" self-schema, with its associated repertoire of harm reduction beliefs and behaviors.

A path analysis of cognitive, affective, and behavioral predictors of treatment response in a methadone maintenance program

PURPOSE

Continued illicit drug use by opioid-dependent patients maintained on methadone is a serious problem, undermining the goal of methadone maintenance treatment and increasing the risk for HIV. The current study employed structural equation modeling (SEM) to examine cognitive, affective, and behavioral predictors of treatment response during the first 12 weeks of methadone maintenance treatment.

METHODS

302 opioid-dependent individuals (72% male; 28% female) entering a methadone maintenance program (MMP) were provided with a comprehensive intake assessment. Heroin and cocaine use were assessed using twice weekly urine toxicology screens. The model accounted for 37 percent of the variance in abstinence from illicit opiates and 38 percent of the variance in abstinence from cocaine.

RESULTS

Continued heroin use while maintained on methadone was predicted by pre-treatment severity of addiction and by strength of self-identity as an "addict." Cocaine use was predicted by pre-treatment severity of addiction, low self-efficacy, lack of negative affect, and strength of self-schema. The strongest predictor of abstinence from both heroin and cocaine was attendance at the adjunctive manual-guided psychosocial group interventions.

IMPLICATIONS

Implications for treatment are discussed.

"Self" and addiction: the role of imagery in self-regulation

In this paper we discuss the role of self-regulation and self-perception in sustaining addictive behavior. We suggest that self-regulation techniques are unlikely to have a sustained positive effect on changing addictive behavior in the absence of a change in "addict" self-perception. We describe treatment approaches that emphasize the use of guided imagery for facilitating a shift in self-perception that may be more compatible with self-regulation.

Activation of memory circuits during cue-elicited cocaine craving

Evidence accumulated over more than 45 years has indicated that environmental stimuli can induce craving for drugs of abuse in individuals who have addictive disorders. However, the brain mechanisms that subserve such craving have not been elucidated. Here a positron emission tomographic study shows increased glucose metabolism in cortical and limbic regions implicated in several forms of memory when human volunteers who abuse cocaine are exposed to drug-related stimuli. Correlations of metabolic increases in the dorsolateral prefrontal cortex, medial temporal lobe (amygdala), and cerebellum with self-reports of craving suggest that a distributed neural network, which integrates emotional and cognitive aspects of memory, links environmental cues with cocaine craving.

Differences between responders and nonresponders to cocaine cues in the laboratory

Previous research has shown that a majority of drug-dependent subjects respond to drug cues in the laboratory with increased craving; however, approximately one-third are not cue responsive. The current study examined differences between responders and nonresponders to cocaine cues in a sample of 69 cocaine-dependent methadone patients. Subjects completed questionnaires assessing selected dimensions of addiction and participated in a cue-reactivity protocol that assessed both cocaine craving and cocaine aversion in response to cues. Four groups of subjects were identified on the basis of their cue responses: (a) increased craving plus decreased aversion; (b) increasing craving only; (c) decreased aversion only; (d) no increase in craving and no decrease in aversion ("nonresponders"). No group differences were found in severity of cocaine dependence, depression, or on any demographic variable, with the exception of parental status. Group differences were found on measures of cocaine expectancies and self-efficacy. There is a discussion of the bearing of these findings upon explanations offered in the literature for nonreactivity to drug cues.

Cue-elicited cocaine craving and autogenic relaxation. Association with treatment outcome

Prior to entering a pharmacotherapy trial for the treatment of cocaine dependence, 19 patients participated in a pretreatment cue-reactivity protocol that concluded with a relaxation exercise. Measures included self-reported craving and skin conductance level (SCL). Post hoc exploratory analyses suggest that neither craving nor change in SCL in response to cocaine cues differentiated patients who subsequently achieved abstinence from those who did not. Craving following the relaxation procedure did differentiate the two groups: patients who subsequently initiated abstinence in treatment reported a reduction in cue-elicited craving to below baseline levels; craving reported by patients who did not successfully complete treatment remained elevated.

Cocaine abuse in methadone maintenance programs: integrating pharmacotherapy with psychosocial interventions

Cocaine abuse by methadone-maintained patients threatens to undermine the success of methadone programs by sustaining a drug-abusing lifestyle as well as contributing to the spread of HIV. The search for a pharmacotherapeutic agent for the treatment of cocaine has met with limited success. The most promising results emerge when specific agents, such as desipramine, are matched appropriately to specific patient characteristics, such as depression or antisocial personality disorder. For some patients, abstinence from cocaine may also require the addition of intensive psychosocial treatments that target the considerable problems faced by inner-city opioid-addicted individuals. This article discusses ways in which future research could be directed toward investigating the interaction between psychosocial services and pharmacologic treatments, while at the same time developing and testing hypotheses concerning appropriate patient-treatment matching variables.