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QUESTION: In patients with cocaine dependence, how effective are psychosocial treatments?
5 university and hospital sites in the US.
487 patients between 18 and 60 years of age (mean age 34 y, 77% men) with a principal diagnosis of DSM-IV cocaine dependence and who had used cocaine in the previous 30 days. Exclusion criteria included unstable living arrangements, opioid or polysubstance dependence, dementia, psychotic symptoms, unstable medical illness, and suicide or homicide risk. 83% of patients completed the 9 or 12 month follow up assessment.
Patients were allocated to 1 of 4 manual guided treatments: (1) individual drug counselling plus group drug counselling (IDC + GDC) (n=121); (2) cognitive therapy plus GDC (CT + GDC) (n=119); (3) supportive expressive therapy plus GDC (SE + GDC) (n=124); or (4) GDC alone (n=123). Treatment lasted for 6 months.
Main outcome measures
Primary outcome measures were change in the Addiction Severity Index-Drug Use Composite score and the number of days of cocaine use in the previous month.
The analysis was by intention to treat. Patients assigned to IDC + GDC showed the greatest improvement on the Addiction Severity Index-Drug Use Composite score compared with those assigned to the 2 psychotherapies (p=0.006) or to GDC alone (p=0.009). IDC + GDC was also superior to the 2 psychotherapies on the number of days of cocaine use in the previous month (p=0.002). More patients assigned to IDC + GDC achieved and maintained abstinence (table).
Individual drug counselling plus group drug counselling was effective in patients with cocaine dependence.
The Collaborative Cocaine Treatment Study (CCTS) is well designed and has implications for matching patients to different psychosocial treatments.
The CCTS results of differential effectiveness of one psychosocial treatment in cocaine dependency are in contrast with findings of other recent trials which found either no differences among psychosocial treatments1–3 or differential effectiveness for cognitive behavioural treatment.4 The heterogeneous results are consistent with clinically distinct subgroups of cocaine dependent patients who respond to specialised treatment methods.1, 4, 5 The problem that clinicians now face is the defining characteristics for the different subgroups have not been firmly established. In addition, the patient matching results from the methadone maintenance studies do not generalise to cocaine dependency.
The manual based group and individual abstinence oriented drug counselling used in the CCTS could be expected to provide effective treatment for a limited number of cocaine dependent patients that fit the study's exclusion criteria. Other clinically relevant exclusions that were not noted in the abstract are bipolar I disorder, legally mandated treatment, pending incarceration, and use of psychotropic medication.
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