Other Substance Abuse

The majority of cocaine-dependent individuals abuse other substances as well; approximately 60 percent are also alcohol dependent, and about 30 percent are marijuana dependent. Many others use such substances but do not meet dependence criteria. Since concurrent drug use may influence outcome, any effective treatment for cocaine dependence must address other forms of substance abuse. This chapter provides a general approach to concurrent use of substances other than cocaine and a more detailed approach to handling alcohol and marijuana problems.

CRA + Vouchers recommends but does not require simultaneous cessation of all abused substances as a condition of treatment.(This chapter does not address concurrent abuse of cocaine and opioids, although vouchers are effective with this population (Silverman et al.1996) as is an adaptation of CRA + Vouchers (Bickel et al. 1997). Cigarette smoking cessation is currently not a treatment goal despite the high usage (over 70 percent) in the cocaine-dependent population. However, that policy may change if it turns out that quitting smoking does not interfere with, or perhaps enhances, cocaine abstinence.) The philosophy of this approach is to, first and foremost, provide patients with treatment for the specific problem for which they are seeking help - cocaine dependence. Many patients do not consider alcohol or other drug use a problem, or may acknowledge it as a problem but express no desire to change. In general, therapists work toward sustaining and strengthening the patients' efforts to resolve their cocaine problem while, at the same time, trying to motivate them to abstain from use of other substances.

Treatment Goals

Therapists should be clear in their recommendations regarding the benefits of abstinence but should adopt a flexible approach toward patients' use of alcohol and drugs other than cocaine. Dwelling on abstinence issues that patients are not interested in may lead to early dropout. Similarly, overemphasis on other drug use can lead to an adversarial or confrontational relationship between patients and therapists that can interfere with effective treatment for cocaine problems.

Also, patients who express no interest in abstaining from other substances during the early stages of treatment may change their minds later.

• They may find that they cannot achieve their goal of cocaine abstinence while continuing to use other drugs.
• Their success with cocaine abstinence may be reinforcing and, in turn, may lead them to try abstaining from other substances.
• They may find that the negative consequences they hoped to avoid by giving up cocaine continue because of their drinking or other drug use, leading them to increase attempts to abstain in order to avoid these consequences. Similarly, other drug use may interfere with patients' ability to meet their lifestyle change goals because of hangovers, low energy levels, or too little time for positive social activities.
• The use of other substances may result in new negative consequences, such as an arrest for driving while intoxicated or possession of marijuana, which change the patients' interest in eliminating other drug use.

A small minority of patients can make progress in discontinuing cocaine use despite using other substances. Therapists can continue to advise total abstinence while accepting the fact that therapeutic goals cannot be dictated to patients. Instead, therapists can engage them in treatment around the issues where there is therapist-patient agreement and attempt to work from there to facilitate more wide-ranging therapeutic changes in the future.

Abstinence

While maintaining a flexible stance toward other drug use, therapists should continue to strive for patient abstinence from alcohol and other drugs. Laboratory research has shown that alcohol, even at relatively low doses, can increase preference for cocaine use over nondrug activities (Higgins et al. 1996). Other drugs may do the same by increasing the reinforcing effects of cocaine, placing patients in closer proximity to cocaine, or directly interfering with the skills needed to successfully avoid cocaine use.

• Patients who stop cocaine use but continue regular use of other substances are likely to remain in a cocaine-using environment within the same social network. This would make it difficult for them to engage in new social activities.
• If patients are abusing other substances, the consequences of that use may prevent them from developing the stable lifestyle that is important to maintaining cocaine abstinence. For example, if patients are getting drunk frequently, it is unlikely that their family relationships will improve, that they will maintain stable employment, or that they will have the time or energy to engage in regular activities unrelated to alcohol abuse.

Reduced Use

Many cocaine-abusing patients are not interested in stopping their use of other drugs or alcohol, even after being given good reasons for doing so. For those patients, the next alternative is to try to set reduction and safe-use goals for the other substances. If patients are willing to work on these reduced use goals, therapists can help them set appropriate goals and teach them self-control skills to increase their ability to achieve those goals. Abstinence from all illicit drug and alcohol use is recommended; however, with patients who refuse that goal, therapists should seek to facilitate at least some movement in a therapeutic direction.

No Intervention

For patients who also refuse reduction goals, therapists should proceed by targeting cocaine only, while monitoring use of other substances. Continue to counsel these patients toward abstinence and reduction goals but, if they refuse, do not provoke a confrontation or discontinue treating their cocaine dependence.

Alcohol is the substance most commonly used or abused in combination with cocaine. Many patients report that they almost always drink alcohol either before, during, or after cocaine use (Higgins et al. 1994c).

• Alcohol is their primary drug of choice.
• They like the high associated with the combination.
• Alcohol helps them counteract cocaine-induced anxiety.
• Alcohol helps relax them.
• Alcohol makes them more sociable.

Some patients report that they do not drink very often and that alcohol is not a problem. Others say they only drink when they use cocaine, whereas some report that they only use cocaine when they drink. Because of this high incidence of alcohol use associated with cocaine dependence, disulfiram therapy is included as a component of CRA + Vouchers.

The general strategy for dealing with alcohol use is as follows.

• If patients meet criteria for alcohol abuse or dependence, strongly recommend abstinence and encourage them to agree to monitored disulfiram therapy. Also focus on behavioral strategies targeted to abstinence.
• If patients do not meet criteria for alcohol abuse or dependence but a positive relationship exists between their alcohol and cocaine use, recommend abstinence with monitored disulfiram therapy and behavioral strategies.
• If patients will not agree to abstinence as a goal, encourage them to reduce drinking and restrict it to safe circumstances. Ask them to agree to a backup contract which states that they will initiate disulfiram therapy if they cannot meet their limited drinking goals.
• Patients should not be discharged or terminated because they refuse to cease or reduce alcohol use or are unable to meet alcohol-related goals.

Abstinence

A combination of behavioral interventions and monitored disulfiram therapy should be provided to patients who agree to set abstinence goals. The behavioral interventions used for cocaine abstinence have been successfully applied to alcohol abstinence; the voucher program is generally not used. The disulfiram procedures should be used with all patients who agree to take this medication.

What Is Disulfiram?

Disulfiram, often sold as Antabuse, is an alcohol-deterrent medication that inhibits the liver enzyme aldehyde dehydrogenase, which assists in the breakdown of acetaldehyde, the major alcohol metabolite (Fuller 1995). Consuming alcohol while disulfiram is in the body causes an accumulation of acetaldehyde, which produces an unpleasant physical reaction. Symptoms can include flushing, rapid or irregular heartbeat, dizziness, nausea, vomiting, difficulty breathing, and headache. This reaction can be medically dangerous, especially in individuals with certain preexisting health conditions. Thus, the medication is available only by prescription, and disulfiram therapy can only be used in collaboration with a physician.

Medical Oversight

The disulfiram protocol must be administered under medical supervision. If a clinic physician is unavailable, disulfiram therapy must be handled by a referral to the patient's family physician or, preferably, by a community physician who is informed about substance abuse and the utility of disulfiram therapy.

It is prudent to work out, in advance, with one or more community physicians, a protocol that facilitates referral, workup, and initiation of disulfiram therapy. Before the first dose of disulfiram is given, it is essential that medical personnel determine the patient's baseline meas-ures. Patients are then monitored regularly for any serious deviations from their normal state.

Disulfiram Protocol

The following disulfiram protocol has two elements. First, therapists must educate appropriate patients about disulfiram therapy. If patients are interested in trying disulfiram therapy, then plans to support medication compliance are developed. (The procedures discussed here were adapted from Sisson and Azrin 1989.) Therapists should discuss disulfiram with appropriate patients early in the treatment process.

Introduce Disulfiram

The topic of disulfiram therapy can be raised with appropriate patients in the manner described below.

• Bring up the topic of alcohol use. Review the patients' history of alcohol-related problems, using information obtained in the intake assessment. During this interaction, elicit patient feedback and confirmation.
• Recommend that patients consider disulfiram therapy and give the rationale for doing so. Find out what the patients know about disulfiram. If they have sufficient knowledge about disulfiram, acknowledge that and offer a brief review. If they are unfamiliar with disulfiram, then request a few minutes to explain.

  "Disulfiram comes in a pill that looks like an aspirin. If you take it daily, it usually has no effect on you, unless if you drink alcohol. If you drink alcohol for up to 14 days after taking disulfiram, you will get sick. Disulfiram can help you refuse to drink because you know alcohol will make you sick. It works by preventing the alcohol you drink from being properly processed in your body. Usually, the alcohol is digested or processed by different enzymes which break it down into a form your body can tolerate. Disulfiram prevents this from happening, which results in your feeling sick."

  "If you drink when you are taking disulfiram regularly, you will start to feel sick in about 5 minutes. You will flush, become nauseous and sweaty, and your heart rate will speed up. This reaction depends on how much you drink. The more you drink, the worse the reaction gets. If you continue to drink, or drink a large amount at once, such as four or five beers or shots, you will probably vomit and feel like you might faint."

  "Because disulfiram's effects can last up to 2 weeks after taking the last pill, it can really help individuals who have mixed feelings about drinking or who tend to drink impulsively. If you were to feel like drinking one day just out of the blue, or for some specific reason, disulfiram can give you a reason not to drink. It also can buy you some time to change your mind again before you do decide to drink."

  "Disulfiram therapy also gives you a way to seek help or advice before you decide to drink again. In disulfiram therapy, we can involve another person in your life to assist you in taking disulfiram at home. You can take your disulfiram at our clinic on the days you come for urinalysis testing. If you feel like drinking, you will want to stop taking your disulfiram, and you will have to discuss this with someone. You can talk about what you are feeling and perhaps find another way to deal with whatever causes you to want to drink."

• Explain the importance of alcohol abstinence. Do not use the term alcoholic. Explain that while alcohol may not be a major problem, it may interfere with their efforts to stop cocaine use. Describe what has been learned about the adverse effects of drinking on cocaine use, that is, that even modest amounts of alcohol can increase cocaine use. Discuss the benefits of disulfiram.
  • Taking disulfiram assures those around you that you're not drinking and that you have made a strong commitment to abstain from alcohol and cocaine use.
  • Disulfiram may help your family or friends trust and work with you.

Compliance Procedures

Those patients who are interested in trying disulfiram therapy should review and sign the consent form (exhibit 29) and meet with the supervising physician to obtain medical clearance. When everything is approved, patients should be given written information to take home about the disulfiram protocol. A booklet, "Disulfiram Guidelines," is available free from Wyeth-Ayerst Laboratories. If this is used, therapists could then have patients take the disulfiram quiz and complete the medical ID card that comes with the booklet.

The following disulfiram assurance procedures are recommended when an appropriate spouse or significant other is available.

• Show the patients (and their partners, if present) what disulfiram looks like. Demonstrate how you would like them to take the disulfiram. Crush it in a ceramic cup and mix it with some warm water. Add a few ounces of juice, stir it, and have the patients drink it.
• Provide encouragement and support if patients have difficulty deciding to drink the disulfiram. Once patients have ingested the medication, offer praise (and instruct the partner, if one is participating, to do so as well). Therapists can make positive statements like: "That was a big step"
• You should feel proud of making such a commitment" or just "Congratulations on making a new start."
• After drinking the disulfiram, it is important for therapists, patients, and partners to take some time to work out the logistics of the compliance procedures.
  • Instruct patients and partners that disulfiram will be taken at the clinic on urinalysis-test days and clinic staff will be their compliance partner. Also, let patients know that the disulfiram prescription will be kept at the clinic, and each time they come to treatment, they will take disulfiram and receive the appropriate number of doses to be taken at home.
  • Decide on a time and place to take disulfiram daily when it is taken at home. Suggest times such as before going to bed, before dinner, before breakfast, or at lunch. Try to find a regularly occurring event that can be paired with disulfiram ingestion.
  • Discuss the importance of reinforcing disulfiram ingestion. Discuss a reciprocal contract in which patients agree to take the disulfiram and partners agree to do something to reinforce compliance, such as verbal praise, which is the simplest form of reinforcement. Emphasize to partners that reminding patients of the importance of disulfiram can help with compliance.
• Complete the Disulfiram Contract (exhibit 30); indicate the time of administration, number of days it is in force, place of administration, and nature of reinforcement provided in response to taking the disulfiram.
• Therapists should then discuss potential problems, that is, under what circumstances might patients feel like drinking and not taking their disulfiram. Preface this with an acknowledgment that this is sometimes hard to talk about but is normal and to be expected. Discuss ways that significant others can help support disulfiram therapy. Also ask patients how they would like clinic staff and significant others to respond if they want to discontinue disulfiram. Remind them again that disulfiram will stay in the system for up to 2 weeks and that they cannot drink during that period.
• Next, engage patients and partners in role-playing on how to handle common problems. If no partner is involved, therapists and patients should role-play the patients' refusal to take the disulfiram. If a partner is involved, training and instruction in positive communication techniques should be used to help with appropriate responses to a decision to discontinue disulfiram. During role-play, therapists should model effective responses for the partner.

  "I know this is difficult for you and that you are under a lot of stress, but since you have been taking disulfiram and not drinking or using cocaine, we have gotten along so much better. I really like being around you when you're not high or drunk. Is there something I can do to help you, so we can keep things the way they are since you stopped drinking? Perhaps we could go to the movies, or you could go out and exercise? It would make me feel so much better if you took your disulfiram."

  Therapists should have patients and partners practice until each one feels comfortable in making effective responses.

• Therapists should also facilitate a behavioral rehearsal on what to do when partners do not want to be part of this procedure any longer. Using modeling and constructive feedback, therapists and partners should role-play possible scenarios in which the partners refuse to participate in the disulfiram plan. This may occur because patients have used cocaine or couples have had an argument. Therapists should instruct patients to still take the disulfiram in front of their partners, even if the partners refuse to participate.
• Therapists should instruct patients and partners to call the clinic promptly any time either of them does not wish to participate in the disulfiram therapy.
• Congratulate patients on taking a big step toward successful resolution of their alcohol and cocaine problem.
• Complete the therapist's disulfiram checklist (exhibit 31).

Limited Alcohol Use/Safe Drinking

Goals for reducing alcohol use and restricting use to safe environments can be set with patients who refuse an abstinence goal. Therapists can help patients develop reasonable goals and teach patients self-control strategies to achieve them. Miller and Munoz's (1982) text, "How to Control Your Drinking," contains a detailed description of the protocol.

Examples of typical goals and the clinical strategies that can be used are -

• Limit the amount of alcohol consumed on any given day.
• Limit the number of days in which alcohol is consumed.
• Limit drinking to safe environments (e.g., only in the home, with spouse present, only at restaurants when accompanied by partner).

Strategies to help achieve these goals include -

• Stimulus-control training.
• Drink substitution.
• Drink-refusal skills.
• Self-monitoring and significant-other monitoring.
• Contingency contracting.

Patients who are unable to meet their reduction goals can be encouraged to set abstinence goals and initiate disulfiram therapy. Obtaining a backup contract can facilitate the transition to an abstinence goal. If patients continue to refuse to set an abstinence goal after failing with their limited drinking goals, continue to work with and counsel them toward abstinence.

Patients Who Hesitate or Refuse

The goal with patients who at first refuse disulfiram is to motivate them to at least sample it for some specified time, perhaps only for a week or a few days. Begin by requesting that they take disulfiram for the entire treatment period but negotiate from there as necessary.

"How about 30 days? Give us 30 days of no drinking by taking disulfiram so we have at least a month to work with you without alcohol being a problem. This way you will be able to focus more on making the lifestyle changes that are important to stopping cocaine use. This doesn't mean that you can never drink again. It just means that you eliminate alcohol from your life for a period of time so it does not interfere with your goal of staying off cocaine."

Patients may refuse or hesitate because they want to succeed on their own or by willpower. If this is the case, let patients know that by taking disulfiram they are doing it on their own.

"You are the one who has to take the pill. You are the one actively doing something to stop cocaine use and drinking. I think you are doing it the smart way - you are taking steps to control the problem before any more difficulties occur. You are not just talking about it, you're taking action."

Another approach is to ask partners how disulfiram therapy would make them feel. Have them tell the patients directly and in a positive manner why they feel that way and the potential benefits they see in disulfiram therapy. If patients still refuse, suggest that it is going to be more difficult to achieve a successful outcome without disulfiram. However, do not push. Use clinical judgment to ensure that patients do not drop out of treatment. Remember, patients are seeking help for cocaine dependence, not alcohol. If patients are adamant, relax and move on to another topic.

Backup Agreement

For patients who do not agree to take disulfiram, try to obtain a Backup Disulfiram Agreement (exhibit 32). This agreement should clearly state that patients will take disulfiram if drinking remains a problem or cocaine use occurs in a drinking context. Here you must work closely with any partner who is involved, so that all parties understand the agreement. If patients agree to this, have them sign the written agreement.

If patients do not agree to sign a Backup Disulfiram Agreement, therapists should move on and not dwell on this issue. If alcohol use continues to be a problem, the suggestion of disulfiram therapy should be raised and discussed with patients in a supportive and caring manner on a regular basis.

Marijuana use, like alcohol use, is common among persons presenting for treatment of cocaine dependence. Common reasons given for the use of marijuana by cocaine abusers are similar to those given for alcohol use: enjoy the high, counteract cocaine-induced anxiety, relieve cocaine-induced depression, and as a substitute when cocaine is scarce. There are large individual differences in the frequency and pattern of marijuana use among patients. As with alcohol, staff should assess and make recommendations based on whether marijuana use seems to be related to cocaine use, not on whether patients meet criteria for abuse or dependence. Consideration should also be given to how marijuana use might interfere with other lifestyle change goals. Marijuana use has rarely been observed to be a direct antecedent of cocaine use.

Some individuals can use marijuana regularly without adversely affecting cocaine abstinence (Budney et al. 1991, 1996). Not surprisingly, many patients are not interested in discounting marijuana use. Nevertheless, abstinence from marijuana is recommended for all patients.

The general strategy for dealing with marijuana use is as follows.

• Recommend abstinence and offer to assist patients in applying the strategies targeting cocaine use for marijuana abstinence as well.
• If patients refuse abstinence as a goal, encourage them to reduce their use through the various treatment strategies used for cocaine and alcohol use.
• Never discharge or terminate patients because they refuse to cease or reduce marijuana use or are unable to meet marijuana-related goals.

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