One-Year Follow-Up After Multimodal Inpatient Treatment
for Cocaine and Methamphetamine Dependencies
| Original Contribution | |
| P. JOSEPH FRAWLEY, MD*, JAMES W. SMITH, MD† *Schick Shadel Hospital of Santa Barbara, California; †Schick Shadel Hospital of Seattle, Washington |
|
| Journal of Substance Abuse Treatment, Vol. 7, pp. 77-82, 1990 | 0740-5472/92 $5.00 + .00 |
| Printed in the USA. All rights reserved. | Copyright © 1988 Pergamon Press Ltd. |
Abstract- Of a randomly selected sample of 214 patients treated with aversion therapy for cocaine dependence in four chemical dependency units operated by Schick Shadel Hospitals, 156 were followed up 12 to 20 months post-treatment (average 15.2 months). Significant other validation was obtained in 33%. Total abstinence from cocaine for the group overall was 53% at one year post-treatment, and current abstinence of at least 6 months at follow-up was 68.6%. Those treating with aversion for cocaine alone had a one-year abstinence of 39% and a current abstinence of 62.4%. Those treating with aversion for alcohol and cocaine had a one-year total abstinence from cocaine of 69% and a current abstinence of 76%. Those treating with aversion for cocaine and marijuana had a one-year total abstinence from cocaine of 50% and a current abstinence of 65%. Those treating with aversion for alcohol, cocaine, and marijuana had a one-year total abstinence from cocaine of 73% and a current abstinence of 73%. One-year total abstinence from alcohol was 54% for those receiving aversion for both alcohol and cocaine and 77% for those receiving aversion for alcohol, cocaine, and marijuana. Current abstinence from alcohol at follow-up was 68% and 81%, respectively. One-year total abstinence from marijuana was 42% for those treating with aversion for cocaine and marijuana and 64% for those treating with aversion for alcohol, cocaine, and marijuana. Current abstinence at follow-up from marijuana was 61% and 81%, respectively. The use of aversion therapy for both alcohol and cocaine in alcoholics who were also using cocaine was associated with higher total abstinence rates (88% vs. 55%) from cocaine when compared with alcoholics who used cocaine but received no aversion as part of their program. The conclusion is tentative since the follow-up rate in this study was lower than that of the previous study (64% vs. 84%). Being around other users accounted for 49% of relapse situations. Family/Work stress was associated with relapse in 33% of cases and unpleasant feelings in 24% of cases. The use of both reinforcement treatments and the use of support following treatment were associated with improved abstinence rates from cocaine. Those patients who reported losing all urges for cocaine after treatment had a total abstinence from cocaine of 90%, those who reported losing all the uncontrollable urges had a total abstinence of 64%, and those who reported still having the urge reported only 33% total abstinence from cocaine.
Keywords-cocaine dependence; aversion therapy; treatment outcome; methamphetamine dependence.
INTRODUCTION
BEGINNING IN THE EARLY 1970s, cocaine use and dependence have risen in the United States (Mittleman & Wetli, 1984). Treatment of cocaine dependence has focused on traditional chemical dependency approaches, neurobehavioral approaches, pharmacologic approaches, and others (Rawson, Obert, McCann, & Mann, 1986; Smith, 1986; Kleber & Gawin, 1984a; Gawin et al., 1989a; 0'Brien et al., 1988; Washton, 1986).
The Schick Shadel hospitals have provided treatment for alcoholism for over 55 years, using chemical and faradic aversion therapy (Voegtlin & Broz, 1949; Smith & Frawley, 1990). Chemical aversion therapy has been used for cocaine dependence (Frawley & Smith, 1989) and for marijuana dependence as well (Morakinyo, 1983). Faradic aversion therapy has been used for alcohol (Jackson & Smith, 1978; Cannon, Baker, & Wehl, 1981), marijuana (Smith, Schmeling, & Knowles, 1988), and heroin (Copeman, 1976). This study reports the results of utilizing aversion therapy as part of a multimodal treatment program for cocaine dependence in patients admitted to four private treatment programs operated by Schick Health Services.
METHODS Follow-Up Methodology
From those patients who completed at least the initial inpatient treatment for cocaine and/or methamphetamine dependence at four hospital-based Schick Shadel treatment programs, 214 patients were randomly selected. The patients entered treatment from May through November of 1987, and the follow-up was conducted from November 1988 through March 1989. Thus, patients had been out of treatment from 12 to 20 months. The average time for contact was 15.2 months.
It was predetermined that a sample of 214 patients would be selected at random and that every attempt would be made to reach each one. This random sample was selected in the following manner:
Using a table of random numbers, 214 two-digit numbers were selected. These randomly selected numbers were then matched to the last 2 digits of patient case numbers from the universe of patients who were eligible for inclusion in the study.
The 214 patients were systematically telephoned by trained interviewers of Facts Consolidated, an independent research firm, until all the patients had been reached, or until every possible means of reaching them had been exhausted. In cases in which pursuit of the interview would cause a breach of confidentiality, all further attempts to reach that patient were abandoned. This resulted in 125 patients who were interviewed and 89 patients who were not interviewed (58.4% phone contact rate). The protocol also called for a verification interview with a significant other in 33% of cases. All respondents were interviewed over the telephone, in person. Over 1700 actual phone calls were made to reach these 125 patients treating for cocaine/methamphetamine dependence.
The patient records were also reviewed for evidence of relapse following treatment. Thirty-one noncontacted patients who had treated for cocaine or methamphetamine dependence and who had a chart-documented relapse on cocaine, methamphetamine, or other drug for which the patient had sought treatment (e.g., alcohol or marijuana) were also included in the follow-up. This group of contacted (n = 125) and chart-documented relapse patients (n = 31) comprised a total of 156 individuals, or 72.9% of the total sample.
Statistical Methods. A sample size of 125, when selected in this manner, has a margin for statistical error of 8.93% at the .95 confidence level if it is a sample from a much larger universe. However, since the total universe consists of a finite number of 234, we have applied the Finite Population Correction Factor, and this reduces the error margin to plus or minus 4.18%.
Chi-squared analyses and two-tailed t tests were utilized to determine statistical significance. A Yates correction was used for chi-squared tests with 1 degree of freedom. A p value of .05 was considered to be statistically significant.
Patient Characteristics
Table 1 lists the demographics of the patients. The first column includes the patients with either phone follow-up or a chart-documented relapse. This is the group for which outcomes will be reported unless otherwise noted. The second column reports on those patients without any phone follow-up, but will include those who had chart-documented relapses.
The third column includes only those patients with neither phone follow-up not chart-documented relapse. Approximately 35% were married, 79% were employed, 80% were male, 66% were Caucasian, 64% were under 30 years of age, and 63% lived within 2 hours driving distance of the hospital. There were no significant differences between any of the three groups.
Table 2 lists the information from the drug histories for these patients. The mean Drug Abuse Severity Test Score (DAST) was 6.7 (SD = ± 2). This score indicates moderately severe drug-related problems (Skinner, 1982). On admission, 58% had cocaine in their urine, and 38% had marijuana in their urine; 22% had no drug found in their urine. Only 9.6% of patients used cocaine exclusively, 38.5% used two drugs (including alcohol), 35% used three drugs, and 19% used four or more drugs. Of the 59 patients also treating for alcohol dependence, 69% were daily drinkers and had an average of 8.9 (SD = ± 5.8) years of alcohol-related problems. Of the patients treating for stimulant dependence, 64% described job problems related to drug use, and 47% had marital discord related to drug use; 24% indicated that they had some physical damage from cocaine or methamphetamine. There were no statistically significant differences between the three groups.
Table 3 lists information on patterns of use. Of the 145 patients treating for cocaine dependence, 54.5% snorted cocaine (36.6% exclusively), 46.9% freebased cocaine (30.3% exclusively), and 17.9% used intravenous cocaine (11% exclusively). There were no statistically significant differences between the three groups, except for a greater percentage of exclusive snorters in the contacted group compared to the no phone follow-up group (p < .001) or the group with neither phone nor chart follow-up (p < .05). For the methamphetamine users, 76.9% snorted the drug, 7.7% smoked it, and 23.1% used it intravenously.
SUBJECTS
Those selected for interview were drawn from the universe of patients who had completed for the first time at least the first 10 days (post detoxification) increment of the inpatient alcoholism treatment program at Schick Shadel Hospital of Santa Barbara, California, during calendar year 1983. Only 3% of the patients admitted that year left the hospital prior to completing the initial 10 day treatment program. Another 2.5% were admitted for detoxification only. Neither group of patients were candidates for inclusion in this study.
The demographics of Schick Shadel Hospital patients have been described in detail elsewhere (Knowles, Smith, & Lemere, 1983). Demographic details of the subjects of the present study are shown in Table 1. In general, they resemble typical patients in other inpatient treatment programs for medically non-indigent persons (Weins & Menustik, 1983; Cordill & Associates, 1988; Moberg, 1978). The majority were males (73%) between the ages of 25 and 55 (79.5%) and were married (61%). Almost all had at least a high school education (93.5%). Most (60%) had at least some college education, and 23% had at least a bachelors degree. The majority (79%) were employed.
All subjects met the DSM-III criteria for alcohol dependence. History of other drug use over the 6 months prior to treatment was obtained (Table 2). Nearly 40% (39.6%) of the patients used some drug other than alcohol during the six months prior to treatment. This use was limited to one drug in 14.3% of cases, two drugs in 15.4% of cases, three drugs in 5.5% of cases, and four or more drugs in 3.8% of cases.
The types of other drugs used are shown in Table 3. Marijuana and cocaine were by far the most commonly used. They were each used by 25.8% of patients. In many cases the same patient used both drugs.
Of this sample, 65% reported no previous formalized treatment of their alcohol dependence prior to treatment at Schick Shadel Hospital, 13.8% had received previous inpatient treatment, 32.5% had received other formalized treatment, and 41.9% reported participation in the fellowship of alcoholics anonymous.
RESULTS
Of the 200 patients selected for the study, 160 were contacted during the survey. The minimum elapsed time since treatment was 13 months, and the maximum was 25 months (mean 20.5 months).
Information was obtained from these patients, with validating information from a significant other in 36% of cases. The information obtained included:
The rate of abstinence at 12 months, 13-25 months (mean 20.5 months), and current abstinence (last 6 months) is shown in Table 4. The contacted group (n = 160) comprised 80% of the 200 individuals selected for follow-up. They had a 12-month abstinence rate of 71.3%, a 13-25 month (mean 20.5 month) abstinence rate of 65.0%, and a current abstinent rate of 78.1%.
The group composed of contacted patients (n = 160) plus chart documented, relapsed, non-contacted patients (n = 22) numbered 182 individuals (91% of the selected sample of 200). They had a 12-month abstinence rate of 62.6%, a 13-25 month (mean 20.5 month) abstinent rate of 57.1%).
The total group of 200 individuals (100% sample) composed of contacted individuals (n = 160), chart documented relapsed, non-contacted patients (n = 22), and non-contacted patients without chart evidence of relapse (n = 18) had abstinence rates of 66.5% at 12 months and 61.5% at 13-25 months (mean 20.5 months).
Table 5 shows the patterns of alcohol consumption for the contacted group following treatment. It will be noted that a few patients had one drink, or part of a drink, either deliberately or accidentally, after treatment. Although these patients were not included in the total abstinence group, it can be reasonably concluded that they were successful in achieving their treatment goal.
THE TREATMENT PROGRAM
All patients received a complete addiction-focused medical history, physical examination, and laboratory tests, including a urine drug screen. Patients who required detoxification from alcohol were stabilized and off medication before they entered into treatment. The treatment phase lasted 11 to 16 days. Each patient gave informed consent regarding the treatment to be received and alternative treatment (or no treatment) before starting. The treatment consisted of aversion treatments for alcohol, cocaine, methamphetamine, and/or marijuana dependence as determined by the physician to be appropriate in each individual case. Five sodium pentothal treatments were usually given on alternate days from the aversion treatment (Smith, Lemere, & Dunn, 1971). In addition, daily educational groups that dealt with various aspects of addiction and recovery were offered in the morning and evening. Patients were exposed to information about specific groups that may be utilized following treatment (e.g., 12-step programs, hospital-sponsored peer or professionally led support groups, and church). Individual counseling was provided to address specific treatment issues such as denial, grief, assertion, resentments, development of a treatment plan, and aftercare planning. Where possible, family members came to the hospital for group education and individual counseling.
The Aversive Stimulus. The aversion therapy for alcohol and marijuana has been described elsewhere (Smith, 1982; Smith, Schmeling, & Knowles, 1988). The aversion therapy for cocaine is of two kinds. Chemical aversion may be used, in which the nausea caused by oral emetine is associated with the act of snorting the cocaine or methamphetamine (Frawley & Smith, 1990). As an alternative, faradic aversion may be used, which pairs an irritating, but not painful, electric stimulus to the forearm with the act of using, imaging, and preparing to use the cocaine or methamphetamine substitute. The type of procedure depends upon the use pattern of the patient and his or her medical condition. The procedure used for faradic aversion is similar to that used for alcohol treatment (Jackson, & Smith, 1978), nicotine dependence (Smith, 1988), or marijuana (Smith, Schmeling, & Knowles, 1988).
The Cocaine or Methamphetamine Substitute. No cocaine is actually utilized in the treatment, but instead a substitute is used that is similar in appearance and smell and has a numbing effect. In our experience, 2% tetracaine and 1% quinine in mannitol is an effective substitute for cocaine that is to be snorted. The freebase substitute utilized at the time of the study was either a type of white candy or a white soap which when burned created smoke. For intravenous simulation, a white powder was dissolved by the patient (as part of their standard ritual) and then taken up into a syringe through the needle. No cocaine substitute is actually injected. Instead, the liquid made from dissolving a white powder (D-xylose works best) is pushed out of the syringe just above the forearm where an injection would normally occur. A cocaine scent (Psychem (R), Old Factory, Inc., Atlanta, Georgia) is also applied to the fingers at the time of treatment in order to achieve the odor of "street cocaine" and enhance the association with their cocaine use experience.
A methamphetamine substitute was developed using 1% quinine in mannitol. (This does not burn the nose as much as real crystal methamphetamine does, but we have not yet found a better substitute).
Aversive Pairing. The process for chemical aversion for cocaine or methamphetamine consists of timing the onset of snorting the lines just prior to the onset of nausea. In the first treatment 18 lines may be snorted, while in the last treatment up to 50 lines may be snorted. The snorting continues until all the lines are used. (After the first 4 lines are snorted, the nose is well-numbed and plain mannitol is used for the rest of the lines until the last 4, when the tetracaine-containing substitute is again used.) Usually the patient receives five aversion treatments. However, when a patient is treated with chemical aversion for both alcohol and cocaine, the patient receives the first two aversion treatments for cocaine only, followed by four additional "divided" treatments using both alcohol and cocaine. These last four treatments involve aversion to alcohol in the first part of the session, and the second part focuses the aversion on cocaine. The procedure is discussed more fully elsewhere (Frawley & Smith, 1990).
The faradic aversion to cocaine is always carried out separately from aversion to any other drug. The process consists of pairing the aversive electric stimulus with each link in the chain of behaviors involved in the individual's use of cocaine (e.g., manipulating the paper packet containing the white powder, opening the packet, pouring the powder onto the mirror, cutting it up into lines and snorting the powder). This may include imagery involving the place of usage, actual stimuli associated with usage (e.g., paraphernalia.) Normally, a patient receives five aversion treatments for the cocaine and/or amphetamine dependence. When patients used both methamphetamine and cocaine, treatment addressed both drugs together. Faradic aversion was utilized with 42.3% of the cocaine "snorters," 90.9% of "freebasers," and 91.3% of intravenous users. Chemical aversion was utilized for 52.1 % of the cocaine "snorters," while 5.6% of "snorters," 9.1% of "freebasers" and 8.7% of intravenous users received both chemical and faradic aversion. The main reason for these variations was that two facilities were treating "snorters" primarily with chemical aversion and two other facilities were treating "snorters" with primarily faradic aversion. Nearly all "freebase" and "IV" users were started with faradic aversion. In a few cases patients were switched to the alternative treatment modality due to either medical concerns (e.g., chemical aversion inappropriate for a patient) or patient concerns (patient strongly felt that the alternative would be more effective for him or her). Patients treating for alcohol addiction also received five specific aversion treatments for alcohol (chemical or faradic), except as noted above when cocaine and alcohol were being simultaneously treated with chemical aversion. Those receiving aversion treatment for marijuana dependence received five faradic aversions (Smith, Schmeling, & Knowles, 1988.)
The aversion therapy is carried out in a small room which during cocaine or methamphetamine treatment has pictures of white powder or "crack" cocaine and cocaine paraphernalia against a black backdrop and/or actual paraphernalia and piles of white powder or "crack rocks" or methamphetamine substitute visible to the patient. The treatment is individualized to each patient and the individual manner in which he or she uses cocaine or methamphetamine. For example, the hospital has a variety of cocaine pipes from which patients may choose, so that the actual experience is as close as possible to what the patient would be doing at home. When possible, the patient is instructed to bring his or her own paraphernalia.
Table 4 summarizes the patients' patterns of alcohol or other drug dependence and the type of treatment received. Data is presented for those followed up by phone or with a chart documented relapse in one column and for those who had no phone follow-up in the second column. The third column contains data from patients with neither phone nor chart follow-up. There were no statistically significant differences between the type of aversive treatment given and the pattern of drug use between the follow-up groups.
Continuing Care. Patients were instructed to return to the hospital at 2 weeks and 6 weeks following their discharge from initial treatment to receive a reinforcement aversion to each of the drugs for which they had received aversion during the primary treatment, to receive one pentothal treatment, and to have their continuing care plan updated by the counseling staff. Such reinforcement activities have been associated with improved outcome and are strongly encouraged (Smith & Frawley, 1990; Weins & Menustik, 1983.) The aversion treatment provided at each reinforcement is similar to that which they received during the initial treatment. In addition, patients received periodic calls on a decreasing frequency schedule over a 2-year period following discharge (from the Schick Aftercare Department) to monitor patient's abstinence status and progress on the continuing care plan and to make any needed modifications. They also participate in a variety of support group activities, principally 12-step programs, weekly Schick Graduate groups, and/or their churches.
Results. Outcome data was principally focused on abstinence measures and on participation in follow-up activities.
Aftercare Activity Participation. Table 5 summarizes the data on completion of reinforcement treatments by each category of patient according to the drug (s) that was (were) treated with aversion. Also included are the utilization of support activity following treatment (based on those with phone follow-up only, since this information could not be obtained from non-contacted patients) during the period of being at risk for relapse. The period of risk is defined as the time prior to their first use of a drug for which they received treatment or, if there was no relapse, the whole follow-up period. The types of support utilized are reported separately. Also reported is whether or not the patient utilized any support at all after treatment (regardless of whether it was initiated before or after a relapse) and whether the patient was using any kind of support in the 3 months prior to follow-up.
This data shows that the majority of patients took both reinforcement treatments. Although over 57% of patients followed up by either chart or by phone took both reinforcements, only 40.4% of those with no phone follow-up took both (p < .05). In those with neither phone follow-up nor chart-documented relapse, the second reinforcement utilization of 48.3% is not statistically different from that of the group with either phone or chart-documented follow-up. The majority of patients with phone follow-up participated in support groups following treatment, with slightly more participating in 12-step groups than in hospital-sponsored groups. Over 40% were still participating in support groups at the time of follow-up over one year later.
Abstinence From Cocaine and Other Drugs. Table 6 summarizes the baseline data for different patterns of drug and alcohol problems. The Michigan Alcoholism Screening Test (MAST; Pokorny, Miller, & Kaplan, 1972) and the Missouri Alcoholism Severity Scale (MASS; Evenson, Reese, & Holland, 1982) indicate that those receiving aversion therapy for alcoholism had significant alcohol problems in contrast to those not receiving aversion therapy for alcoholism. Patients receiving aversion for cocaine and marijuana only were less likely to be married and were younger than patients in other groups. Patients treating for alcohol tended not to use as much cocaine on the average as those not receiving aversion for alcohol. There was no statistically significant difference between groups with regard to the percentage with a urine negative for all mood altering chemicals. Table 7 summarizes the results of assessing abstinence from cocaine and any other drugs for which the patient received treatment, as well as abstinence from all mood altering drugs except those prescribed by a physician. Total abstinence from cocaine for the 15.2 months' follow-up period was achieved by 51.9% of the patients. The abstinent rates from cocaine were significantly better in those treating for both alcohol and cocaine.
Keywords-cocaine dependence; aversion therapy; treatment outcome; methamphetamine dependence.
INTRODUCTION
BEGINNING IN THE EARLY 1970s, cocaine use and dependence have risen in the United States (Mittleman & Wetli, 1984). Treatment of cocaine dependence has focused on traditional chemical dependency approaches, neurobehavioral approaches, pharmacologic approaches, and others (Rawson, Obert, McCann, & Mann, 1986; Smith, 1986; Kleber & Gawin, 1984a; Gawin et al., 1989a; 0'Brien et al., 1988; Washton, 1986).
The Schick Shadel hospitals have provided treatment for alcoholism for over 55 years, using chemical and faradic aversion therapy (Voegtlin & Broz, 1949; Smith & Frawley, 1990). Chemical aversion therapy has been used for cocaine dependence (Frawley & Smith, 1989) and for marijuana dependence as well (Morakinyo, 1983). Faradic aversion therapy has been used for alcohol (Jackson & Smith, 1978; Cannon, Baker, & Wehl, 1981), marijuana (Smith, Schmeling, & Knowles, 1988), and heroin (Copeman, 1976). This study reports the results of utilizing aversion therapy as part of a multimodal treatment program for cocaine dependence in patients admitted to four private treatment programs operated by Schick Health Services.
METHODS Follow-Up Methodology
From those patients who completed at least the initial inpatient treatment for cocaine and/or methamphetamine dependence at four hospital-based Schick Shadel treatment programs, 214 patients were randomly selected. The patients entered treatment from May through November of 1987, and the follow-up was conducted from November 1988 through March 1989. Thus, patients had been out of treatment from 12 to 20 months. The average time for contact was 15.2 months.
It was predetermined that a sample of 214 patients would be selected at random and that every attempt would be made to reach each one. This random sample was selected in the following manner:
Using a table of random numbers, 214 two-digit numbers were selected. These randomly selected numbers were then matched to the last 2 digits of patient case numbers from the universe of patients who were eligible for inclusion in the study.
The 214 patients were systematically telephoned by trained interviewers of Facts Consolidated, an independent research firm, until all the patients had been reached, or until every possible means of reaching them had been exhausted. In cases in which pursuit of the interview would cause a breach of confidentiality, all further attempts to reach that patient were abandoned. This resulted in 125 patients who were interviewed and 89 patients who were not interviewed (58.4% phone contact rate). The protocol also called for a verification interview with a significant other in 33% of cases. All respondents were interviewed over the telephone, in person. Over 1700 actual phone calls were made to reach these 125 patients treating for cocaine/methamphetamine dependence.
The patient records were also reviewed for evidence of relapse following treatment. Thirty-one noncontacted patients who had treated for cocaine or methamphetamine dependence and who had a chart-documented relapse on cocaine, methamphetamine, or other drug for which the patient had sought treatment (e.g., alcohol or marijuana) were also included in the follow-up. This group of contacted (n = 125) and chart-documented relapse patients (n = 31) comprised a total of 156 individuals, or 72.9% of the total sample.
Statistical Methods. A sample size of 125, when selected in this manner, has a margin for statistical error of 8.93% at the .95 confidence level if it is a sample from a much larger universe. However, since the total universe consists of a finite number of 234, we have applied the Finite Population Correction Factor, and this reduces the error margin to plus or minus 4.18%.
Chi-squared analyses and two-tailed t tests were utilized to determine statistical significance. A Yates correction was used for chi-squared tests with 1 degree of freedom. A p value of .05 was considered to be statistically significant.
Patient Characteristics
Table 1 lists the demographics of the patients. The first column includes the patients with either phone follow-up or a chart-documented relapse. This is the group for which outcomes will be reported unless otherwise noted. The second column reports on those patients without any phone follow-up, but will include those who had chart-documented relapses.
The third column includes only those patients with neither phone follow-up not chart-documented relapse. Approximately 35% were married, 79% were employed, 80% were male, 66% were Caucasian, 64% were under 30 years of age, and 63% lived within 2 hours driving distance of the hospital. There were no significant differences between any of the three groups.
Table 2 lists the information from the drug histories for these patients. The mean Drug Abuse Severity Test Score (DAST) was 6.7 (SD = ± 2). This score indicates moderately severe drug-related problems (Skinner, 1982). On admission, 58% had cocaine in their urine, and 38% had marijuana in their urine; 22% had no drug found in their urine. Only 9.6% of patients used cocaine exclusively, 38.5% used two drugs (including alcohol), 35% used three drugs, and 19% used four or more drugs. Of the 59 patients also treating for alcohol dependence, 69% were daily drinkers and had an average of 8.9 (SD = ± 5.8) years of alcohol-related problems. Of the patients treating for stimulant dependence, 64% described job problems related to drug use, and 47% had marital discord related to drug use; 24% indicated that they had some physical damage from cocaine or methamphetamine. There were no statistically significant differences between the three groups.
Table 3 lists information on patterns of use. Of the 145 patients treating for cocaine dependence, 54.5% snorted cocaine (36.6% exclusively), 46.9% freebased cocaine (30.3% exclusively), and 17.9% used intravenous cocaine (11% exclusively). There were no statistically significant differences between the three groups, except for a greater percentage of exclusive snorters in the contacted group compared to the no phone follow-up group (p < .001) or the group with neither phone nor chart follow-up (p < .05). For the methamphetamine users, 76.9% snorted the drug, 7.7% smoked it, and 23.1% used it intravenously.
| Table 1 Demographics of Stimulant Dependent Population |
|||||
 |
|||||
| Column | |||||
|
|
|||||
| #1 Phone + |
#2 No |
#3 No Phone |
p Value | ||
| Chart Rel | Phone F/U | or Chart Rel | |||
| n = 156 | n = 89 | n = 58 | 1v2 | 1v3 | |
|
|||||
| Marital Status (%) | NS | NS | |||
| Married | 35 | 33 | 38 | ||
| Div/Sep | 25 | 30 | 28 | ||
| Single | 40 | 37 | 35 | ||
| Employment (%) | NS | NS | |||
| Employed | 79 | 79 | 86 | ||
| Unemployed | 17 | 17 | 10 | ||
| Not Working | 4 | 5 | 3 | ||
| Male (%) | 80 | 76 | 79 | NS | NS |
| Ethnic Background (%) | NS | NS | |||
| Caucasian | 66 | 55 | 57 | ||
| Black | 25 | 37 | 36 | ||
| Hispanic | 8 | 7 | 5 | ||
| Native American | 1 | 1 | 2 | ||
| <30 years old (%) | 64 | 65 | 62 | NS | NS |
|
|||||
| Note. Percentages rounded to nearest integer. | |||||
| Table 2 Drug Histories and Admission Data |
|||||||
|
|||||||
| Column | |||||||
|
|
|||||||
| #1 Phone + |
#2 No |
#3 No Phone |
p Value | ||||
| Chart Rel | Phone F/U | or Chart Rel |
|
||||
| n = 156 | n = 89 | n = 58 | 1v2 | 1v3 | |||
|
|||||||
| MAST mean | 8 | 8 | NS | ||||
| (SD) | 9 | 9 | |||||
| MASS mean | 12 | 11 | NS | ||||
| (SD) | 13 | 13 | |||||
| DAST mean | 7 | 7 | NS | ||||
| (SD) | 2 | 2 | |||||
| On Admission (%) | |||||||
| Urine Coc pos. | 58 | 70 | 67 | NS | NS | ||
| Urine Mar pos. | 38 | 39 | 43 | NS | NS | ||
| Urine Amphet pos. | 6 | 5 | 5 | NS | NS | ||
| Urine Neg. | 22 | 14 | 14 | NS | NS | ||
| Number of Drugs (%) | NS | NS | |||||
| 1 Drug | 10 | 14 | 10 | ||||
| 2 Drugs | 39 | 36 | 38 | ||||
| 3 Drugs | 35 | 32 | 41 | ||||
| 4 Drugs | 19 | 18 | 14 | ||||
| Problems Due to Drug Use (%) | |||||||
| Job Problems | 64 | 70 | 67 | NS | NS | ||
| Marital Discord | 47 | 57 | 60 | NS | NS | ||
| Withdrawal | 18 | 10 | 10 | NS | NS | ||
| Ultimatum from spouse | 17 | 16 | 19 | NS | NS | ||
| Arrest for possession | 15 | 11 | 7 | NS | NS | ||
| Ultimatum from employer | 10 | 6 | 5 | NS | NS | ||
| Arrest for being under drug influence | 7 | 9 | 10 | NS | NS | ||
| Physical Damage | 24 | 29 | 27 | NS | NS | ||
|
|||||||
| Note. MAST, MASS, DAST not available separately for the subgroup with neither phone nor chart follow-up. | |||||||
| Note. Percentages rounded to nearest integer. | |||||||
| Table 3 Cocaine and Methamphetamine Use Patterns |
||||||
|
||||||
| Column | ||||||
|
|
||||||
| #1 | #2 | #3 | p Value | |||
| Phone + | No | No Phone |
|
|||
| Chart Rel | Phone F/U | or Chart Rel | 1v2 | 1v3 | ||
|
||||||
| Cocaine | ||||||
| N | 145 | 87 | 58 | |||
| Snort (%) | 55 | 39 | 53 | 0.05 | NS | |
| Eclusive (%) | 37 | 14 | 17 | 0.001 | 0.05 | |
| Freebase (%) | 47 | 59 | 41 | NS | NS | |
| Eclusive (%) | 30 | 38 | 33 | NS | NS | |
| IV (%) | 18 | 26 | 28 | NS | NS | |
| Eclusive (%) | 11 | 16 | 19 | NS | NS | |
| Other (%) | 3 | 7 | 7 | NS | NS | |
| Eclusive (%) | 2 | 5 | 3 | NS | NS | |
| Frequency/Duration Days/mo. | 16.8 | 18.7 | NS | |||
| SD | 10.7 | 11 | ||||
| Years Use | 5.2 | 5.4 | NS | |||
| SD | 4.5 | 5 | ||||
| Amount When Using (gm) | ||||||
| Average | 1.2 | 1.3 | NS | |||
| SD | 1.1 | 1 | ||||
| Maximum | 2.2 | 2.2 | NS | |||
| SD | 1.7 | 1.7 | ||||
| Methamphetamine | ||||||
| N | 13 | 3 | 1 | |||
| Snort (%) | 77 | 67 | 100 | |||
| Eclusive (%) | 69 | 67 | 100 | |||
| Smoke (%) | 8 | 0 | 0 | |||
| Eclusive (%) | 0 | 0 | 0 | |||
| IV (%) | 23 | 33 | 0 | |||
| Eclusive (%) | 23 | 33 | 0 | |||
| Other (%) | 0 | 0 | 0 | |||
| Eclusive (%) | 0 | 0 | 0 | |||
| Frequency/Duration Days/mo. | 22.2 | 13.0 | ||||
| SD | NA | NA | ||||
| Years Use | 2.6 | 4.3 | ||||
| SD | 1.6 | 1.7 | ||||
| Amount When Using (gm) | ||||||
| Average | 0.9 | 0.5 | ||||
| SD | 1 | 1 | ||||
| Maximum | 1.1 | 1 | ||||
| SD | 1 | 0.5 | ||||
|
| ||||||
| Note. Frequency, duration, and quantity information was not available separately for the subgroup with neither phone nor chart follow-up. | ||||||
| Note. Percentages rounded to nearest integers except when computing means and standard deviations. | ||||||
SUBJECTS
Those selected for interview were drawn from the universe of patients who had completed for the first time at least the first 10 days (post detoxification) increment of the inpatient alcoholism treatment program at Schick Shadel Hospital of Santa Barbara, California, during calendar year 1983. Only 3% of the patients admitted that year left the hospital prior to completing the initial 10 day treatment program. Another 2.5% were admitted for detoxification only. Neither group of patients were candidates for inclusion in this study.
The demographics of Schick Shadel Hospital patients have been described in detail elsewhere (Knowles, Smith, & Lemere, 1983). Demographic details of the subjects of the present study are shown in Table 1. In general, they resemble typical patients in other inpatient treatment programs for medically non-indigent persons (Weins & Menustik, 1983; Cordill & Associates, 1988; Moberg, 1978). The majority were males (73%) between the ages of 25 and 55 (79.5%) and were married (61%). Almost all had at least a high school education (93.5%). Most (60%) had at least some college education, and 23% had at least a bachelors degree. The majority (79%) were employed.
| TABLE 1 Demographics (N = 200) |
|
|
|
| Variable | % |
|
|
| Sex | |
| Males | 73.0 |
| Females | 27.0 |
| Age | |
| <26 | 8.5 |
| 26-55 | 79.5 |
| >55 | 12.0 |
| Marital status | |
| Married | 61.0 |
| Single | 13.8 |
| Widowed | 2.5 |
| Separated/Divorced | 22.5 |
| Education | |
| <12 years | 6.5 |
| 12 years (high school graduate) | 24.0 |
| Some college (but no degree) | 37.0 |
| College graduate | 23.5 |
| Refused to answer | 9.0 |
| Occupation | |
| Professional | 32.0 |
| Other white collar | 19.5 |
| Blue Collar | 27.0 |
| Unemployed | 4.5 |
| Not working-other | 16.5 |
 |
|
All subjects met the DSM-III criteria for alcohol dependence. History of other drug use over the 6 months prior to treatment was obtained (Table 2). Nearly 40% (39.6%) of the patients used some drug other than alcohol during the six months prior to treatment. This use was limited to one drug in 14.3% of cases, two drugs in 15.4% of cases, three drugs in 5.5% of cases, and four or more drugs in 3.8% of cases.
The types of other drugs used are shown in Table 3. Marijuana and cocaine were by far the most commonly used. They were each used by 25.8% of patients. In many cases the same patient used both drugs.
Of this sample, 65% reported no previous formalized treatment of their alcohol dependence prior to treatment at Schick Shadel Hospital, 13.8% had received previous inpatient treatment, 32.5% had received other formalized treatment, and 41.9% reported participation in the fellowship of alcoholics anonymous.
| TABLE 2 Drugs used in the 6 months prior to treatment (N = 200) |
|
|
|
| Drugs | % |
|
|
| Alcohol only | 61.0 |
| Alcohol and other drug (s) | 39.0 |
| 1 other drug | 14.3 |
| 2 other drugs | 15.4 |
| 3 other drugs | 5.5 |
| 4 or more other drugs | 3.8 |
|
|
| TABLE 3 Drugs other than alcohol used in the 6 months prior to treatment* |
|
|
|
| Drug | Percent who used** |
|
|
| No other drug use | 60.4 |
| Cocaine | 25.8 |
| Marijuana | 25.8 |
| Amphetamines | 12.1 |
| Sedative drugs | 5.5 |
| Opiates | 4.9 |
| Hallucinogens | 4.4 |
|
|
| * Patient population N = 182. | |
| ** Percentages add up to over 100% because some patients used more than one drug. | |
RESULTS
Of the 200 patients selected for the study, 160 were contacted during the survey. The minimum elapsed time since treatment was 13 months, and the maximum was 25 months (mean 20.5 months).
Information was obtained from these patients, with validating information from a significant other in 36% of cases. The information obtained included:
- Alcohol abstinence status over the entire span of time since treatment (total abstinence).
- Alcohol abstinence status over the last six months (current abstinence).
- Alcohol abstinence status over the first 12-month span of time following treatment (12-month abstinence).
The rate of abstinence at 12 months, 13-25 months (mean 20.5 months), and current abstinence (last 6 months) is shown in Table 4. The contacted group (n = 160) comprised 80% of the 200 individuals selected for follow-up. They had a 12-month abstinence rate of 71.3%, a 13-25 month (mean 20.5 month) abstinence rate of 65.0%, and a current abstinent rate of 78.1%.
| TABLE 4 Abstinence Status |
|||
|
|||
| Follow-up Group | Percent 12-month Abstinence |
Percent 13- to 25-month Abstinence (Mean 20.5 mos) |
Percent Current Abstinence |
|
|||
| Telephone contact group (N = 160) | 71.3 | 65.0 | 78.1 |
| Telephone contact plus chart- | |||
| documented relapses (N = 182) | 62.6 | 57.1 | N/A |
| Telephone contact plus chart- | |||
| documented relapse plus no chart- | |||
| documented relapse (N = 200) | 66.5 | 61.5 | N/A |
|
|||
The group composed of contacted patients (n = 160) plus chart documented, relapsed, non-contacted patients (n = 22) numbered 182 individuals (91% of the selected sample of 200). They had a 12-month abstinence rate of 62.6%, a 13-25 month (mean 20.5 month) abstinent rate of 57.1%).
The total group of 200 individuals (100% sample) composed of contacted individuals (n = 160), chart documented relapsed, non-contacted patients (n = 22), and non-contacted patients without chart evidence of relapse (n = 18) had abstinence rates of 66.5% at 12 months and 61.5% at 13-25 months (mean 20.5 months).
Table 5 shows the patterns of alcohol consumption for the contacted group following treatment. It will be noted that a few patients had one drink, or part of a drink, either deliberately or accidentally, after treatment. Although these patients were not included in the total abstinence group, it can be reasonably concluded that they were successful in achieving their treatment goal.
| TABLE 5 Pattern of alcohol use of the contacted group after treatment (N = 160) |
|
|
|
| Alcohol Use | Percent |
|
|
| No alcohol for at least 12 months | 71.3 |
| No alcohol since treatment (mean 20.5 mo.) | 65.0 |
| Accidental consumption, once only, abstinent | |
| since then | 0.6 |
| Deliberate consumption, once only, abstinent | |
| since then | 3.1 |
| Drank but abstinent 6 mo. or longer prior to | |
| follow-up | 10.0 |
| Drank but abstinent at follow-up less than 6 mo. | 5.0 |
| Still drinking at follow-up | 16.3 |
|
|
THE TREATMENT PROGRAM
All patients received a complete addiction-focused medical history, physical examination, and laboratory tests, including a urine drug screen. Patients who required detoxification from alcohol were stabilized and off medication before they entered into treatment. The treatment phase lasted 11 to 16 days. Each patient gave informed consent regarding the treatment to be received and alternative treatment (or no treatment) before starting. The treatment consisted of aversion treatments for alcohol, cocaine, methamphetamine, and/or marijuana dependence as determined by the physician to be appropriate in each individual case. Five sodium pentothal treatments were usually given on alternate days from the aversion treatment (Smith, Lemere, & Dunn, 1971). In addition, daily educational groups that dealt with various aspects of addiction and recovery were offered in the morning and evening. Patients were exposed to information about specific groups that may be utilized following treatment (e.g., 12-step programs, hospital-sponsored peer or professionally led support groups, and church). Individual counseling was provided to address specific treatment issues such as denial, grief, assertion, resentments, development of a treatment plan, and aftercare planning. Where possible, family members came to the hospital for group education and individual counseling.
The Aversive Stimulus. The aversion therapy for alcohol and marijuana has been described elsewhere (Smith, 1982; Smith, Schmeling, & Knowles, 1988). The aversion therapy for cocaine is of two kinds. Chemical aversion may be used, in which the nausea caused by oral emetine is associated with the act of snorting the cocaine or methamphetamine (Frawley & Smith, 1990). As an alternative, faradic aversion may be used, which pairs an irritating, but not painful, electric stimulus to the forearm with the act of using, imaging, and preparing to use the cocaine or methamphetamine substitute. The type of procedure depends upon the use pattern of the patient and his or her medical condition. The procedure used for faradic aversion is similar to that used for alcohol treatment (Jackson, & Smith, 1978), nicotine dependence (Smith, 1988), or marijuana (Smith, Schmeling, & Knowles, 1988).
The Cocaine or Methamphetamine Substitute. No cocaine is actually utilized in the treatment, but instead a substitute is used that is similar in appearance and smell and has a numbing effect. In our experience, 2% tetracaine and 1% quinine in mannitol is an effective substitute for cocaine that is to be snorted. The freebase substitute utilized at the time of the study was either a type of white candy or a white soap which when burned created smoke. For intravenous simulation, a white powder was dissolved by the patient (as part of their standard ritual) and then taken up into a syringe through the needle. No cocaine substitute is actually injected. Instead, the liquid made from dissolving a white powder (D-xylose works best) is pushed out of the syringe just above the forearm where an injection would normally occur. A cocaine scent (Psychem (R), Old Factory, Inc., Atlanta, Georgia) is also applied to the fingers at the time of treatment in order to achieve the odor of "street cocaine" and enhance the association with their cocaine use experience.
A methamphetamine substitute was developed using 1% quinine in mannitol. (This does not burn the nose as much as real crystal methamphetamine does, but we have not yet found a better substitute).
Aversive Pairing. The process for chemical aversion for cocaine or methamphetamine consists of timing the onset of snorting the lines just prior to the onset of nausea. In the first treatment 18 lines may be snorted, while in the last treatment up to 50 lines may be snorted. The snorting continues until all the lines are used. (After the first 4 lines are snorted, the nose is well-numbed and plain mannitol is used for the rest of the lines until the last 4, when the tetracaine-containing substitute is again used.) Usually the patient receives five aversion treatments. However, when a patient is treated with chemical aversion for both alcohol and cocaine, the patient receives the first two aversion treatments for cocaine only, followed by four additional "divided" treatments using both alcohol and cocaine. These last four treatments involve aversion to alcohol in the first part of the session, and the second part focuses the aversion on cocaine. The procedure is discussed more fully elsewhere (Frawley & Smith, 1990).
The faradic aversion to cocaine is always carried out separately from aversion to any other drug. The process consists of pairing the aversive electric stimulus with each link in the chain of behaviors involved in the individual's use of cocaine (e.g., manipulating the paper packet containing the white powder, opening the packet, pouring the powder onto the mirror, cutting it up into lines and snorting the powder). This may include imagery involving the place of usage, actual stimuli associated with usage (e.g., paraphernalia.) Normally, a patient receives five aversion treatments for the cocaine and/or amphetamine dependence. When patients used both methamphetamine and cocaine, treatment addressed both drugs together. Faradic aversion was utilized with 42.3% of the cocaine "snorters," 90.9% of "freebasers," and 91.3% of intravenous users. Chemical aversion was utilized for 52.1 % of the cocaine "snorters," while 5.6% of "snorters," 9.1% of "freebasers" and 8.7% of intravenous users received both chemical and faradic aversion. The main reason for these variations was that two facilities were treating "snorters" primarily with chemical aversion and two other facilities were treating "snorters" with primarily faradic aversion. Nearly all "freebase" and "IV" users were started with faradic aversion. In a few cases patients were switched to the alternative treatment modality due to either medical concerns (e.g., chemical aversion inappropriate for a patient) or patient concerns (patient strongly felt that the alternative would be more effective for him or her). Patients treating for alcohol addiction also received five specific aversion treatments for alcohol (chemical or faradic), except as noted above when cocaine and alcohol were being simultaneously treated with chemical aversion. Those receiving aversion treatment for marijuana dependence received five faradic aversions (Smith, Schmeling, & Knowles, 1988.)
The aversion therapy is carried out in a small room which during cocaine or methamphetamine treatment has pictures of white powder or "crack" cocaine and cocaine paraphernalia against a black backdrop and/or actual paraphernalia and piles of white powder or "crack rocks" or methamphetamine substitute visible to the patient. The treatment is individualized to each patient and the individual manner in which he or she uses cocaine or methamphetamine. For example, the hospital has a variety of cocaine pipes from which patients may choose, so that the actual experience is as close as possible to what the patient would be doing at home. When possible, the patient is instructed to bring his or her own paraphernalia.
Table 4 summarizes the patients' patterns of alcohol or other drug dependence and the type of treatment received. Data is presented for those followed up by phone or with a chart documented relapse in one column and for those who had no phone follow-up in the second column. The third column contains data from patients with neither phone nor chart follow-up. There were no statistically significant differences between the type of aversive treatment given and the pattern of drug use between the follow-up groups.
| Table 4 Patterns of Drug Problems and Percentage of Each Type of Aversion Therapy Practiced |
|||||
|
|||||
| Column | |||||
|
|
|||||
| #1 | #2 | #3 | p Value | ||
| Phone + | No | No Phone |
|
||
| Chart Rel | Phone F/U | or Chart Rel | 1v2 | 1v3 | |
|
|||||
| N | 156 | 89 | 58 | ||
| Cocaine (only) | 62 (40%) | 53 (60%) | 39 (67%) | NS | .05a |
| Nausea (%) | 18 | 4 | 5 | ||
| Faradic (%) | 81 | 94 | 95 | NS | NSb |
| Both (%) | 2 | 2 | 0 | ||
| Alcohol/Cocaine | 37 (24%) | 14 (16%) | 8 (14%) | ||
| Nausea (%) | 51 | 62 | 50 | ||
| Faradic (%) | 41 | 39 | 50 | NS | NSb |
| Both (%) | 8 | 0 | 0 | ||
| Cocaine/Marijuana | 24 (15%) | 9 (10%) | 5 (9%) | ||
| Nausea (%) | 4 | 0 | 0 | ||
| Faradic (%) | 88 | 100 | 100 | NS | NSb |
| Both (%) | 8 | 0 | 0 | ||
| Alc/Coc/Marijuana | 22 (14%) | 11 (12%) | 6 (10%) | ||
| Nausea (%) | 27 | 35 | 67 | ||
| Faradic (%) | 55 | 41 | 0 | NS | NSb |
| Both (%) | 18 | 24 | 33 | ||
| Crystal Met. (*) | 13 (88%) | 3 (3%) | 1 (2%) | ||
| Nausea (%) | 23 | 0 | 0 | ||
| Faradic (%) | 69 | 100 | 100 | NS | NSb |
| Both (%) | 8 | 0 | 0 | ||
|
|||||
| Note. Percentages rounded to nearest integer. | |||||
| * Because of the small number, the methamphetamine cases are lumped together. Two cases of methamphetamine also treated for cocaine in the followed-up group and one in each of the no phone follow-up and the no phone follow-up or chart relapse group. | |||||
| a Chi-squared (4 df ) p < .05 for difference in distribution of cocaine diagnoses between the followed-up group and the no phone follow-up or chart relapse group. | |||||
| b Chi-squared (2 df ) for difference of aversion modality between Followed-Up Group and No Phone Followed-up or Chart Relapse Group. | |||||
Continuing Care. Patients were instructed to return to the hospital at 2 weeks and 6 weeks following their discharge from initial treatment to receive a reinforcement aversion to each of the drugs for which they had received aversion during the primary treatment, to receive one pentothal treatment, and to have their continuing care plan updated by the counseling staff. Such reinforcement activities have been associated with improved outcome and are strongly encouraged (Smith & Frawley, 1990; Weins & Menustik, 1983.) The aversion treatment provided at each reinforcement is similar to that which they received during the initial treatment. In addition, patients received periodic calls on a decreasing frequency schedule over a 2-year period following discharge (from the Schick Aftercare Department) to monitor patient's abstinence status and progress on the continuing care plan and to make any needed modifications. They also participate in a variety of support group activities, principally 12-step programs, weekly Schick Graduate groups, and/or their churches.
Results. Outcome data was principally focused on abstinence measures and on participation in follow-up activities.
Aftercare Activity Participation. Table 5 summarizes the data on completion of reinforcement treatments by each category of patient according to the drug (s) that was (were) treated with aversion. Also included are the utilization of support activity following treatment (based on those with phone follow-up only, since this information could not be obtained from non-contacted patients) during the period of being at risk for relapse. The period of risk is defined as the time prior to their first use of a drug for which they received treatment or, if there was no relapse, the whole follow-up period. The types of support utilized are reported separately. Also reported is whether or not the patient utilized any support at all after treatment (regardless of whether it was initiated before or after a relapse) and whether the patient was using any kind of support in the 3 months prior to follow-up.
| Table 5 Completion of Reinforcement Treatments and Participation in Support Group Activity Following Treatment |
||||||||
|
||||||||
| Number of Reinforcements | ||||||||
|
|
||||||||
| n | 0 (%) |
1 (%) |
2 (%) |
|||||
|
||||||||
| Drug Category* | ||||||||
| Tot. Phone + Chart Rel | 156 | 18 | 82 | 57 | ||||
| Cocaine | 69 | 25 | 75 | 52 | ||||
| Alcohol/Cocaine | 39 | 13 | 87 | 59 | ||||
| Cocaine/Marijuana | 26 | 15 | 85 | 54 | ||||
| Alc/Coc/Marijuana | 22 | 9 | 91 | 73 | ||||
| Tot. No Phone F/U | 89 | 27 | 73 | 40 | ||||
| Tot. No Phone/Chart Rel | 58 | 21 | 79 | 48 | ||||
| p values (xú) | ||||||||
| Tot. P + C v No Pa (1 df) | NS | NS | .05 | |||||
| Tot. P + C v No P/Ca (1 df) | NS | NS | NS | |||||
| C vs AC vs CM vs ACMb (3 df) | NS | NS | NS | |||||
| Support Group Activity | ||||||||
| During Risk Period | Whole F/U Time | |||||||
|
|
|
|||||||
| n | 12-Step (%) |
Grad (%) |
Church (%) |
None (%) |
Any (%) |
Last 3 months (%) |
||
|
||||||||
| Drug Category* | ||||||||
| Tot. Phone F/U | 125 | 36 | 30 | 6 | 38 | 75 | 48 | |
| Cocaine | 54 | 30 | 22 | 5 | 43 | 73 | 50 | |
| Alcohol/Cocaine | 32 | 44 | 38 | 12 | 34 | 81 | 51 | |
| Cocaine/Marijuana | 22 | 41 | 27 | 0 | 32 | 75 | 40 | |
| Alc/Coc/Marijuana | 17 | 35 | 41 | 6 | 41 | 71 | 47 | |
| p values (xú, 3 df) | ||||||||
| C vs AC vs CM vs ACM | NS | NS | NA | NS | NS | NS | ||
|
||||||||
| * Cocaine and amphetamine are lumped together in this table due to small number of methamphetamine users. | ||||||||
| a P + C = phone and chart follow-up; No P = no phone follow-up; No P/C = no phone or chart follow up. | ||||||||
| b C = cocaine only; AC = alcohol/cocaine; CM = cocaine/marijuana; ACM = alcohol/cocaine/marijuana | ||||||||
This data shows that the majority of patients took both reinforcement treatments. Although over 57% of patients followed up by either chart or by phone took both reinforcements, only 40.4% of those with no phone follow-up took both (p < .05). In those with neither phone follow-up nor chart-documented relapse, the second reinforcement utilization of 48.3% is not statistically different from that of the group with either phone or chart-documented follow-up. The majority of patients with phone follow-up participated in support groups following treatment, with slightly more participating in 12-step groups than in hospital-sponsored groups. Over 40% were still participating in support groups at the time of follow-up over one year later.
Abstinence From Cocaine and Other Drugs. Table 6 summarizes the baseline data for different patterns of drug and alcohol problems. The Michigan Alcoholism Screening Test (MAST; Pokorny, Miller, & Kaplan, 1972) and the Missouri Alcoholism Severity Scale (MASS; Evenson, Reese, & Holland, 1982) indicate that those receiving aversion therapy for alcoholism had significant alcohol problems in contrast to those not receiving aversion therapy for alcoholism. Patients receiving aversion for cocaine and marijuana only were less likely to be married and were younger than patients in other groups. Patients treating for alcohol tended not to use as much cocaine on the average as those not receiving aversion for alcohol. There was no statistically significant difference between groups with regard to the percentage with a urine negative for all mood altering chemicals. Table 7 summarizes the results of assessing abstinence from cocaine and any other drugs for which the patient received treatment, as well as abstinence from all mood altering drugs except those prescribed by a physician. Total abstinence from cocaine for the 15.2 months' follow-up period was achieved by 51.9% of the patients. The abstinent rates from cocaine were significantly better in those treating for both alcohol and cocaine.
| Table 6 Baseline Demographic and Drug Use Histories |
|||||||
|
|||||||
| Baseline Variables | Total* | Cocaine | Alc/Coc | Coc/Mar | ACM | Item | p Value |
|
|||||||
| n | 156 | 69 | 39 | 26 | 22 | ||
| Married (%) | 35 | 42 | 41 | 15 | 27 | C vs CM | .05 |
| Employed (%) | 79 | 84 | 77 | 69 | 77 | NS | |
| Male (%) | 79 | 84 | 77 | 69 | 77 | NS | |
| Caucasion (%) | 66 | 59 | 77 | 65 | 68 | NS | |
| <30 Y/O (%) | 64 | 67 | 49 | 81 | 64 | AC vs CM | .05 |
| MAST mean | 8 | 2 | 14 | 6 | 13 | Note 1 | |
| MASS mean | 12 | 1 | 22 | 4 | 20 | Note 2 | |
| DAST mean | 6 | 7 | 6 | 7 | 7 | NS | |
| Urine Neg (%) | 22 | 25 | 28 | 12 | 14 | NS | |
| Cocaine (n) | 145 | 62 | 37 | 24 | 22 | ||
| Snort (%) | 55 | 40 | 73 | 50 | 68 | Note 3 | |
| Freebase (%) | 47 | 53 | 35 | 46 | 50 | NS | |
| I.V. (%) | 18 | 19 | 19 | 21 | 9 | NS | |
| Ave/Use (gm) | 1.2 | 1.5 | 0.9 | 1.3 | 1 | Note 4 | |
| Max/Use (gm) | 2.2 | 2.4 | 2.1 | 1.7 | 2.4 | NS | |
| Amphetamine (n) | 13 | 7 | 3 | 2 | 1 | ||
| Snort (%) | 77 | 86 | 67 | 100 | 0 | ||
| Freebase (%) | 8 | 14 | 0 | 0 | 0 | ||
| I.V. (%) | 23 | 14 | 33 | 0 | 100 | ||
| Ave/Use (gm) | 0.9 | 1.1 | 0.8 | 0.3 | N/A | ||
| Max/Use (gm) | 1.1 | 1.4 | 0.9 | 0.6 | N/A | ||
|
|||||||
| Note. Percentages rounded to nearest integer except for mean and maximum grams of drug use. | |||||||
| * Because of the small number of amphetamine patients they are lumped together with the cocaine patients. | |||||||
| Comparisons items and p values (Xú, 1 df). | |||||||
| Note 1: p < .001 for C vs AC, AC vs CM, C vs ACM. p < .01 for CM vs ACM. | |||||||
| Note 2: p < .001 for C vs AC, AC vs CM, CM vs ACM, C vs ACM; p < .05 for C vs CM. | |||||||
| Note 3: p < .01 for C vs AC; p < .05 for C vs ACM. | |||||||
| Note 4: p < .002 for C vs AC; p < .05 for C vs ACM. | |||||||
| Table 7 Abstinence from Cocaine, Alcohol, Marijuana, and Other Non-prescribed Mood-Altering Drugs |
||||||
|
||||||
| Outcome Variables | Total | Coc | Alc/Coc | Coc/Mar | A/C/M | p Value |
|
||||||
| N = 156 | n = 69 | n = 39 | n = 26 | n = 22 | ||
| F/U percent | 73 | 64 | 83 | 83 | 79 | Note 1 |
| Abstinence from Cocaine/Amphetamine: | ||||||
| 1 year (%) | 53 | 39 | 69 | 50 | 73 | Note 2 |
| 15.2 months (%) | 52 | 38 | 69 | 50 | 68 | Note 3 |
| If Relapse, Current Status: | ||||||
| Used Once (%) | 5 | 9 | 3 | 0 | 5 | |
Abstain  6
mos. (%) |
12 | 16 | 5 | 15 | 5 | |
| Abstain < 6 mos. (%) | 5 | 7 | 0 | 12 | 0 | |
| Still Using (%) | 26 | 30 | 23 | 23 | 23 | NS |
| Abstinence from alcohol and all drugs except those prescribed by a physician: | ||||||
| 1 year (%) | 31 | 28 | 44 | 19 | 32 | NS |
| 15.2 months (%) | 29 | 28 | 36 | 19 | 32 | NS |
| For Those Treating for Alcohol Dependence: | ||||||
| n | 61 | 39 | 22 | |||
| Abstain 1 year (%) | 62 | 54 | 77 | NS | ||
| Abstain 15.2 months (%) | 56 | 44 | 77 | Note 4 | ||
| If Relapse, Current Status at Follow-Up: | ||||||
| Used Once (%) | 13 | 18 | 5 | |||
| Abstain 6
mos. (%) |
5 | 8 | 0 | |||
| Abstain < 6 mos. (%) | 7 | 8 | 5 | |||
| Still Using (%) | 20 | 23 | 14 | NS | ||
| For Those Treating for Marijuana Dependence: | ||||||
| n | 48 | 26 | 22 | |||
| Abstain 1 year (%) | 52 | 42 | 64 | NS | ||
| Abstain 15.2 months (%) | 52 | 42 | 64 | NS | ||
| If Relapse, Current Status at Follow-Up: | ||||||
| Used Once (%) | 2 | 4 | 5 | |||
| Abstain 6
mos. (%) |
15 | 15 | 14 | |||
| Abstain < 6 mos. (%) | 2 | 4 | 0 | |||