Journal of Psychoactive Drugs

ISSN: 0279-1072 (Print) 2159-9777 (Online) Journal homepage: http://www.tandfonline.com/loi/ujpd20

Treating Crack Cocaine Dependence: The Critical Role of Relapse Prevention Barbara C. Wallace To cite this article: Barbara C. Wallace (1992) Treating Crack Cocaine Dependence: The Critical Role of Relapse Prevention, Journal of Psychoactive Drugs, 24:2, 213-222, DOI: 10.1080/02791072.1992.10471641 To link to this article: http://dx.doi.org/10.1080/02791072.1992.10471641

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Dependence: The Critical Role of Relapse Preventiont Barbara C. Wallace, Ph.D.* Abstract - In order to adequately address the treatment needs of crack cocaine dependent persons, a multidimensional approach to relapse prevention must be utilized. The value of a biopsychosocial model of crack addiction and the concept of phases of recovery in providing a rationale for the recommended approach to relapse prevention are emphasized. Research fmdings on the determinants of relapse for crack dependent patients and the psychosocial characteristics of the crack dependent individual justify the utility of certain relapse prevention strategies. Specifically, an approach to relapse is advocated that includes the provision of pharmacological adjuncts, psychoeducation on the multideterminants ofrelapse, and psychotherapy that attempts to remediate underlying psychological problems that are typically found in crack dependent patients. Keywords - biopsychosocial model , crack , cocaine, recovery, relapse prevention, treat ment

As a consequence of the cocaine and crack epidemic of the 1980s, clinicians and researchers have responded to a difficult treatment challenge by focusing on the critical role of relapse prevention (Rawson et al. 1990: Wallace 1989a, 1989b; Washton 1989a; Kertzner 1987; Stone, Fromm & Kagan 1984; Anker & Crowley 1982). In essence, relapse prevention plays a critical role in the treatment and recovery of cocaine and crack dependent patients. There are numerous crucial components of cocaine/crack dependence treatment that have been described elsewhere (Wallace In press-b; Rawson 1990; Rawson et al. 1990; Washton 1989a, 1989b; Kleber 1988; Washton, Stone & Hendrickson 1988; Rosecan & Spitz 1987; Washton & Gold 1987; Wallace 1987), but no treatment program aspiring to provide efficacious treatment in the 1990s should fail to include relapse prevention as a vital component.

In anticipation of the high risk of relapse that recovering crack patients face, it is imperative that treatment programs be designed at the outset to hold some promise of reducing the likelihood of relapse. The question arises, How can a decline in staff morale and patient disillusionment with treatment that does not seem to work be avoided? A substantial reduction of the risk of relapse can be accomplished, and there is hope of not only reducing the risk of relapse that crack patients face, but also for designing efficacious treatment models for the hard-core, compulsive crack cocaine smoker (Rawson 1990). Even the inner-city crack smoker who lives in a crack-saturated environment can behold a vision of successful recovery. However, clinicians and researchers must first envision and design treatment programs that contain a multidimensional approach to relapse prevention. This article presents a rationale for an overall approach to relapse prevention by discussing the utility of a biopsychosocial model of crack addiction and the concept of phases of treatment and recovery. Specifically, relapse prevention for crack dependent patients involves (1) the pro vision of pharmacological adjuncts, (2) psychoeducation on the multideterminants of relapse, and (3) remediation

tResearch for this article was conducted in cooperation with Interfaith Med ical Center, Department of Psychiatry, Brooklyn, New York. • Assistant Professor, African-American Studies Department, John Jay College of Criminal Justice , City University of New York, 454 West 59th Street, New York, New York 10019. Journal of Psychoactive Dru gs

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treatment strategies. A phase of early initial abstinence/withdrawal involves the first two weeks following the last administration of a dose of crack. The specific interventions to be discussed in the present article should be provided during this first period of recovery, the withdrawal phase. Next, a phase of prolonging abstinence extends up to the first six months of recovery. Again, specific interventions to be presented should occur during this second phase, where the risk of relapse remains high and the goal is to prolong the period of abstinence. Thus, the task of avoiding a slip or relapse is positively and cognitively reframed in terms of the goal of prolonging the period of abstinence. A third phase of pursuing lifetime recovery involves a one -year to several-year to lifetime period where a risk of relapse continues to exist. Here, it is important to remember that a risk of relapse to crack remains beyond just a year or two of recovery. In fact, future involvement in a compulsive, destructive, drugfree behavior remains a relatively strong possibility for these recovering persons. Continuing long-term treatment, which further reinforces adaptive alternative behaviors to the use of drugs, can reduce the chances of engaging in compulsive or destructive behaviors of any kind. Treatment should also attempt to remedy underlying psychological and emotional problems that represent a vulnerability or susceptibility to the development and maintenance of addictive disorders . This treatment will vary in length. In this way, continuing interventions up to one year or for several years may hold the promise of further reducing the risk of relapse to crack or involvement in another addictive or compulsive behavior. The idea of phases of treatment and recovery plays an important role in determining the timing of the provision of specific treatment interventions. Whether addressing biological, psychological or social factors that underlie crack addiction, understanding when it is most important to implement a specific intervention in order to avoid relapse is ultimately related to the concept of phases ofrecovery. A particular relapse prevention strategy can be utilized during either an early initial abstinence/withdrawal phase, a second phase of prolonging abstinence or a third phase of pursuing lifetime recovery.

of underlying psychological and emotional problems that crack dependent patients typically possess. Relapse prevention is viewed as a set of strategies encompassing multiple interventions.

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A BIOPSYCHOSOCIAL MODEL OF CRACK DEPENDENCE The model of relapse prevention presented in this article grows out of a biopsychosocial approach (Donovan 1988; Donovan & Marlatt 1988) to crack addiction. A biopsychosocial approach focuses attention on biological, psychological, and social factors that underlie the development and maintenance of an addictive behavior. In this regard , Wallace (In press-b) presents an elaborate biopsycho social model of crack addiction. Similarly, the model of relapse prevention presented in the present article acknowledges that multiple interacting variables playa role in the addictive process. In addition, a biopsychosocial model of addiction embrac es the principle that careful assessment determines which specific treatment interventions are necessary for individual patients throughout various phases of treatment (Donovan & Marlatt 1988). Marlatt (1988) also debunked the uniformity myth that the same treatment approach can be used for all addicts. A careful, individualized assessment guides decisions on matching patients to specific treatments following a graded series of interventions; that is, the least inten sive interventions are attempted before more intensive treatment interventions are pursued. A relaps e or failure to achieve abstinence in one treatment modality indicates the need for further assessment and determination of the kind of strategies and intensive treatment necessary to lead to a successful recovery. In accordance with Marlatt (1985), a microanalysis of relapse episodes through a Clinical Relapse Interview (Wallace In press-b, 1989a) will permit the clinician and patient to engage in a detailed analysis of a relapse episode in search of the determinants of that relapse. Findings should indicate how treatment must be intensified and relapse prevention strategies modified if the period of abstin ence is to be successfully prolonged and another relapse episode avoided. In this way, a relapse episode may represent an opportunity for positive growth, indicating areas in which behavioral change must occur; a view that is consistent with that of Marlatt (1988, 1985). Understanding the process of relapse empowers patients to avoid unwittingly "setting themselves up" for a relapse episode or "slip" to use Marlatt's terminology (1985).

USE OF PHARMACOLOGICAL ADJUNCTS IN THE TREATMENT OF CRACK DEPENDENCE The use of medications, amino acids, nutrients, and vitamins as adjunctive treatment for cocaine and crack dependence reflects developments in a field that is still virtually in its infancy. However, a rationale exits for using pharmacological adjuncts to address the consequences of chronic crack smoking.

PHASES OF TREATMENT AND RECOVERY The concept of phases of treatment and recovery also guid es decisions on the process of implementing diverse Journal of Psychoact ive Dru gs

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dependent individuals (Trachtenberg & Blum 1988) . The provision of Tropamine significantly reduced the rate of departure against medical advice (AMA): only 4.2% of Tropamine patients left AMA compared to 37.5% leaving AMA among the control group (Blum et al. 1988). In addition, Tropamine-treated patients were compliant, cooperative, less agitated, and acted out much less . Overall, the severity of the cocaine crash was reduced ; but most importantly, craving or drug hunger decreased significantly in comparison to controls. Blum and colleagues (1988) argued that the performance of Tropamine is all the more impressive because 92% of those patients given Tropamine were intravenous cocaine users or free-base smokers. These researchers asserted that Tropamine is a prototypical nutrient product that serves as an important adjunct that permits realizing the first goal of treatment, which is to retain the patient in the treatment facility. Retention in the facility is important to permit separating the user from the drug -using environment, for the provision of education during treatment, and to help facilitate a patient making the first steps toward abstinence from cocaine (Blum ct al. 1988). Blum and colleagues also emphasized that Tropamine is important for the early phase of treatment or recovery and for patients who need to be separated from the drugusing environment because they are chronic users. Tropamine seems to be a very promis ing pharmacological adjunct in so far as it permits 95.8% of patients to manage drug hunger and complete inpatient detoxification, in comparison to 62.5% among controls. However, the weakness ofthis study involves the fact that it was an open trial. As Blum and colleagues stated, the data from this clinical trial warrants further investigation in double-blind placebocontrolled studies. Bromocriptine. Herridge and Gold (1988: 238) challenged the widely held belief that "in the early phase of cocaine withdrawal the symptoms are mild and do not require treatment" They argued the importance of an alternative view that recognizes that drug craving in particular - which is a "powerful brain-driven force that tends to make patients behave in whatever way will insure the acquisition and ingestion of cocaine" - justifies the use of pharmacological adjuncts in the withdrawal phase . Within their perspective, the first phase of withdrawal may last up to four days and also includes symptoms of agitation and anorexia, and is followed by fatigue, exhaustion, depression, hypersomnia, and diminished craving. In accordance with a dopam ine depletion hypothesis, Herridge and Gold administered the dopaminergic agonist bromocriptine to cocaine abusers in a randomized doubleblind placebo-controlled study in an inpatient hospital setting. In the study, bromocriptine reduced craving significantly more than placebo. In an additional open trial with 40 patients, bromocriptine reduced craving for cocaine and

Rosecan and Spitz (1987) reconceptualized cocaine as a uniquely addictive drug, based on its neurochemical actions. These researchers stressed that while the cocaine addict resembles the alcohol, heroin or amphetamine addict, there are important differences . When used over time, cocaine is powerfully addicting, justifying the assertion that it may be the most addictive drug and is unique among those substances abused by drug users . Acute tolerance, rebound depression (or the crash), and craving have been specifically attributed to dopamine depletion and receptor supersensitivity that follows from chronic cocaine use (Nunes & Rosecan 1987). The neurochemical changes produced by chronic cocaine use also explain the withdrawal syndrome that includes lethargy, depression, oversleeping, and overeating, in addition to the eventual craving for more cocaine (Rosecan & Spitz 1987) . Users actually experience a neurochemicaIly based need for more cocaine, which after chronic use manifests itself as an allconsuming cocaine craving (Rosecan & Spitz 1987). Because crack is a much more potent form than intranasal cocaine, the chemical disruptions it produces in the brain are more deleterious, which led Rosecan, Spitz and Gross (1987) to assert that crack is the most addictive form of the most addictive drug, cocaine. These researchers posited that the depletion of brain neurotransmitters and a supersensitivity of their receptors are presumably accelerated with crack because it is so potent. Using knowledge of etiological factors as a rationale for treatment, it follows that the neurochemical disruptions created in the brain of the crack user suggest the necessity of using pharmacological adjuncts in the treatment of crack addiction as a relapse prevention strategy addressing an important biological factor.

Inpatient Drug Abuse Treatment Programs Tropamine. Blum and colleagues (1988) presented findings that the provision of the nutritional supplement or pharmacological adjunct Tropamine" to patients (N=54) in a 30-day hospital treatment program during an open trial showed that Tropamine reduced drug craving or drug hunger. The rationale for the provision of Tropamine involves the need for neurotransmitter replacement or augmentation because of the actions of cocaine. The approach recognizes that numerous neurotransmitter systems are impacted by cocaine. The approach goes beyond a dopamine depletion hypothesis that only focuses on one neurotransmitter system. Chronic cocaine use may cause a supersensitivity of at least the dopamine, norepinephrine, and serotonin receptors while both catecholamine and indolamine transmitters are depleted (Blum et al. 1988). Tropamine includes precursors for each of the affected neurotransmitters, and it includes substances that inhibit destruction of neuropeptidyl opioids, as well as vitamins and minerals usually found to be low in drug Journal of Psychoa ctive Drugs

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also reversed the typical withdrawal symptoms of depression, irritability, anergia, and sleep disturbance. The treatment protocol of Herridge and Gold also recognizes that a brain-driven craving could result in outpatients relapsing to cocaine use and could result in inpatients signing out of the hospital. They explained that patients may remain in treatment and avoid relapse if immediate withdrawal symptoms can be reduced, which summarizes their rationale for the provision ofbromocriptine. Thus, according to their perspective, the provision of bromocriptine is phase specific for the first period of initial abstinence or withdrawal, and those chronic cocaine users suffering cravings and requiring an inpatient setting should receive bromocriptine.

nence, and early desipramine level best predicts which persons require inpatient treatment. Gawin (1989) also reported preliminary work with f1upentixol, which is an injectable and slow-release antidepressant, in an open trial. Finding suggest that cravings may decrease dramatically and further research is being pursued with this agent.

PSYCHOTROPIC MEDICATION FOR PSYCHIATRIC ILLNESS Another prominent perspective involves the use of psychotropic medication to address preexisting or coexisting psychiatric illness. From this perspective, Rosecan and Nunes (1987) discussed the use of antidepressants, lithium, methylphenidate (and other stimulants), bromocriptine, and amino acids. The use of medication in chronic cocaine abusers follows a rationale that they have a greater prevalence of affective disorders (e.g., depression, manic-depression, cyclothymia) than other substance abusers. While Rosecan and Nunes recognized that accurate diagnosis of affective illness is difficult to make with active cocaine users or those in withdrawal, they cited the fact that chronic use may intensify preexisting affective illness, that cocaine may be depressogenic for some patients, and that neurochemical changes found in depression as part of the rationale behind the use of medication. In keeping with this perspective, lithium is indicated in the treatment of cyclothymia or manic-depressive illness. Where evidence of major depression exists, the use of antidepressants is indicated. Methylphenidate or other stimulants are indicated for attention deficit disorder, and neuroleptic (antipsychotic) medication is indicated for the treatment of paranoid or other psychoses that do not resolve within 24 hours of cessation of cocaine use. Rosecan and Nunes recognized that from a psychiatric perspective, the only indication for the use ofbromocriptine involves refractory cases of cocaine abuse where relapse is a problem. From the perspective of medicating preexisting or coexisting psychiatric illness, the indication for the use of amino acids is unclear.

Outpatient Drug Abuse Treatment Programs Gawin (1989) conceived of the use of desipramine as a form of abstinence induction; once abstinence has been achieved, the standard outpatient treatment may be given an opportunity to "take hold." In this regard, Gawin views the use of antidepressants during withdrawal as facilitating discontinuation of cocaine use. Regarding phases of recovery, Gawin recognizes a "crash" that lasts from nine hours to four days. This is followed by a second period of withdrawal lasting from one to 10 weeks. In regard to the treatment of crack patients, Gawin recognized that compliance is poor and difficult with crack outpatients; some patients sell desipramine for money. Another problem involves the fact that the oral desipramine regimen takes two weeks to take effect (Gawin 1989). More recent work supports previous open trials of desipramine in combination with psychotherapy (Gawin & Kleber 1986), which showed that cocaine use decreased and eventually stopped in addition to reducing craving. Gawin (1989) reported that administering desipramine to cocaine patients during withdrawal suggests that the best predictor (r= .8) of initial abstinence being maintained is the 24-hour desipramine level that a patient presents with. Where the 24-hour desipramine level was high, patients did poorly; such individuals should be placed in an inpatient hospital setting. Individuals with a high 24-hour desipramine level seem unable to become abstinent as outpatients, and desipramine seems to fail for them at such high levels as a form of abstinence induction. On the other hand, individuals with a lower 24-hour desipramine level did well and the achievement of abstinence seemed to be facilitated by taking desipramine. Unclear as to the significance of the 24-hour desipramine level , Gawin wondered whether it is a matter of metabolism. However, these findings suggest that it is essential to carefully examine early desipramine levels, while, as Gawin stressed, the question as to what it means remains unanswered. A definite implication of early desipramine level results is that indeed some patients will require inpatient treatment in order to successfully achieve abstiJournal of Psychoactive Drugs

A SUMMARY VIEW OF PHARMACOTHERAPY Kleber (1988) characterized the literature on pharmacotherapy by pointing out that while multiple positive clinical reports exist, most of these reports are anecdotal and uncontrolled. As this research progresses, Kleber emphasized the need to elucidate the differences between treatments, to specify the target populations, and to establish the optimal dosages and duration. Kleber also emphasized that the use of pharmacological adjuncts should represent only one part of a treatment approach that includes a careful assessment of patients for individual needs, and cited 216

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a particular strategy is recommended and for whom. Whether in a phase of early initial abstinence/withdrawal, a second phase of prolonging abstinence or a third phase of pursuing lifetime recovery, an individualized assessment may bring to light the need for anyone of a number of pharmacological/medication strategies. However, it is crucial that nonpharmacological interventions also be implemented to strengthen a patient's ability to regulate behavior and spontaneously recurring impulses, feelings, and cravings. Psychoeducational interventions are invaluable toward this end as another set of strategies within a multidimensional approach to relapse prevention.

the other crucial components of what emerges as the preferred comprehensive, intensive, and multifaceted treatment approach for cocaine and crack users: provision of individual, group, and family therapy to address psychological issues; relapse prevention; learning self-control strategies (within therapy); learning ways to resist craving; and recommendations for lifestyle changes. The neurochemical disruption created in the brain of the crack smoker may be so deleterious - and neurochemically based crack craving may be so intense - that treatment professionals may be safer in assuming that restoration of brain chemistry should be pursued through the use of safe pharmacological adjuncts that require very little rationale or indication for use other than a diagnosis of crack dependence. This may be crucial in the phase of early initial abstinence/withdrawal so that crack cravings will not lead to departure from treatment and relapse to crack use. It might bedebated that in later phases, beyond withdrawal, or when patients are attempting to prolong abstinence, nonpharmacological interventions or a range of behavioral and other interventions might best address spon taneous cravings and cravings that occur in response to classically conditioned stimuli. The prolonged use ofpharmacological interventions in preparation for spontaneously occurring cravings and cravings triggered by conditioned stimuli might be judged as inappropriate and as reinforcing the concept that drug use can be self-regulated. The anhedonia that characterizes cocaine and crack patients may be a result of neurochemical events in the brain brought about by cocaine use (Gawin 1989). Or, anhedonia may beone among many defensive and/or emotional states that result when an individual has yet to learn how to identify, label , process, and manage negative feeling states and function emotionally without the use of stimulant drugs . Anhedonia may reflect a rebound phenomenon, a brain-based phenomenon, a return to a baseline personality unable to process and experience feelings in a normal fashion, or an interaction of these probable processes. Education and therapeutic support in learning to manage these dysphoric states and cravings without resorting to crack smoking or self-medication strategies may be esscntial if patients are to prolong the period of abstinence. Indeed, it may be deceptive to suggest to patients that longterm provision of a drug or medication is a solution to their emotional and behavioral problems. On the other hand, not evaluating patients for the provision of antidepressant medication can constitute an ethical neglect of some patients' needs, or failure to recognize disruptions to the brain's reward center as Gawin suggested . Only careful, individualized assessment of a patient's history, past and current functioning, mental status, and responses throughout treatment can determine when Journal

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PSYCHOEDUCATION ON THE MULTIDETERMINANTS OF RELAPSE Other important relapse prevention strategies arise from research fmdings on the multideterminants of relapse in compulsive crack cocaine smokers treated on an inpatient detoxification unit (Wallace 1989a). After a review of the pertinent research findings, a discussion of the nature of psychoeducation on the multideterminants of relapse will follow .

Research Findings on the Determinants of Relapse Among crack cocaine patients who returned for a second inpatient detoxification (N=35), microanalysis of their relapse episodes (via a Clinical Relapse Interview) yielded a typology of psychological and environmental determinants of relapse (Wallace In press-b, 1989a). The typology has value in predicting the probable determinants of relapse for crack dependent patients in general and provides the basis for psychoeducational interventions. The Psychological/Personality Domain. The typology reveals that among the internal or psychological determinants of relapse, many involve personality characteristics, such as predominance of narcissism in the newly abstinent Other internal factors involve cravings and psychological factors, such as the experience of painful or dysphoric emotional states. Specifically, findings (Wallace 1989a) show that psychological or internal determinants of relapse involve a painful emotional state (40%), den ial exacerbated by narcissistic inflation (28.5%), failure to enter arranged aftercare treatment (37.14 %), refusal of aftercare treatment before leaving drug detoxification (I 1.42%), and drug craving (5.7%). The Environmental/Interpersonal Domain. An environmental/interpersonal domain within the typology predicts determinants of relapse that involve a range of external factors. Research has revealed (Wallace 1989a) that external determinants of relapse involve environmental stimuli of people/places/drugs (34.28%) , interpersonal stress (24.38%), and escalation to drug of choice (i.e. , crack) after use of marijuana/alcohol/intranasal cocaine 217

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(14.28%). Another detenninantofrelapse within this environmental domain involves failing the hard test of handling money (11.42%). Newly abstinent patients often respond to possession of money as if it was a classically conditioned stimulus capable of provoking the response of crack smoking. Typically, possession of money (or payday) has been repeatedly paired with the pursuit of crack and compulsive crack smoking. Given the nature of Wallace's sample (1989a), the severe psychosocial deterioration characteristic of many of her patients (Wallace In press-a), and the lack of availability of treatment of sufficient intensity (for those within the New York metropolitan area without private insurance or adequate finances), other external determinants prevail. Because many patients have stolen from family members, lost family support,lost their apartments and/or have been asked to leave the residences of family and friends, homelessness results for some (19%) (Wallace In press-a). Being homeless or lacking family support can serve as a determinant of relapse (14.28%). Such individuals require direct entrance into a residential therapeutic community (TC) after completing inpatient detoxification. This is not only the intervention of sufficient intensity for many compulsive, high-dose, high-frequency crack smokers, but also the only rational treatment intervention for the homeless. However, TC shortcomings also account for instances of relapse (20%) (Wallace In press-a). TC shortcomings include long waiting lists (three days to three weeks for the homeless; two, eight to sixteen weeks for domiciled clients), an inability to accommodate residents with a history of suicide attempts or assaultive homicidal behavior, rejection of those who require psychiatric medication, and refusal to admit those with significant medical problems. In light of these TC deficiencies, many individuals experience these factors as determinants of a relapse episode. Despite the recommendations of Rainone, Kott and Maranda (1988), many TCs have yet to add the psychiatric and medical staff needed in order to meet the needs of crack addicts within these settings. MultideterminantsofRelapse. Perhaps most important is that research findings indicate that multideterminants underlie the process of relapse. Relapse episodes emerge as complex events occurring across a period of time and involving a number of factors. Wallace (1989a) reported that the majority of relapse episodes do not involve only one factor (14.28%), or only a psychological determinant (8.57%), or only an environmental determinant (I 7.14%). Instead, among the eleven determinants of relapse falling under the two domains of the typology, the majority of relapse episodes involve a combination of two factors (37.13%) or a combination of three determinants (40%). In fact, the vast majority (85.7%) involve muItidetenninants. Numerous case examples (Wallace In press-b, 1989a) illustrate the process of relapse and how mulitdeterminants of relapse operate in bringing about a Journal of Psychoactive Drugs

return to a pattern of compulsive crack smoking. Time to Relapse. Within the research sample (Wallace 1989a), all patients underwent a 14-day inpatient detoxification during the period of early initial abstinence/withdrawal. After leaving detoxification, results for "time to relapse" indicated that 31.4% relapsed within a week, 24.3% relapsed between two weeks and a month, 20% relapsed between 60 and 90 days, 8.6% relapsed between 3.5 and 4 .5 months, and 5.7% relapsed between six and seven months; totaling 94.3% before six months had expired. Within the first 90 days postdetoxification, 76% relapsed. These findings highlight the kind of vulnerability that patients have in the second phase of prolonging abstinence, where the risk of relapse persists. Also, these findings underscore the necessity of direct entrance into an aftercare treatment modality of appropriate intensity. Moreover, these findings emphasize the need for treatment to extend at least up to six months if not up to a year or more for many crack dependent patients.

THE NATURE OF PSYCHOEDUCATIONAL INTERVENTIONS A total of27 psychoeducational interventions directly arise from the research findings (Wallace 1989a) summarized above on the multidetenninants of compulsive crack cocaine smokers' relapse episodes. Interventions spell out in substantial detail what clinicians can actually say and do within the context of a one-hour psychoeducational group, providing extensive relapse prevention directives that go beyond the usual "avoid people, places, and things." The interventions graphically and persuasively depict the vulnerability to relapse that patients have. Interventions explain behavioral principles of classic conditioning and the process of extinction through metaphorical forms of communication. This provides patients with a cognitive and intellectual framework in which they can understand the challenge involved in prolonging abstinence. Wallace (1989b) placed great emphasis on the value of metaphorica forms of communication in bypassing narcissism and denial, and in increasing the patients' motivation to engage in preventive alternative behaviors to avoid relapse. Interventions educate patients to the numerous psychological and emotional vulnerabilities that they have and how to manage high-risk situations that may trigger relapse, offering hope of successful avoidance of relapse. Clinicians draw on knowledge of psychodynamic theory in explaining self-medication strategies and the impact of childhood trauma on psychological development. The provision of education on defensive functioning (e.g., denial, inflation) represents an important component of relapse prevention in psychoeducational groups. Metaphorical forms of communication also serve to circumvent the very defenses that are being described. 218

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Patients identify with the graphic and colorful descriptions of defensive activities that they have utilized, and are drawn into an appreciation of how they are dangerous and may lead to relapse, instead of rapidly dismissing the information (Wallace 1989b). Education spells out how defensive functioning may have roots in inadequate childhood development in dysfunctional family systems. Psychoeducation also covers the psychological, behavioral, and emotional impact of childhood experiences in dysfunctional families, and it attempts to convey the process of therapy and remediation of resulting problems. Interventions provide an in-depth description of the process and purpose of individual psychotherapy. Thus, after psychoeducational groups, patients are better prepared to meaningfully engage in individual sessions on inpatient detoxification and within aftercare treatment modalities postdetoxification. Detailed descriptions of all 27 of these interventions have appeared elsewhere (see Wallace In press-b, 1989b). The value of the interventions lies in their being directly derived from research findings (Wallace 1989a) on the multideterminants of relapse in crack cocaine smokers.

crack patients. Subtle psychopathology found in patterns of personality or affective disturbance that fail to meet criteria for mental disorders involve many of the problems attributed to adult children of alcoholics (ACA s), such as problems with intimacy, trust and control, as well as difficulty identifying or expressing feelings (Ackerman 1987; Black 1985, 1981; Wanck 1985; Woititz 1985, 1983; Cermak & Brown 1982). Also, "defects in ego and self capacities which leave people ill-equipped to regulate and modulate feelings, self-esteem, relationships and behavior" (Khantzian 1985 : 1) are evident through clinical assessments of crack dependent patients. Because of these characteristics, ACAs and adult children of dysfunctional families may possess a greater susceptibility to development of an addiction. Drugs are experienced as extrareinforcing - beyond the pharmacological actions of cocaine as the most reinforcing of all drugs, as indicated in laboratory animal studies (Rosecan & Spitz 1987; Johanson 1984) - when they serve to ameliorate underlying feelings of bodily tension, anxiety, depression or low self-esteem. The impact of drugs is also extrareinforcing when they improve self-regulatory capacities. When drugs are experienced as ex trarein forcing , experimental users are likely to seek out the psychoactive effects again and again, becoming recreational users. Because of the susceptibility or vulnerability to experience drugs as extrareinforcing, ACAs and children of dysfunctional families may easily escalate to abuse and dependence syndromes. Having escalated to crack dependence, it follows that a third dimension or relapse prevention should involve remediating those underlying psychological, behavioral, and emotional problems that characterize crack patients and left them vulnerable to development of crack addiction. The remediation of deficits in self-regulatory capacities remains an essential part of any treatment strategy aiming to insure long-term successful recovery and avoidance of relapse to crack or involvement in any other compulsive behavior. As Tuchfeld (1986) suggested, psychoeducation is a sufficient intervention for many ACAs, while others require more substantial treatment interventions. In the case of crack dependent individuals who are also ACAs or children of dysfunctional families, psychoeducation of the kind described above (also see Wallace 1989b) may prepare patients for engagement in long-term treatment. Psychoeducation alone remains insufficient for those crack patients presenting either diagnosable and even more subtle psychopathology that left them vulnerable for escalation to an addictive disorder. During the first 90 days to six months of abstinence, patients need substantial support to manage painful emotional states and interpersonal stress arising from poor selfregulatory capacities. Individual and group psychotherapy

REMEDIATION OF PSYCHOPATHOLOGY AS RELAPSE PREVENTION A rationale exists for viewing remediation of underlying psychological and emotional problems that are characteristic of crack dependent patients (Wallace 1990) as a third important component of a broad relapse prevention strategy. This rationale is based on research findings on the psychosocial characteristics of crack dependent patients. Evidence of psychosocial development in a dysfunctional family and ofresulting psychological and social problems suggests the necessity of treatment that attempts to remediate underlying psychological problems of crack patients. Findings suggest that the majority of crack dependent patients are adult children of alcoholic families (60.7%) and adult children of dysfunctional families (96.7%) of one kind or another (Wallace 1990). The consequences of development in a dysfunctional family vary (Ackerman 1987). A thorough, individualized assessment can determine the role, meaning, and impact of these childhood events and the possible relationship to drug use. As a result of clinical assessment through interviews and observation, Wallace reported fmding an interesting pattern of personality and affective disorders in crack patients that may be a manifestation of traumatic childhood developmental experiences . In many cases, patients present narcissistic traits and patterns of personality and affective disturbance that do not meet the criteria for mental disorders. Narcissistic traits of grandiosity, very fragile self-esteem, and a wellhidden (painfully) low self-esteem characterize many Journal of Psychoactive Drugs

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can playa crucial role in helping patients learn to identify, label, and process painful feeling states instead of resorting to self-medication strategies with illicit drugs. Moreover, within individual and group psychotherapy, crack patients need help integrating into consciousness recurrent dysphoric slates and traumatic memories of childhood events. Treatment professionals must also assist patients in understanding and changing behavioral dramas and transference states in which they act out dysfunctional childhood dynamics. An inability to regulate behavior and impulses in interpersonal relationships typically rests in a tendency to master the anxiety of childhood trauma by unconsciously acting out transference dramas or recreating dysfunctional family patterns in adult relationships. These dynamics may emerge within residential treatment programs and within group therapy settings, or they are described and acted out within long-term individual therapy. When this occurs, an opportunity exists for promoting conscious awareness of behavioral patterns and creating new and more adaptive behaviors, as well as reducing chances of engagement in destructive, compulsive behavioral patterns. Thus, the third dimension of a multidimensional ap proach to relapse prevention includes the provision of professional psychotherapy on a long-term basis, which can empower patients to better regulate their interpersonal behavior, imp ulses , affective states, and self-esteem. Remediation of underlying behavioral, psychological, and emotional problems that are typical of crack dependent individuals cannot be overlooked as an important avenue by which successful long-term recovery from crack addiction can be achieved. Meanwhile, chances of a future addiction developing with a new designer drug, such as ice (methamphetamine), or of engagement in some other destructive compulsive behavior, such as gambling, overeating, workaholism or shopaholism, are substantially reduced.

from crack. Thus, administration of pharmacological adjuncts constitutes one dimension of relapse prevention that may be absolutely necessary for the vast majority of crack dependent patients, who very likely suffer intense cravings. However, only individualized assessment can determine the appropriateness of administering pharmacological adjuncts. However, given the state of this nascent field, further research is necessary to specify which pharmacological adjuncts are best for which kinds of patients. It is important to note that the work of several researchers in this field has emphasized that treatment professionals may be remiss in assuming that the withdrawal from crack and the nature of chronic crack-induced neurochemical brain disruption does not warrant the use of pharmacological treatment adjuncts. Instead, those designing treatment programs and attempting to reduce high-relapse or highdropout rates need to review the best available research data and implement the use of pharmacological adjuncts. A second strategy within a multidimensional ap proach to relapse prevention is the utilization of psychoeducational interventions that prepare patients to avoid high-risk situations that are likely to lead to relapse. In light of research findings on the multideterminants of relapse for crack cocaine smokers, a model of relapse prevention is proposed that encompasses 27 interventions that can be used in group or individual contexts. The recommended interventions maximize the value of metaphorical forms of communication in bypassing defenses of denial , grandiosity and inflation, as well as motivating patients to engage in alternative preventive behaviors to avoid relapse. The interventions are in keeping with a biopsychosocial model of crack addiction that recognizes that social and psychological factors interact in the development and maintenance of an addiction; they also recognize the social/environmental factors and even explicate behavioral principles of classic conditioning and extinction. Moreover, psychological factors receive recognition, with education extensively covering the impact of growing up in dysfunctional families, the resulting problems in identifying feelings, and the process of therapy that is necessary to permit patients to achieve self-regulation without resorting to self-medication with drugs. Thus, the second dimension of this approach to relapse prevention attempts to practically equip patients to engage in alternative preventive behaviors and empower patients to avoid high-risk situations through psychoeducation. The third dimension of this approach to relapse prevention involves the need for remediation of the underlying behavioral, psychological, and emotional problems of crack patients that are rooted in childhood trauma experienced in dysfunctional families. Only by learning how to identify and process feelings or to better regulate selfestee m or to manage recurrent painful feeling states and

CONCLUSION Thi s article articulates an approach to relapse prevention that grows out of an appreciation of the biopsychosocial variables that underlie the development and maintenance of an addictive disorder. In recognition of biological factors, there has been an attempt to justify the use of pharmacological adjuncts through knowledge of the etiology of compulsive crack smoking, inasmuch as it partially rests in crack-induced neurochemical disruption of brain function . This understanding of biological variables in the development and maintenance of crack addiction supports the logic of administering pharmacological adjuncts to crack dependent patients. The provision of pharmacological adjuncts may reduce neurochemically based cravings that are likely to lead to relapse in the withdrawal phase Journal of Psychoacti ve Dru gs

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bodily tension can patients avoid relapse and successfully recover from addiction. Moreover, the chances of addiction to some new designer drug in the future or engagement in some other compulsive behavior may only be reduced through remediating those underlying vulnerabilities or susceptibilities that left experimental crack users vulnerable for escalation to the abuse and dependence syndromes. Treatment professionals seeking to dev elop, refine or evaluate crack cocaine treatment models will find within this article a prescription for the kind of multidimensional approach to relapse prevention necessary to reduce the high risk of relapse among crack dependent patients. Even the hard-core compulsive crack smoker who must negotiate crack-ridden neighborhoods can receive sufficiently intensive and comprehensive treatment services that will substantially reduce chances of relapse. However, such services must first be designed and then made available to those without sufficient funds or private medical insurance. However, there are several limitations to thisapproach to relapse prevention. The present author has not validated through long-term outcome evaluation research the value of this multidimensional approach to relapse prevention. Nevertheless, individual components of this approach have received some direct and indirect support. Preliminary research indicates the value and importance of the use of various pharmacological adjunctive approaches, as the studies reviewed in this article suggest. Based on research fmdings of "what works" with employed cocaine and crack addicts, Wash ton (l989b) reported on the success of outpatient rehabilitation treatment, the success of inpatient treatment followed by intensive

and comprehensive outpatient treatment, and especially the importance of intensive long-term aftercare treatment emphasizing relapse prevention for all substance abusers. Of those who had inpatient treatment prior to long-term aftercare treatment, 64% were abstinent at six- to 18-month follow-up; and of those who were outpatients all along , 68% were abstinent according to urine tests and clinical interviews. What is somewhat novel and not supported by research at this time is the assertion that remediation of underlying problems in self-regulation that are characteristic of crack dependent individuals reduces the chances of relapse. The literature on psychopathology in individuals with addictive disorders discusses the relationship between the two, but it does not include research with crack dependent persons (Meyers 1986). However, Wanck (1985) reported that ACAs recovering from alcoholism present higher relapse rates than those without this status. Thus , in a roundabout fashion, and in light of data that significant numbers of crack smokers are ACAs and/or from dysfunctional families, a rationale exists for remediating the psychological consequences of inadequate childhood development within dysfunctional families, even though supportive empirical evidence is lacking. Only long-term outcome evaluation research can support the validity of the multidimensional approach to relapse prevention offered in the present article. On the other hand, for those working with the challenging crack dependent patient population, it provides a timely description of a comprehensive and promising model of relapse prevention that is specifically designed to improve treatm ent outcome with the compulsive crack cocaine smoker.

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