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 (1990) Treating Crack Cocaine Dependence: The Critical Role of Relapse Prevention, Journal of Psychoactive Drugs, 22:2, 149-158, DOI: 10.1080/02791072.1990.10472540 To link to this article: http://dx.doi.org/10.1080/02791072.1990.10472540

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Treating Crack Cocaine

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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. treatment

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 pr0grams be designed at the outset to hold some promise of reducing the likelihood ofrelapse. 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 tha; 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 provision of pharmacological adjuncts, (2) psychoeducation on the multideterminants of relapse, and (3) remediation

tResearch for this article was conducted in cooperation with Interfaith Medical Center, Depanment of Psychiatry, Brooklyn,New York. • Assistant Professor, African-American Studies Department, John Jay College of CrirninalJustice, City University of New York, 454 West 59th Street, New York, New York 10019.

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

treatment strateg ie s. A ph as e 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 arti cle should be provided during this first period of reco very, the with draw al phase . Next, a phas e of prolon ging abstinence ex tends up to the first six months of rec overy. 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 abs tinence. Thus, the task of avoiding a slip or relap se is positively and cognitively reframed in terms of the goal of prolon ging the period ofabstinence. A third phase of pur suing lifetime recovery involv es a one-year to several-year to lifetime period where a risk of relapse co ntinues to exi st. Here, it is impor tant 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, drugfrec behavior remains a relatively strong possibility for these recovering persons. Con tinuing long-term treatment, which further reinforces adaptive alternative beha viors to the use of drugs, can reduce the chances of engaging in compu lsive or destruc tive behaviors of any kind. Trea tment should also attempt to remedy underlying psychological and emotional problems that represent a vulnerability or suscepti bility to the development and maintenance of addictive disorders . This tre a tment will vary in length. In this way, co ntinui ng 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 anoth er addicti ve or compulsive behavior. The idea of phases of treatment and recovery play s an importan t role in determ ining 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 con cept of phases ofrecovery. A particular relapse prevention strategy can be utilized duri ng either an early initial abstinence/withdrawal phase. a second phase of prolonging abstinence or a third phase of pursuing lifetime recovery.

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A BIOPSYCHOSOCIAL MODEL O F CRACK DEPENDENC E

The model of relapse prevention presented in this article grows out of a biopsychosocial approach (Donovan 1988; Donovan & Marlatt 1988) to crack addic tion. A biopsychosocial approach focuses attention on biological, psychological, and social facto rs that underlie the deve lopment and maintenance of an addictive behavior. In this regard, Wallace (In press-b) presents an elaborate biopsychosocial model of crack addiction . Sim ilarly, the model of relapse prevention prese nted in the presen t article acknowledges that multiple interacting variables play a role in the addic tive proce ss. In addition, a biopsychosocial model of addiction embraces the principle that careful assessment determin es which spec ific 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 spec ific treatments following a graded series of interventions; that is, the least intensive inte rventions are attempted befor e more intensive treatment interventions are pursued. A relapse or failure to achieve abstine nce 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 Marl att (1985), a microanalysis of relap se episodes through a Clinical Relapse Intervi ew (Wallace In press-b, 1989a) will permit the clinician and patient to engage in a detailed analysis of a relapse episode in searc h of the determinants of that relapse. Findings should indicate how treatment must be intensified and relapse prevention strategies modi fied if the period of abstinence is to be successfully prolonged and another relapse episode avoided. In this way, a relapse episode may represent an opportunity for positive grow th, indicating areas in which behavioral change must occur; a view that is co ns istent 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 (198 5).

USE OF PHARMACOLOGICAL ADJUNCTS IN THE TREATMENT OF CRACK DEPENDENCE

The use of medications, am ino acids, nutri ents, and vitami ns 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 pharmac ological adjuncts to address the consequences of chro nic crack smoking.

PHASE S OF T R E ATMENT AND R ECOVERY

The concept of phases of treatment and recovery also guides decisions on the process of implementing diverse Journal ofPsychoac tive Drugs

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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 et 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 promising 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 of this 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 patieets 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 dopamine 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 ad dict, 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 neurochemically based need for more cocaine, which after chronic use manifests itself as an all consuming 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 re searchers 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 Troparninef 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 a1. 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 JOIU7laI ofPsychoactive 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 rem ain in treatment and avoid relapse if immediate withdrawal symptoms can be reduced, which summarize s their rationale for the provision ofbromocriptine. Thus, according to their perspective, the provision of bro mocrip tine is phase specific for the first period of initial abstinence or withdrawal , and tho se chronic cocain e user s suffering cravings and requiring an inpatient setting should receive bromoc rip tine,

nence, and early desipramine level best predicts which persons require inpatient treatment. Gawin (1989) also reported preliminary work with tlupentixol, which is an injectable and slow-release antidepressant, in an open trial. Finding sugges t that cravings may dec rease dramatically and further research is being pursued with this agent. PSYCHOTROPIC MEDICATION FOR PSY CHIATRIC ILLNESS Another prominent perspective involves the usc of psychotropic medicat ion to address preexisting or coexisting psychiatric illness. From this perspective, Rosecan and Nun es (1987) discu ssed the use of antidepres san ts, li thi um , methylpheni da te (a nd other stim ulan ts ), bromocriptinc, and amino acids. The use of medication in chro nic cocaine abusers follows a rationale that they have a greater prevalence of affective disorders (e.g., depression , manic-depression, cyclo thymia) than other substance abusers. While Rosecan and Nunes recognized that accurate diagnosis of affective illn ess is di fficult to make with active cocaine users or those in withdrawal, they cited the fact that chronic use may intensify preexi sting affective illness , that cocaine may be depressogenic for some pa tients, and that neurochemical changes found in depres sion as par t of the rat ionale behind the use of medication . In keeping with this perspec tive.Iithium is indi cated in the treatment of cyclothymia or manic-depressive illness. Where e.videnc e of major de pression exist", the use of antidepressants is indicated. Methylph enidate or other sti mulants arc indicated for auention defi cit disord er, and neuroleptic (antipsychotic) medication is indicated for the treatment of paranoid or oth er psychoses that do no t resolve within 24 hours of cessation of cocaine use. Rosecan and Nunes recognized that from a psychiatric perspective, the only ind ication for the use ofbromocri pti ne involves refractory cases of cocaine abuse where relap se is a problem . From the perspective of medicating preexisting or coexisting psychiatric illness, the indic ation for the use of amino acids is unclear.

Outpatient Drug Abuse Trea tmen t Programs Gawin (1989) conceived of the use of des ipramine as a form of abstinence induction; once abstinence has been achi eved, the standard outpatient treatment may be given an opportunity to "tak e hold." In this regard, Gawin views the use of antidepressants during withdrawal as facilitating discontinuation of cocaine use. Regardin g phases of recovery, Gawin recogni zes a "crash " that lasts from nine hours to four days. Thi s is follow ed by a second pe riod of w ithdrawal lasting from one to 10 week s. In regard to the treatment of crack patients, Gawin recognized that compliance is poor and difficult with crack outpatients; some patients sell desipramine for mon ey. Another problem involves the fact that the oral desipramin e regimen tak es tw o weeks to take effect (Gawin 1989). More recent work supports prev ious open trials of desip ramin e in combination with psychotherapy (Gawin & Kleber 1986), which showed that cocaine use decreased and eve ntually stopped in addition to reducing craving. Gawi n (1989) reported that administering desipramine to cocaine patien ts 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 , pati ents did poorly; su ch individuals s hould be pla ced in an inpatient hospital setting. Individuals with a high 24- hour desip ramin e level seem unable to becom e 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 lowe r 24-hour desipramine level did well and the achievement of abstinence see med 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 care fully exa mine early desipramine levels, whil e, as Gawin stressed , the question as to what it means remains un an sw ered. A definite implication of early desipramine lev el results is that indeed some patien ts will req uire inpati ent treatment in order to successfully achieve abs tiJourn al ofPsychoactiv e Drugs

A SUMMARY VI EW 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 elu cidate the differences between treatments, to specify the targ et populations, and to establish the optimal dosages and duration . Kleber also emphasized that the lISC of pharmacological adjuncts should represent only one part of a treatm ent approach that includes a carefu l assessment of patients for ind ividual nee ds, and cited 152

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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 be debated that in later phases, beyond withdrawal, or when patients are attempting to prolong abstinence, non pharmacological interventions or a range ofbe havioral and other interventions might best address spontaneous cravings and cravings that occur in response to classically conditioned stimuli. The prolonged use of pharmacological 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 be one among many defensive and/or emotional states that result when an individual has yet to learn how to identify, label, process, and manage negative feel ing 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 essential 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 JOUTNJI

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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 or 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. ThePsychological/Personality Domain. The typology reveals that among the internal or psychological determinants ofrelapse, 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%), denial exacerbated by narcissistic inflation (28.5%), failure to enter arranged aftercare treatment (37 .14%), refusal of aftercare treatment before leaving drug detoxification (11.42%), and drug craving (5.7%). The Environmentaltlnterpersonal 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 153

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(14.28 %). Another determinant ofrelapse 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 conditio ned stimulus capable of provoking the response of crack smoking. Typically, poss ession of money (or payday) has been repeatedly paired with the pursuit of crack and compulsive crack smoking. Given the nature ofWallacc's sample (1989a), the severe psychosocial deterioration characteristic of many of her patients (Wallace In press-a), and the lack of availability of treatmen t of sufficient intensity (for those within the Ne w York metropolitan area without private insurance or adequate finances) , oth er ex terna l determ inan ts preva il. Because many patien ts have stolen from family members, lost family support, lost their apartments and/or have been asked to leave the residenc es of family and friends, homelcssness results for so me (19 %) (Wallac e 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 therap eutic 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 treatm ent interve ntion for the homeless. However, TC shortcomings also account for instances of relapse (20 %) (Wallace In press-a) . TC shortcomings include lon g waiting lists (three days to three weeks for the homeless; two, eight to sixteen weeks for domi ciled clients), an inability to accommodate residents with a history of suicide attempts or assaultive homicidal behavior, rejection of those who require psychiatric medication, and refu sal to admit those with significant medic al problem s. In light of these TC deficiencies, many individuals experienc e these factors as determinants of a relapse episode. Despite the re commendations of Rainone , Kott and Maranda (1988), many TCs have yet to add the psychiatric and medical sta ff needed in order to meet the needs of crack addicts within these settings. Multideterminants ofRelapse. Perhaps most important is that research findings indicate that multideterm inants underlie the proc ess of relapse. Relapse episodes emerge as complex events occurring across a period of time and involv ing a number of factors. Wallac e (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 determi nant (17 .14%). Instead, among the eleven determinants of relap se falling under the two dom ains of the typolo gy, the majo rity of relapse episodes involve a combination of two factors (37.13 %) or a combination of three determinan ts (40%). In fact , the vast majority (85 .7%) involv e multid eterminants. Numerous case examples (Wallace In press- b. 1989a) illustrate the proc ess of rela pse and how mulit determi nan ts of relapse oper ate in bringing about a Journa l ofPsyc hoa ctive 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" indi cated that 31.4% relapsed within a week, 24.3% relapsed between two weeks and a month , 20% relapsed between 60 and 90 day s, 8.6 % relapsed between 3.5 and 4.5 months, and 5.7% relapsed between six and seve n 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 per sists. 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 cra ck dependent patients.

THE NATURE OF PSYCHOEDUCATI ONAL INTERVENTIONS A total of27 psychocducational interventions directly arise from the research finding s (Wallace 1989a) summarized above on the multidetenninants of compulsive crack cocaine smokers' relapse episodes. Intervention s spell out in substantial detail what clinicians can actually say and do within the context of a one-hour psy choeducational group, providing extensive relapse prevention directives that go beyond the usu al "a vo id peopl e, 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 proc ess 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 metaphorical 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., de nial, inflation) represents an important component of rel ap se pr evention in psychoeducational groups. Metaphorical forms of communication also serve to ci rcumven t the very defenses th at a re bein g described. 154

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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 (ACAs), 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 extrareinforcing, 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 10 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 of resulting 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 ofPsychoactive Drugs

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fro m crack. Thus, adm inistration of pharmacological adjuncts constitutes one dim ension of relapse prevention that may be abso lutely necessary fo r the vast maj orit y of crack dependent patients, who very likely suffer intense cravings. However, only individualized assessm ent can determ ine the appropriateness of adm inistering pharm acologi cal adj uncts . However, given the state of this nascent field, fur ther research is necessary to spec ify which pharmacological adjuncts are best for which kinds of patients. It is im portan t to not e that the work of several researchers in this fie ld has emphasized that trea tment professionals may be remiss in ass uming that the withdrawal from crack and the nature of chronic crack-induced neurochemical brain dis ruption docs not warra nt the use of pharmacological treatmen t adju ncts. Instead, those de signing treatment programs and attempting to reduce high-rel ap se or highdro pout rates need to review the bes t available research data and implement the use of pharmacological adjuncts, A second stra teg y within a m ultidi men sional approach to relapse prevention is the uti lization of psychoed uca tional int erventions that prepar e pati ents 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 mode l of relapse preven tion is proposed that encompasses 27 interve ntions that can be used in group or individual contexts. Th e recommended in terventions maximize the value of metaphorical forms o f c om munica tion in b ypassing de fenses o f deni al, gran diosity and infl ation, as well a s mot ivating pa tients to engage in alternative preventive behaviors to avoid relapse. The interventions are in keeping with a biopsychosocial mod el of crack addiction that recogni zes that soc ial and psychological factors interact in the development and maintenance of an add iction; they also recogni ze the so cial/e nvironmental factors and even explicate behavioral pr incip les o f classic co ndi ti oni ng and e xtinctio n . Moreover, psychological factors receive recognition, with ed ucation 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 patien ts to achieve self-regulation without resorting to self-medication with drugs. T hus, the sec ond dimension of this approach to relap se prev ention attempts to practically equip pati ents to engage in alt ernative preventi ve behaviors and empower patients to avo id high-risk si tuati ons through psychoeducation. The third dimension of this approach to relapse preven tio n involves the need for remediation of the und er lying behavioral, psychological, and emotional problems of crack pa tients that are rooted in childhood trauma experienced in dysfunctional families. Only by learnin g how to identify and process feelings or to better regulate se lfes tee m or to man age recurrent painful feel in g sta tes an d

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 drug s. Moreover, within individual and group psychotherapy, crack patients need help integrating into consciousness recurrent dysphoric states and traumatic memori es of childhood events. Treatment pro fes sionals must al so assist patients in understanding and changing behavioral dramas and transferen ce states in which they act out dysfu nctional childhood dynamics. An inability to regulate behavior and impulses in interpersonal relation ship s typ icall y res ts in a tendency to master the anxiety of childhood trauma by uncon sciou sly acting out transference dram as or recrea ting dysfunctional family patterns in adult relation ships. These dyn am ics may emerge with in resid enti al treatm ent programs and w ithin group therapy se ttings, or they are described and acted out within long-term individual therapy. When this occurs , an opportun ity exists for promoting conscious awareness of behavioral patterns and creating new and more adaptive behaviors, as well as reducing chances of engagement in destru ctive, compulsive behavio ral patterns. Thus, the third dimension of a multidimension al ap proach to relapse prevention includes the provision of professional psychotherapy on a long -term basis, wh ich can empower patients to better regulate their interpersonal behav ior, impu lses , affective sta tes, and se lf -estee m . Remediation of underlying behavioral, psychological, and emo tio nal problems that are typi cal of crack depen den t indiv iduals can not be overlooked as an important avenue by which successful long-term recovery from crack ad diction can be ach ieved. Mea nwhil e, chances of a future addiction developing with a new design er dru g, such as ice (methamphetamine), or of eng agem ent in som e other destructive compulsive behavior, such as gamblin g, overeating, workaholism or shopaholism, are substantially reduced .

CONC LUS ION This 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 disord er. 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 func tion. Th is under standing of biological variables in the development and mai ntenance of crack addi ction supports the log ic of administering ph armacologic al adj uncts to crack dependent patients. The pro vision of pharmacological adj uncts may reduc e neurochemicall y based cra vings that are like ly to lead to relapse in the wi thdrawal phase Journal of Psychoactive Dr ugs

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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% wereabstinentatsix-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 treatment outcome with the compulsive crack cocaine smoker.

bodily tension can patients avoid relapse and suceessfu~ly 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 develop, 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 thisapproach 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 (1989b) reported on the success of outpatient rehabilitation treatment, the success of inpatient treatment followed by intensive

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