Epidemiology

In the past, narcotic addicts commonly were addicted primarily to heroin, and much less often secondarily addicted to alcohol and benzodiazepines. Before 1980, less than 10 percent of methadone patients had at least one cocaine-positive urine. Today, however, many heroin addicts entering MTPs are simultaneously addicted to cocaine, and cocaine use among this population has increased steadily since the 1980s. In 1981, a New York City study noted that only 21 percent of methadone patients had at least one cocaine-positive urine, but by 1988, the figure had risen to 63 percent (Hartel et al. 1989). However, widespread cocaine use by methadone patients has not been limited to New York City and other East Coast metropolitan areas: two studies of methadone programs nationwide found that 20-40 percent of the patients were using cocaine (Condelli et al. 1991; Magura et al. 1991).

Increased cocaine use among methadone patients partly reflects a widespread increase in cocaine use nationwide since 1973. Johnson and Muffler (1992), in their overview of the epidemiology of drug use and abuse, call the years 1965-1973 the "heroin era," 1975-1984 the "cocaine and freebase era," and 1985 to the present the "crack era." Data from the National Institute on Drug Abuse (NIDA) Drug Abuse Warning Network (DAWN) show that the number of cocaine mentions in emergency room episodes increased progressively during the 1980s. Since 1990, this number has continued to increase. Following a 27-percent decrease between 1989 and 1990, mentions of cocaine use rose 26 percent between 1990 and 1991 and an additional 18 percent between 1991 and 1992 (NIDA 1993) (see figure).

Cocaine and heroin are sometimes used together in a practice commonly known as "speedballing." Some patients claim that methadone lengthens and mellows the effects of cocaine, presumably attenuating the negative reinforcers associated with cocaine crash (Condelli et al. 1991). Some patients also use alcohol or benzodiazepines or both concurrently with cocaine and heroin to reduce these effects of the cocaine crash, often marked by anxiety, depression, fatigue, and jitteriness. Thus, just as heroin use can increase the likelihood of cocaine dependence, cocaine use can increase the risk of heroin dependence as cocaine's side effects are titrated with opioids to modulate the cocaine crash and reduce cocaine-induced agitation (Barthwell and Gastfriend 1993).

Cocaine and heroin may also be used separately. When a heroin addict receives a blocking dose of methadone, heroin will not produce euphoria because of the increased cross-tolerance produced by the methadone (Kosten et al. 1987b). Cocaine remains effective because it does not work through the opioid receptors. Cocaine use has been known to influence methadone patients to buy additional methadone illicitly because they believe that cocaine decreases methadone levels in the system and fear opioid withdrawal symptoms (Hunt et al. 1984). Some clinicians also believe that methadone patients who abuse cocaine are more likely to divert their methadone take-home bottles to support their stimulant habit.

The increased availability of both cocaine and heroin has further exacerbated the problem. Cocaine is available in relatively affordable quantities and can be obtained easily, often in close proximity to many MTP sites. The cost of heroin has declined in many communities, making it easily affordable as well.

Studies have been conducted on indicators that predict cocaine use among methadone patients. The findings are diverse. Preadmission use of cocaine is a possible predictor of postadmission use. Depressive symptoms at admission, demographics, and psychiatric comorbidity have also been examined as possible risk factors for continued cocaine use during treatment. Some patients use cocaine because they used it before using methadone; others use it because it is prevalent and cheap. A subgroup of methadone patients that is difficult to characterize may use cocaine to ameliorate psychiatric symptoms or the sedating effects of opioids. At this time findings about subgroups of cocaine users remain inconclusive (Magura et al. 1991).

Program Interventions

Studies of MTPs show that they are generally effective in reducing heroin use. However, the literature review of Dunteman and coworkers (1992) on the effectiveness of MTPs regarding cocaine use indicates both a paucity of published research on the subject and diverse, somewhat conflicting findings. For example, Magura et al. (1991) reported a decrease in cocaine use from 84 percent at admission to 66 percent after 6 months in treatment; Hartel et al. (1989) reported that prevalence of cocaine use was lower for patients receiving more than 70 mg/day of methadone. However, Chaisson et al. (1989) noted that while methadone therapy was associated with substantial reductions in heroin use and some reduction in cocaine use, 24 percent of cocaine users receiving methadone began or increased cocaine use after entry into treatment.

Research by Kosten et al. (1987b; 1992) on cocaine abuse among methadone patients suggests that the combination of methadone maintenance and routine drug counseling is poorly suited to control concurrent drug abuse. Instead, MTPs must begin to deal with the increase in cocaine abuse among their patients by supplementing routine methadone treatment with additional counseling focused on cocaine abuse and possibly with other pharmacological interventions. In addition to reducing cocaine use among methadone patients, MTPs are also challenged to address the social, psychological, and physiological problems that elicit and reinforce the use of cocaine (Condelli et al. 1991). Condelli and coworkers found that interventions used for other types of cocaine users do not always work for methadone patients addicted to cocaine. Furthermore, their literature review indicates that only a few MTPs have implemented any behavioral interventions for cocaine abuse. Stark and Campbell's (1991) research suggests that methadone patients addicted to cocaine are more difficult to treat, in part because of their longstanding addiction and its concomitant effects in psychological, legal, social, and vocational realms. It is important to remember that individual patients and subgroups of patients have different needs and, therefore, require different interventions.

Although some programs have attempted a variety of interventions to treat concurrent dependency on opioids and cocaine, a significant need remains for additional research. Some of these interventions have met with controversy. For example, a number of programs have experimented with lowering methadone doses or withdrawing and discharging patients after they have had a succession of positive urine tests for cocaine. Since patients often highly value methadone maintenance, the possibility of being withdrawn from methadone because of continued cocaine or other stimulant abuse may motivate some patients to discontinue their cocaine use. Even when this strategy is not successful for a particular patient, adherence to this policy may have a beneficial effect on the program overall by discouraging other patients from beginning or continuing to use other stimulants. It may also have a delayed impact on the patient who is discharged from the methadone program for continued stimulant abuse. On subsequent readmission, the patient may be less likely to begin or to continue stimulant use for fear of being withdrawn from methadone.

Proponents of this approach believe that the failure to respond to a patient's continued stimulant abuse with a series of progressively stringent negative sanctions allows patients to ignore the negative consequences of their stimulant abuse.

Opponents of this view argue that in this era of increasing human immunodeficiency virus (HIV) infection rates among injecting drug users, there are health reasons for not implementing interventions that may cause an injecting drug user to leave treatment. Continuation of an adequate dose of methadone can help patients to achieve a stable lifestyle, which may result in improved family relationships, better employment status, decreased criminal behavior, and reduced behavioral problems. These benefits, however, have not been evaluated within the context of concurrent cocaine abuse.

MTPs addressing the cocaine addiction of their patients have attempted a variety of behavioral interventions. For example, after a number of cocaine-positive urine tests, a program may increase individual and group counseling, develop contingencies for testing urine more frequently, integrate measures for treating all psychosocial needs, and implement services targeted at reducing problems that reinforce continued drug use. It is important to retain patients in treatment for concurrent addictions to enable them to continue receiving an array of medical, psychological, and social services for continued use of drugs.

In conclusion, the issue of discharging or retaining patients because of continued cocaine use is controversial, and programs remain divided on both the policy in general and its application to specific patients. Programs should remember that individuals injecting cocaine while on methadone remain at risk for HIV and should carefully consider whether retaining such patients is in the best interests of either the patient or the program.

Health Consequences

Medical complications among substance abusers are common. However, for addicts concurrently dependent upon narcotics and cocaine, medical problems, as well as psychological problems, may be severe.

A variety of preexisting medical problems may be present among addicts entering MTPs primarily because many opioids are self-administered by injection. Injecting drug users are at risk for pneumonia, hepatitis, tuberculosis (TB), tetanus, thrombophlebitis, endocarditis, skin and soft tissue infections, and HIV. Other common diseases among persons addicted to opioids include liver disease, cardiovascular disorders, and sexually transmitted diseases.

The poor health status of patients entering treatment is often related to their abuse of other drugs as well, including alcohol. Because cocaine abuse is popular among opioid addicts, many patients entering MTPs also have medical complications related to such abuse: cardiovascular, neurologic, pulmonary, and gastrointestinal problems; anemia; dental caries; sexual dysfunction; trauma; seizures; psychiatric problems; and neuropsychological impairment. If cocaine is injected, the patients are at increased risk for the complications of parenteral drug abuse mentioned above, most notably hepatitis and HIV infection.

Overall, prolonged disease and infection due to continued drug abuse is a significant concern with regard to concurrently dependent patients. The drug-using population often avoids medical facilities, and MTPs are sometimes the only place where methadone patients receive medical care. As a result of the more severe physical and psychosocial deterioration, depression, and poor general state of health among the concurrently dependent patients, treatment programs are now in the position of managing complex medical problems.

Although the patient may substantially reduce heroin use upon entry into an MTP, it has been found that many patients also dependent on cocaine continue to abuse heroin as well as other drugs. There is considerable concern about possible complications from the interaction between methadone and other drugs. Kreek (1993) conducted a number of studies investigating these interactions and her findings indicated significant negative interactions between methadone and cocaine. For example, methadone patients report that cocaine appears to interfere with the efficiency and duration of methadone dosage and that they begin to feel opioid withdrawal symptoms before their next scheduled dose. However, these findings need to be confirmed, and ongoing studies are being conducted.

Neurochemical and Psychological Effects of Cocaine and Heroin

Associated Psychiatric and Psychological Conditions

Treatment of concurrently dependent narcotic and cocaine users may be challenged by several associated complications. One such complication is cocaine or amphetamine psychosis. This condition can occur with prolonged high-dose administration of amphetamine or cocaine. Paranoia and other acute psychotic symptoms appear but can generally be treated with haloperidol (Haldol) (Smith 1986; Smith and Wesson 1988). Although rare, occasional cases of a longer lasting cocaine-precipitated thought disorder may appear. These cases, however, are usually complicated by multiple substance abuse (Smith 1986).

Psychiatric diagnoses are significantly overrepresented among patients in substance abuse treatment programs. The Epidemiologic Catchment Area (ECA) study by Regier and coworkers (1990) revealed that over 50 percent of substance abusers who received treatment had a coexisting psychiatric disorder. In an overview of research on psychiatric comorbidity, Gawin and Ellinwood (1988) state that among cocaine and opioid abusers, patients with affective (or mood) disorders, including depression, are overrepresented. Among cocaine abusers and cocaine-abusing opioid addicts, antisocial personality (ASP) disorder is overrepresented (Kosten et al. 1986a; Kosten et al. 1986b), and appears more frequently among populations of addicted persons than in the general population (Barthwell and Gastfriend 1993). Multidrug use can actually be seen as an associated feature of ASP (Barthwell and Gastfriend 1993).

Sexual dysfunction is a complicating factor among cocaine and other stimulant abusers and may need to be addressed in treating concurrently addicted patients. While at low doses cocaine enhances sexual desire, at higher doses it appears to impair sexual functioning in both males and females (Smith 1986; Smith and Wesson 1988). More importantly, high doses of cocaine or amphetamines can lead to compulsive sexual behavior such as compulsive masturbation rituals or multipartner marathons that the individual self-defines as aberrant and unhealthy (Smith 1986; Millman 1988; Smith and Wesson 1988).

Social and Community Complications

Hunt and coworkers (1986) revealed a direct relationship between escalating cocaine use among methadone patients and increasing involvement in crime. With occasional use, criminal activity may serve to buffer expenses in general, including the expense of cocaine, but may not be motivationally linked to cocaine use. When frequency of use exceeds one or two times per week, property and drug-dealing crimes increase significantly because of both financial need and lifestyle considerations (frequent use related to the social norms of career criminals). The authors point out that as cocaine use escalates, the likelihood of concurrent heroin use increases, thus adding the expense of another drug and further accelerating criminal activity.

It is important to view the interrelationship of substance abuse and crime within a larger social context. Wallace and coworkers (1992) examine the literature on the decay of America's urban communities and its effect on intensified patterns of substance abuse. They assess the decay of the social network structure in these communities and the decline in the physical and mental health of their residents. The decline of urban areas can be attributed to several factors, including an increase in violence, often associated with the presence of drugs; a loss of middle-class populations and affordable housing, which is a critical factor in the public health status of residents; and abandonment of buildings.

Homelessness is another factor related to urban decay and substance abuse. The homeless substance-abusing population is more susceptible than the general population to certain health conditions, including vascular disease, trauma, hypertension, poor dentition, gastrointestinal disorders, hepatic diseases, neurological and seizure disorders, arthritis, and generalized infections. Homeless substance abusers are also at risk for contracting HIV, tuberculosis, and syphilis (Joseph 1992).

Children of substance abusers require special attention. They are at risk of developing educational, medical, and emotional problems and have the potential for abusing illicit drugs themselves. Children of substance abusers may also have physical or developmental disabilities or both, and they are at risk of contracting HIV infection if born to infected mothers. Such children require special approaches and treatment (Juliana and Goodman 1992).

Impact on Various Treatment Settings

The needs of addicts seeking treatment vary, as do therapies available to treat them in a given community. In many communities, for instance, methadone treatment is not available. Nine States-Idaho, Maine, Mississippi, Montana, New Hampshire, North Dakota, South Dakota, Vermont, and West Virginia-presently have no approved MTPs. An important treatment issue is determining the appropriate treatment for each patient or population group. Originally, substance abuse treatment modalities were designed to treat a specific type of addiction or patient population. For example, MTPs were specifically designed as outpatient treatment for individuals with extended dependence on opioids (usually heroin); therapeutic communities (TCs) were designed for drug-dependent individuals with major impairments and social deficits, including histories of criminal behavior; outpatient nonpharmaco- therapeutic programs were developed for individuals with less serious social issues and nonopioid addictions; and chemical dependency residential programs were developed as treatment for alcoholism (Gerstein and Harwood 1990).

Increasingly, treatment programs are admitting addicts who do not fit neatly into a category or a precise modality. Concurrent opioid-stimulant dependency as well as related social, medical, and funding issues present challenging management problems for the different treatment modalities. Within each modality, treatment for concurrent opioid-stimulant dependency may require an increased intensity of treatment structure. Selwyn and O'Connor (1992) found that issues such as addiction severity, medical status, psychiatric status, treatment history, and social support network need to be carefully examined at the time of admission. If a particular treatment modality is not capable of treating the needs of a specific patient, efforts should be made to refer the patient to an appropriate setting. (For a discussion of appropriate levels of care, see appendix B.)

However, because of the diverse needs of patients entering treatment, programs are becoming multidisciplinary. Treatment teams at inpatient, outpatient, and residential programs are often finding it necessary to include a wide range of highly specialized professionals, such as addictionists, psychiatrists, psychologists, nurses, and social workers (Barthwell and Gastfriend 1993).

The Needs of Minority Patients

It has been suggested that addiction among African-Americans and other minority groups may occur for a number of reasons; therefore, their treatment needs may also differ (Brown and Alterman 1992). National Drug and Alcoholism Treatment Utilization Survey (NDATUS) statistics show that over one third of all clients in treatment for substance abuse are African-Americans and Hispanic-Americans. Further, African-Americans and Hispanic-Americans show a higher percentage of injecting drug users within their respective groups (NIDA 1993), thus placing these populations at special risk for developing HIV/AIDS, STDs, tuberculosis, and hepatitis.

Many cultural and historical factors distinguish minorities from the rest of American society. These factors, along with social, political, and economic realities, have significantly influenced the lives of minority Americans (Grace 1992). For example, in the African-American community, four systems have been major vehicles for providing cultural focus, cultural patterning, and social development: the church, community, neighborhood, and social organizations (Butler 1992). Far too often, however, the lack of real knowledge and awareness of the varying lifestyle patterns and needs of minority populations has resulted in inadequate service delivery, lack of compliance with expected norms and standards of behavior, and inconsistent or poor responses to caregivers and care facilities providing treatment services.

The reality of minority groups includes racism, segregation, poverty, and discrimination. These may result in low educational achievement, unemployment and underemployment, homelessness, excess or premature mortality and morbidity, crime, and widespread substance abuse, which is often used as a way to cope with depression and frustration.

The proliferation of these social problems has resulted in the widespread breakdown of "traditional values" and family and community life. Theories have stated that with the breakdown of one's support structure and the lack of opportunity and fulfillment of basic needs, many Americans, particularly minorities, have turned to substance abuse as a substitute (Brown et al. 1992).

Important differences often exist among individuals within minority groups. Ruiz and Langrod (1992) note that Hispanic-Americans may differ considerably depending upon their country of origin. These differences may include socially acceptable behavior, etiquette, family rituals, gestures, hospitality, and religion. In general, however, it is found that the family is of utmost importance to Hispanic-Americans. Each member of the family plays a unique role in family dynamics, and the use of positive family resources when treating Hispanic-American addicts would enhance quality care. However, effective treatment must also deal with real-life social issues that confront minorities, such as poverty, racism, discrimination, and the feeling of powerlessness.

Native Americans have long been using culture and rituals as healing methods for alcoholism. These methods include shamanistic ceremonies, community "sings," herbal medication, and sweat lodges. A key factor in Native American programs has also been the inclusion of Native American staff who can serve as role models for recovering persons (Westermeyer 1992).

The research of Ruiz and Langrod (1992) shows that the promotion of culture and relevant belief systems can play a positive role in the treatment process and that efforts should be focused on creating and promoting culturally appropriate services. They recommend that the design, content, and staffing patterns of treatment programs respond to the values, belief systems, and behaviors of the particular cultural group. The presence of a number of cultural groups in one program and tight funding, however, may make such staffing and programming difficult to achieve.

Summary

The steady increase of cocaine use among opioid addicts since the 1980s has caused treatment providers to develop interventions that meet the needs of these concurrently dependent patients. Although the increase corresponds to a general escalation in cocaine use throughout the United States, the opioid abuser is at special risk because the route of administration is often injection, increasing the risk for hepatitis and HIV.

A major challenge for MTPs is to work with patients to reduce their cocaine use and to address the social, psychological, and physiological problems associated with cocaine dependency. Several behavioral interventions have been implemented by programs attempting to treat this population, with varying degrees of success. Additional research is needed to determine the most effective treatment modalities.

Patients concurrently dependent on opioids and cocaine experience more severe medical problems, both physiological and psychological, than individuals addicted to cocaine or heroin alone. Antisocial personality disorder is overrepresented among cocaine-abusing opioid patients, and sexual dysfunction is often a complicating factor that needs to be addressed in treatment.

Escalating criminal activity, particularly theft and drug dealing, is directly related to the increase of cocaine use among methadone patients. The decline of urban neighborhoods, including the loss of affordable housing and middle class populations, abandonment of buildings, increased violence, and homelessness are often also related to the presence of drugs in the community.

Finally, treatment of concurrently dependent patients must take into account the individual's ethnic or racial heritage. Minority groups often must deal with racism, segregation, poverty, and discrimination, all factors that affect substance abuse treatment. Yet the cultural strengths of minority groups-for example, the church and social organizations of the African-American community and the strong family dynamics of the Hispanic community-can be tapped to enhance a comprehensive treatment program.