Old Psychotherapies for Cocaine Dependence Revisited
The publication of the results of the National Institute on Drug Abuse Collaborative Cocaine Treatment Study (CCTS; Crits-Christoph et al., 1999) like the publication of and comments on some of the first pharmacologic trials in Archives of General Psychiatry a decade ago (Arndt, Dorozynsky, Woody, McLellan, & O'Brien, 1992; Kosten, Morgan, Falcioni, & Schottenfeld, 1992; Meyer, 1992), denotes a landmark in the development and evaluation of treatments for cocaine dependence. Since 1992, myriad pharmacotherapies have failed to demonstrate efficacy against the Goliath of cocaine dependence. Instead, "weak" approaches, such as psychotherapy, have emerged as the David of this field; note that the review by Meyer in 1992 of the state of pharmacotherapies for cocaine dependence ended with the words "lest we forget the importance and efficacy of nonpharmacological treatments." Behavioral therapies, in particular contingency management approaches (Higgins et al., 1991, 1994; Higgins, Budney, Bickel, & Hughes, 1993; Silverman et al., 1996,1998), have been demonstrated to be effective and sufficient treatments for most cocaine-dependent patients who receive them. While important efforts continue to identify effective pharmacotherapies, the results of this excellent study (CCTS) highlight several points deserving further comment, including (a) poor retention but generally good improvement across treatments; (b) failure to replicate an earlier study on the effects of professional psychotherapy versus disease-model approaches for methadone-maintained opiate addicts; and (c) the need to distinguish the therapies evaluated in the CCTS from other behavioral treatments demonstrated to be effective for cocaine dependence. First, however, this outstanding group of investigators is to be applauded on an extraor-
dinarily well-conducted study, and in particular on their use of the most rigorous methods to define and implement the treatments studied, which make these findings so compelling.