Elsevier

Drug and Alcohol Dependence

Volume 71, Issue 2, 20 August 2003, Pages 207-211
Drug and Alcohol Dependence

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Cognitive impairment, retention and abstinence among cocaine abusers in cognitive-behavioral treatment

https://doi.org/10.1016/S0376-8716(03)00092-9Get rights and content

Abstract

Cognitive-behavioral therapy (CBT) depends on adequate cognitive functioning in patients, but prolonged cocaine use may impair cognitive functioning. Therefore, cognitive impairment may impede the ability of cocaine abusers to benefit from CBT. To begin to address this issue, we investigated the relationship between cognitive impairment and two treatment outcomes, therapy completion and abstention. Eighteen carefully screened non-depressed cocaine-dependent patients in a psychopharmacological clinical trial were administered the MicroCog computerized battery to assess cognitive performance at treatment entry. T-tests were used to compare cognitive functioning between completers (patients remaining in treatment at least 12 weeks) and dropouts. The results indicated that treatment completers had demonstrated significantly better cognitive performance at baseline than patients who dropped out of treatment. Cognitive domains that significantly distinguished between treatment completers and dropouts were attention, mental reasoning and spatial processing. This study provides preliminary evidence that cognitive impairments may decrease treatment retention and abstinence in CBT of cocaine dependence.

Introduction

According to the 1997 National Household Survey on Drug Abuse, approximately 1.5 million adults use cocaine in the US, signaling a widespread problem that can often lead to dependence requiring therapeutic intervention. To address this need, a variety of psychopharmacological and psychosocial treatments have been developed to treat cocaine dependence. The use of manual-guided psychotherapy in pharmacotherapy clinical trials has been advocated on theoretical grounds, and it appears to improve compliance and reduce unwanted variance due to therapist differences (Klein, 1991, Nunes, 1997). One of these, cognitive-behavioral treatment (CBT), has shown considerable promise (Carroll et al., 1991, Maude-Griffin et al., 1998). However, for a substantial proportion of patients its efficacy remains limited. Documented dropout rates from CBT treatments have been reported to range from 33 to 64%. (Carroll et al., 1991, Carroll et al., 1994). Thus, it is important to identify factors associated with treatment drop-out or poor outcome.

A fundamental component of CBT is the use of cognitive processing as a mediator of behavioral change (Carroll, 1998). However, impairment in cognitive functioning has been found in a substantial proportion of cocaine dependent patients (Bolla et al., 1999, Bolla et al., 2000). Specifically, attention, learning, memory, and cognitive flexibility are often impaired in cocaine abusers (Ardila et al., 1991, Berry et al., 1993, Horner, 1997), It is reasonable to hypothesize that treatment-seeking cocaine abusers who cannot comprehend the interventions presented to them within the CBT framework (e.g. functional analysis, skills developing) are more likely to drop out of treatment or do poorly.

Surprisingly, only a few studies have investigated the effects of cognitive functioning on treatment outcome among cocaine abusers (Fals-Stewart and Schafer, 1992, Teichner et al., 2001), and none has investigated this specifically as pertaining to CBT. To address this gap in knowledge, we conducted an initial study of the relationship between cognitive functioning at treatment entry on retention and level of abstinence. The study was conducted among cocaine dependent users in short-term psychopharmacotherapy that included weekly individual manualized-CBT. We hypothesized that treatment completers (those completing at least 12 weeks in CBT) would score higher on cognitive measures than dropouts and that greater abstinence would be associated with higher cognitive functioning at baseline.

Section snippets

Participants

Eligible patients consecutively enrolled during a 12-month period (from 6/00 to 6/01) in an ongoing clinical trial for non-depressed cocaine patients were approached about participation in the present study. The placebo-controlled clinical trial consisted of 15 weeks of CBT+medication (either gabapentin or placebo). To evaluate eligibility for this trial, patients were administered an evaluation including the SCID I/P interview (DSM-IV version) administered by trained Ph.D. level psychologists.

Results

Completers and dropouts did not differ significantly on demographic variables or patterns of cocaine use. The mean age for completers was 41.8 (SD 6.6) vs. 37.1 (SD 6.6) for the dropouts; t(1; 16)=1.4; P=0.17. The mean years of education for the completers was 14.3 (SD 2.06) vs. 13.5 (SD 1.38) for the dropouts; t(1, 16)=1.02; P=0.32. African Americans constituted 66.6% of the completers vs. 58.3% of the dropouts; χ2(2)=2.04; P=0.35 and 27.7% of the completers vs. 38.8% of the dropouts were

Discussion

This study provides preliminary evidence that levels of cognitive functioning differ between treatment completers and dropouts. The low cognitive scores of the treatment dropouts indicate that compared with completers, these patients may suffer from difficulties in ability to focus, hold and sustain attention. These patients with deficits in attention and mental reasoning may have difficulties participating in CBT. For example, some patients may have difficulties attending throughout the 60

Acknowledgements

The authors thank Ivana Huang for assisting in data collection and Valerie Richmond for manuscript preparation, Drs Suzanne Vosburg for her comments on an earlier draft and Adam Bisaga for sharing his data on these patients. This research was supported by NIDA grant (PI 50 DA09236, H.D. Kleber). Support for Dr Hasin is acknowledged from NIAAA grant AA K02 AA00151. The New York State Psychiatric Institute also contributed support to this work.

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