Cocaine Use Disorder Diagnosis and Intervention Program
I created this proposal for my graduate addictions class at the University of Rochester. It outlines a diagnosis and intervention program for Cocaine Use Disorder (CUD) using the Transtheoretical Model (TTM). I called the program "Clear Stage," and I have displayed my proposal below. Download a PDF of the presentation here.
Clear Stage Diagnosis and Intervention Program
Introduction
This paper details the design of the "Clear Stage Program" (CSP), a twelve-week inpatient addiction diagnosis and prevention program for individuals suspected of suffering from Cocaine Use Disorder (CUD). The program integrates proven Transtheoretical Model (TTM) techniques to facilitate recovery.
Cocaine Use Disorder
According to the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5), CUD, a kind of Stimulant Use Disorder, is defined by a pattern of cocaine use "leading to clinically significant impairment or distress" (American Psychiatric Association [APA], 2013, p. 561). Each year, approximately 1.9% of the population, or 5.3 million people, use cocaine, according to data from the Substance Abuse and Mental Health Services Administration (SAMHSA, 2023, p. 17). Furthermore, it is estimated that 0.5% of the population, or 1.4 million people, meet the criteria for Cocaine Use Disorder, as reported by SAMHSA (2023, p. 35).
Schwartz et al. (2022) suggest that "Recent nationwide epidemiological data show that both cocaine use and cocaine-related problems, including CUD, are increasing in adults as well as in adolescents" (p. 25). Research by Hedegaard et al. (2018) describes an increase in drug overdose deaths from 41,340 in 2011 to 63,632 in 2016 and notes that the proportion of cocaine-related deaths appears to be growing from 5,892 of total drug overdose deaths in 2011 (approximately 12.26%) to 11,316 in 2016 (approximately 17.78%), as documented on page 4. Furthermore, cocaine use contributed to over 500,000 emergency room visits and is responsible for frequent encounters with the criminal justice system (Schwartz et al., 2022, p. 25).
Substance misuse and abuse disorders in the United States are estimated to cost more than $400 billion annually in crime, health, and lost productivity (U.S. Department of Health and Human Services [HHS], 2016, pp. 1-2). It is reasonable to extrapolate that CUD contributes significantly to these costs. According to the SAMHSA, only 24% of individuals recognized as needing treatment for substance use were able to obtain it in the last year. This lack of treatment represents a significant gap, with only approximately one in four people needing treatment actually receiving it (SAMHSA, 2023, p. 51).
Transtheoretical Model (TTM) for Addiction
Initially developed in the 1970s, the Transtheoretical Model (TTM) was a meta-analysis of many existing theories, looking for commonalities regarding how people change (Cavaiola & Smith, 2020, Chapter 9, p. 148). TTM suggests that all individuals undergo five stages of change: Precontemplation, Contemplation, Preparation, Action, and Maintenance (Cavaiola & Smith, 2020, Chapter 9, p. 149). Change is a process, according to TTM, and contains two parts: cognitive/experiential and behavioral processes. Cognitive/experiential processes include five parts: consciousness-raising, emotional arousal, self-evaluation, environmental re-evaluation, and social liberation. Behavioral processes include five parts: self-liberation, stimulus generalization or control, conditioning or counterconditioning, reinforcement management, and helping relationships (Cavaiola & Smith, 2020, Chapter 9, p. 150).
Prochaska and DiClemente, the founders of TTM, conducted a landmark study in 1983 applying the TTM to individuals who were attempting to quit smoking. They studied 872 individuals attempting cessation independently (Prochaska & DiClemente, 1983). The findings indicated that depending on the TTM stage in which an individual was categorized, different strategies were employed to influence their smoking cessation efforts. This study underscores the significance of tailoring interventions to match the specific stage of change in which an individual is engaged (Prochaska & DiClemente, 1983).
Project MATCH (Matching Alcoholism Treatments to Client Heterogeneity) was another significant study involving TTM, sponsored by the National Institute on Alcohol Abuse and Alcoholism (NIAAA). Conducted from 1989 to 1998, the study aimed to test whether different types of alcoholism treatment could be more effective if matched to specific characteristics of patients. It involved 1,726 participants, who were randomly assigned to receive one of three treatment approaches: Cognitive-Behavioral Therapy (CBT), Motivational Enhancement Therapy (MET), or Twelve-Step Facilitation (TSF), each tailored to specific stages of the TTM. The results showed that matching specific treatments to patient characteristics did impact outcomes, with notable differences based on individual client needs and their stage of readiness for change (Project MATCH Research Group, 1998).
A 2006 review by Velicer et al. analyzed results from seven studies involving thousands of subjects, each utilizing computer-based, tailored messages designed to assist people in quitting smoking. These messages were tailored based on each individual's readiness to quit, as determined by the TTM. The review found that between 22% and 26% of participants were able to quit smoking and maintain cessation at follow-up. This cessation rate is significantly higher than the typical success rate of 5-7% for individuals attempting to quit on their own, demonstrating the effectiveness of tailored interventions (Velicer et al. 2006).
In 2012, Evers et al. applied the (TTM) as an intervention for alcohol, tobacco, and other drugs (ATOD) among 1,590 middle school students. The study categorized students into groups based on their perceived TTM stage of change. Experimental groups received educational content tailored to their stage of change, delivered three times over three months, approximately thirty minutes each session (Evers et al., 2012). Results indicated that students who received TTM-based educational content exhibited significantly higher cessation rates than the control group.
Further studies have explored the use of the TTM in the treatment of substance use. For instance, Velasquez (2009) conducted a clinical trial involving 138 subjects who used cocaine and demonstrated some effectiveness of the intervention. Additionally, Nidecker et al. (2008) performed an analysis on 240 subjects with a history of co-occurring schizophrenia/schizoaffective disorder and cocaine use disorder. Their findings confirmed that the instruments used to measure TTM stages were mainly reliable and valid (Nidecker et al., 2008).
Program Overview
The CSP is designed around the TTM, which identifies five stages individuals progress through in overcoming addiction: Precontemplation, Contemplation, Preparation, Action, and Maintenance. This model is helpful in understanding and treating CUD, as it recognizes that recovery is not a linear process but a dynamic journey that requires different interventions at different times.
Empirical research, such as the Project MATCH study (Project MATCH Research Group, 1998) and findings by Velicer et al., (2006), underscores the effectiveness of TTM-based interventions. These studies have demonstrated that tailored treatments to the individual’s stage of change significantly enhance the chances of successful recovery by aligning interventions with the client's readiness to change. In CSP, diagnostic tools like URICA and SOCRATES are utilized to determine the client's current stage of change, guiding the deployment of specific therapeutic strategies ranging from motivational enhancement in the early stages to relapse prevention strategies in the later stages.
Diagnostic Criteria
CSP will use a variety of instruments to assess and diagnose each potential subject before confirming their acceptance into the treatment program.
Initial Screening, Informed Consent and Intake
When a candidate applies to participate in the CSP, a representative will contact the individual, typically via the phone, to conduct an initial screening. When the phone call begins, the CSP representative will outline a summary of the critical details of the CSP, and the candidate will be required to give initial verbal consent to proceed. An initial screening will be conducted over the phone to capture the candidate’s primary demographic data, including their name, address, phone number, email address, age, gender, gender identity and other key items that could help the representative assess whether the candidate meets the inclusion criteria and does not meet the exclusion criteria.
After the demographic data collection, if the candidate wishes to proceed, the representative will carry out a fuller intake with the client. The intake script is a modified version of the "Integral Intake" designed by Andre Marquis (2008). The intake script can be done over the phone with the representative or emailed or texted to the candidate for self-completion at a later date. After the call, the representative will email or text over a package containing full details on the program and the data captured on the call, along with an official informed consent form that the candidate must sign to continue.
Once the client is accepted into the program, further clinical instruments will be used to officially confirm their diagnosis of CUD and any other comorbidities, assess their stage of change, and assess their overall well-being. These instruments and diagnostic techniques are described in the next section.
Confirm Diagnosis of Cocaine Use Disorder (CUD) and Assess Comorbidities
An assessment will confirm the presence and severity of CUD and identify any additional primary diagnoses.
Structured Clinical Interview for DSM-5 (SCID-5). This semi-structured interview covers the DSM-5 diagnostic criteria for Substance Use Disorders, including CUD. It involves modules with variable numbers of questions tailored to the specific disorder being assessed, using yes/no and open-ended questions to explore the diagnostic criteria thoroughly. This tool is particularly effective for confirming the presence of CUD in clinical settings.
Addiction Severity Index (ASI). The ASI is comprised of approximately 200 items. It assesses the severity of addiction across multiple life areas, including medical status, employment and support, drug use, alcohol use, legal status, family/social relationships, and psychiatric status. Questions are rated on a 5-point Likert scale, reflecting severity and impact on the patient's life.
Determine the Client’s Stage of Change
Key to the CSP will be assigning attendees to groups and tailoring their treatment interventions based on their TTM stage. Both the URICA and SOCRATES instruments will be used to assess the attendee’s group assignment.
University of Rhode Island Change Assessment Scale (URICA). Includes 32 items rated on a 5-point Likert scale from "strongly disagree" to "strongly agree". This scale assesses an individual's readiness to change by identifying their stage of change within the TTM.
Stages of Change Readiness and Treatment Eagerness Scale (SOCRATES). This tool features 19 items using a 5-point Likert scale to assess motivational readiness to change substance use behavior. It is specifically designed for individuals with alcohol and substance misuse issues.
Assess Well-being and Risk
A thorough psychological, emotional, and physical assessment will be conducted along with assessing for CUD, comorbid diagnosis, and stage of change. Assessment for suicide risk will also be included.
Brief Symptom Inventory (BSI). This 53-item inventory measures psychological distress and symptoms of psychiatric disorders, rated on a 5-point scale of distress from "not at all" to "extremely." It provides a quick measure of psychological distress and helps monitor treatment outcomes.
Health Screening and Physical Examination. These assessments do not follow a fixed questionnaire format but involve a variety of physical checks and tests as per standard clinical procedures.
Columbia-Suicide Severity Rating Scale (C-SSRS). This scale includes a series of questions that assess suicidal ideation and behavior through yes/no responses, essential for determining suicide risk in vulnerable populations.
Inclusion and Exclusion Criteria
The inclusion and exclusion criteria for the CSP were modeled after those used in a previous study conducted by the National Institute on Drug Abuse (NIDA, 2017), which explored a TTM group therapy for cocaine use disorders.
Inclusion Criteria
Participants will be recruited for the program if they meet the following criteria: (a) female or male adults between the ages of eighteen and sixty-five years old who meet the DSM-IV criteria for cocaine abuse or dependence disorder; (b) judged to be in generally good physical and psychiatric health, except for possible acute drug-related problems; (c) willing and able to participate in the twelve-week, group inpatient treatment program; (d) able to provide the name of at least one person who can generally locate their whereabouts; and (e) willing to be followed for three months after treatment completion. Potential participants with simple drug charges will be included if their legal contacts will forego data revelation. Participants who are abusing substances in addition to cocaine will not be excluded.
Exclusion Criteria
Individuals will be ineligible for participation in the program if they meet any of the following criteria: (a) current diagnosis of an Axis I psychiatric disorder other than cocaine dependence; (b) current psychiatric symptoms requiring medication; (c) severe medical, cognitive, or psychiatric impairment that precludes cooperation with the study protocol; (d) substance withdrawal symptoms requiring medical attention; (e) currently receiving other psychosocial therapy for substance abuse, except twelve-step programs; (f) impending incarceration; (g) inability to read, write, or speak English; or (h) inability or unwillingness to participate in the twelve-week, group inpatient treatment program (e.g., due to halfway house or other aftercare program restrictions).
Week by Week Treatment Intervention Overview
CSP is designed to provide a comprehensive inpatient treatment experience tailored to the individual's stage of change, as conceptualized by the TTM. The program is designed for up to 12 weeks, although the duration is flexible depending on the client's stage and progress. Throughout the program, participants will have access to a range of services and amenities, including individual and group psychotherapy, an on-site medical center with regular health check-ups, an on-site chef and nutritional planning, a fitness studio with personal training, a wellness spa offering massage and aromatherapy, a swimming pool, yoga classes, meditation and mindfulness training, nature walks, art and music therapy rooms, a game room, a wellness library, a community garden, career counseling, family therapy and visitation, as well as access to the clearstage.com mobile app and online community.
Weeks One to Three (Precontemplation and Contemplation)
For individuals in the Precontemplation and Contemplation stages, the first three weeks will focus on consciousness-raising, emotional arousal, self-reevaluation, environmental reevaluation, and social liberation. Specific interventions during this period may include psychoeducation on CUD, testimonials from former users, group personal story sharing, art therapy, journaling, visualizing a future life without substance use, group work on the impact of use on others, and education on societal supports.
Weeks Four to Six (Preparation)
During weeks four through six, targeted at the Preparation stage, the emphasis will shift to self-reevaluation, environmental reevaluation, social liberation, self-liberation, stimulus control, and counterconditioning. Interventions may involve commitment ceremonies or intent-to-change statements, goal-setting workshops, developing coping plans, removing triggers, exploring new hobbies and habits, stress management techniques, and establishing support networks and mentorship opportunities.
Weeks Seven to Nine (Action)
For participants in the Action stage, weeks seven through nine will concentrate on self-liberation, stimulus control, counterconditioning, helping relationships, and reinforcement management. Activities during this phase include reinforcing commitments, refining coping strategies, further developing healthy habits and routines, strengthening support networks, and implementing new reward systems.
Weeks Ten to Twelve (Maintenance)
Finally, during the Maintenance stage, weeks ten to twelve, the focus will be on social liberation, self-liberation, stimulus control, counterconditioning, helping relationships, and reinforcement management. Interventions will solidify gains made during earlier stages and prepare participants for long-term recovery through continued support, relapse prevention strategies, and ongoing personal growth and development.
Conclusion
CSP represents a comprehensive approach to treating CUD, grounded in the proven framework of the TTM. By integrating empirical research and TTM's stages of change, CSP provides a structured yet flexible treatment regimen tailored to the unique needs of individuals at various stages of their recovery journey.
Throughout the twelve-week intervention, CSP emphasizes progression through the stages of change, from Precontemplation to Maintenance, ensuring that interventions are appropriate to participants' readiness and motivational levels. This alignment increases the likelihood of participant engagement and reduces the rates of relapse, which is a common challenge in addiction treatment.
This paper has detailed an evidence-based, stage-specific, and person-centered treatment framework. CSP aims to bridge the treatment gap highlighted by SAMHSA, providing practical and accessible care informed by current research and best practices in addiction treatment. The ongoing measurement of outcomes, as suggested by the diagnostic criteria and tools employed within CSP, will help refine and adapt the program to meet the evolving needs of its clientele better.
As society continues to grapple with the impacts of substance use disorders, programs like CSP offer hope and a clear path to recovery, emphasizing not just abstinence but holistic wellbeing and sustained personal growth. It is hoped that implementing such targeted and theoretically grounded programs will contribute significantly to reducing the burden of addiction and enhancing the health and productivity of communities nationwide.
References
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Hedegaard, H., Bastian, B. A., Trinidad, J. P., Spencer, M., & Warner, M. (2018). Drugs Most Frequently Involved in Drug Overdose Deaths: United States, 2011–2016. National Center for Health Statistics. https://www.cdc.gov/nchs/data/nvsr/nvsr67/nvsr67_09-508.pdf
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