Researchers investigate non-abstinent recovery for people with cocaine use disorder

A coalition of researchers at The University of New Mexico have just taken a huge step forward for addiction research, in emphasizing a recovery process that has long been needed for a specific drug.

This comes from the minds of Center on Alcohol, Substance use, And Addictions (CASAA) Director Katie Witkiewitz, UNM alumna and McLean Hospital/Harvard Medical School Clinical Psychology Intern Victoria Votaw and Psychology Doctoral Students Felicia Tuchman and Hanna Hebden.

These four women just published the study, "Examining cocaine use reductions and long-term outcomes in two clinical trials of continuing care for cocaine dependence," in the Journal of Substance Use & Addiction Treatment.

Building on a previous study by UNM alumnus and Yale School of Medicine Assistant Professor of Psychiatry Corey Roos, Witkiewitz took the initiative to further the research into validating non-abstinent techniques in substance misuse.

"This is a multi-generational lab project going back years thanks to Dr. Roos' work," Witkiewitz said.

Non-abstinent methods for addiction recovery are an essential component for recovery but have not always gotten the attention they deserve.

"Katie has been doing work in validating non-abstinent outcomes for alcohol use disorder for a really long time, which I think drew Hanna, Felicia, and me to work in Katie's lab. She's been a leader in this area," Votaw said.

Recent research has shown benefits associated with reductions in alcohol use short of strict abstinence, but that approach hadn't been fully explored with cocaine use until now. In fact, the Federal Drug Association (FDA) does not have an approved medication for cocaine use disorder (CUD).

"I think that is one of the big pushes for this research. Alcohol use disorder and opioid use disorder both have FDA-approved medications to treat those disorders, so there's really been a movement in the field of cocaine use disorder treatment to think more broadly about non-abstinent endpoints that are sensitive to change," Votaw said.

"We're interested in examining whether reductions in cocaine use frequency are associated with improvements in functioning, and validating these endpoints to hopefully be approved by the FDA in the future."

With over $1.4 million from the National Institute on Alcohol Abuse and Alcoholism, the UNM group analyzed clinical trials of continuing care for CUD.

"One of the conditions examined in these studies was contingency management, which is the best treatment for CUD. It's very effective at targeting engagement in treatment, which this study did. I think this study also shows that engagement is a good target because people can improve quality of life, without stopping completely, whereas a lot of contingency management studies in the past have really focused on incentivizing abstinence," Witkiewitz said.

The goal of the recent research was to not only identify whether success in non-abstinent recovery was possible for people with cocaine use disorder but also to provide the FDA with potential endpoints to use in future medication development trials.

'"There's been some research on provider perceptions of non-abstinent outcomes, and providers are far more supportive of non-abstinent outcomes for alcohol and cannabis use disorders, so that's why I think it is really important to examine the evidence for non-abstinent outcomes in other drug use disorders," Votaw said.

In each of the analyzed clinical trials, which established an endpoint of using one to four days in the past month, reductions in cocaine use to this non-abstinent endpoint predicted sustained reductions in cocaine use 24 months following treatment entry.

"That finding is so important because there are people who are anti-harm reduction; they believe that any use is a failure, but the data just doesn't support that. Our findings indicate that many individuals who engage in infrequent use of cocaine have outcomes that are similar to those who abstain completely," Witkiewitz said.

With a slow, encouraging decrease in frequency among users, in just a year, 62% of those who used at a high frequency (5+ days of use in a month) reached abstinence. In that same timeline, an additional 21% went from a high frequency use to low frequency use (1–4 days of use in a month) and 12.2% went from low use to abstinence.

"Examining who can achieve a successful non-abstinent outcome is important on the patient level, but I think more at the structural level," Votaw said. "There are things that treatment providers can do that make people more likely to achieve success. If somebody is trying to reduce to a non-abstinent goal in a very abstinence-oriented treatment environment, what's that experience going to be like for the patient? Will they feel supported?"

This reduction to a low-frequency level had an incredibly positive effect. In the 12-month period, lower levels of negative consequences related to the drug were reported for those with this reduction.

"One implication of these data is that reductions in the frequency of cocaine use, including those short of abstinence, are associated with lower cocaine use disorder severity," Tuchman said. "It seems that abstinence is not the only viable goal for people with cocaine use disorder who want to improve their functioning, and that's important for patients and health care providers to know."

The one to four days per month target is also important in reduction because of the autonomy it provides patients.

"I think it's really important to ask patients what they want, whether it's abstinence they want or if they want to reduce. I find it helpful, at least in the beginning, to set concrete guidelines for their goals, so we can determine what strategies are helpful for achieving those goals. We can have these conversations with patients," Votaw said.

It was not just the telephone care which played a part in improving substance use; it was other diversified, personable approaches as well.

The contingency portion of this plan is extremely critical to overcoming addiction. If there is a slip-up in use, it's not game over.

"We're also basically rewarding people or incentivizing people for the behavior change that they're moving towards. If you place it in the context of substance use, substance use is highly, quickly reinforcing. People either feel relief really quickly or reward really quickly. In that context, it can be helpful to incentivize reducing substance use to move towards people's goals," Votaw said.

That's extremely important for the participants in the analyzed critical trials, as well; 86% of those studied were Black, and 77% were male. People of color and other marginalized populations are historically less likely to receive harm reduction interventions.

"It was a unique sample as compared to the other samples that this type of research has been done with, which I think is really important when examining a harm reduction outcome," Votaw said. "There's research showing that people of color and other marginalized populations are less likely to receive harm reduction interventions, so that's why it was really important to see that this outcome was associated with benefits in this population."

This research is further proof of the success that comes along with not only having FDA-approved endpoints for substance recovery, but with those endpoints being non-abstinent.

"I think that's the ultimate goal. I mean, for so long, providers were really, really focused on abstinence because there wasn't data showing alternatives," Witkiewitz said. "Now you can target reductions in use, which might be more appealing to some people."