The benefits of methadone maintenance for the treatment of opioid dependence have been well documented (1). For those patients who discontinue use of illicit drugs, methadone maintenance has the important public health benefits of reducing crime and the spread of human immunodeficiency virus (HIV) consequent to injection drug use and transactions involving sex for drugs (2, 3). However, attaining complete abstinence from all illicit drug use has been a difficult goal for many methadone-maintained patients to achieve (4). Prescribing additional pharmacologic agents supplemental to methadone to patients unable to achieve abstinence has met with limited success (5), and while the provision of adjunctive psychosocial services such as employment, family, and psychological counseling has shown promise in reducing drug use in this patient population (6), simply providing more intensive psychosocial services is not in itself sufficient for initiating and maintaining abstinence (7).
One potentially fruitful perspective: on this problem was enunciated over two decades ago. Cohen (8) suggested that the continued use of illicit substances by methadone-maintained patients "is a reflection of the client's continuing inability to cope with stress, a disability which had been unsuccessfully dealt with during maintenance therapy" (p. 328). This suggestion is consistent with social learning theories of substance abuse (9), which hypothesize that abuse of substances is influenced not only by acute physiological and situational demands, but also by the individual's early social learning history. Individuals learn how to cope with stressful situations through parental and peer modeling and develop expectancies concerning a substance's ability to reduce stress-related negative affective states. It is this combination of deficiencies in coping, situational demands, and positive drug expectancies that is posited to lead to substance abuse (see Refs. 10-12).
Several theoretical models have been proposed to explain the role of coping in the addictions (for a comprehensive review, see Ref. 12), One synthesizing model differentiates between "approach" and "avoidant" coping strategies and considers both the focus of coping (problem focused or emotion focused), as well as the method of coping (cognitive or behavioral) (13-15). Over the past decade, a substantial body of evidence has been acquired using this model to support a link between maladaptive coping and substance abuse, specifically a reliance on avoidant rather than approach coping strategies (for a review, see Ref. 16). Although much of the literature has focused on the relation between maladaptive coping and alcohol use, associations between illicit drug use and avoidant coping have also been shown across quite diverse patient populations (HIV-seropositive individuals, see Ref. 17; adolescents, see Ref. 18; individuals with personality disorders, see Ref. 19; minority women, see Ref. 20).
A substance abuser's style of coping has also been shown to predict treatment outcome (21, 22). At entry into treatment, greater reliance on approach strategies, such as problem solving, and less reliance on avoidant strategies, such as emotional discharge, resigned acceptance, and cognitive avoidance, have been found to be associated with better outcomes in the treatment of alcoholism (23, 24). What is becoming increasingly clear is that it is not the absolute amount of stress a person experiences that is linked to substance abuse or relapse following treatment, but rather a reliance on certain types of avoidant coping strategies to cope with the stress, together with positive expectancies concerning the ability of the substance to relieve negative affective states associated with the stress (25).
There have been relatively few studies investigating coping among methadone-maintained patients. In a series of studies conducted with an all-male veteran patient population, Chaney and Roszell (26) concluded that methadone patients have a limited repertoire of coping skills and tend to use inappropriate coping strategies in the face of high-risk situations. They did not find a relation between type of coping and illicit drug use. A more recent study did find a link between the use of avoidant coping strategies by methadone patients, specifically behavioral disengagement and denial, and use of alcohol and drugs to cope (27). No study to date has investigated the association between improved coping and abstinence from illicit drug use in this patient population. Moreover, no previous study has examined the potential influence of depression on drug use and coping. This may be especially important given the high rates of depression among methadone patients, especially in those who continue to use illicit drugs (28), and the established link between depression and the use of certain avoidant coping strategies (see Ref. 29). Experienced both antecedent and consequent to illicit drug use, symptoms of depression, in conjunction with maladaptive strategies for coping with negative affect, can create a vicious cycle of "self-medication" that sustains addictive behavior (30, 31). To address these gaps in our knowledge, the current study investigated the influence of coping and depression on abstinence from heroin and cocaine among inner city opioid-dependent patients maintained on methadone.
METHOD
Participants
Participants were 307 opioid-dependent patients (308 patients were assigned to the intervention; pretreatment Coping Responses Inventory [CRI] data were not collected for 1 patient) entering a randomized clinical trial comparing two intensities of psychosocial intervention adjunctive to methadone-maintenance. At entry into the trial, all patients were currently using illicit opiates. There were 21% who had not previously been maintained on methadone; 62% had a history of methadone maintenance and were beginning a new treatment episode; 17% were currently being maintained on methadone and were being referred in lieu of detoxification due to unremitting drug use. Results of the trial have been reported elsewhere (7). Participants were paid $25 for completing the assessment battery. No other financial incentives were offered.
Characteristics of the sample. Participants were 71% male, 29% female; and 59% white, 29% African-American, and 12% Hispanic. Their mean ([+ or -] SD) age was 36.8 ([+ or -] 6.9) years; 37% had not completed high school; 46% were married or living with a significant other. All patients were opioid dependent and had been using heroin for 12.6 ([+ or -] 8.3) years. They reported using an average of 17.3 ([+ or -] 20.9) "bags" of heroin the week prior to entering the study, primarily intravenously (73% intravenous, 27% intranasal). Also, 67% also had a DSM-III-R diagnosis of cocaine dependence, either current or past, and had been using cocaine for 9.03 ([+ or -] 7.26) years. In the first week of treatment, 64% of the sample provided a cocaine-positive urine. These dually dependent patients reported using an average of 3.2 ([+ or -] 6.6) "dime bags" of cocaine the week prior to entering the study; the primary route of cocaine administration was intravenous (44% intravenous, 21% free base, 25% intranasal). The DSM-III-R criteria for major depression were met by 25% of patients.
Treatment Context: Methadone Maintenance with Coping Skills Training
According to the clinical trial protocol, patients were randomly placed in one of two treatment contexts: a day treatment program or an enhanced-standard methadone maintenance (E-STD), both of which included the same 12-session coping skills training intervention, which was based on the treatment program for alcoholism developed by Monti and colleagues (32) and adapted for use with methadone-maintained patients. Because there were no significant differences in pre- and posttreatment coping strategy scores based on whether coping skills training was provided in the context of a day treatment program or standard methadone maintenance program, results are presented collapsed across treatment context. Of the 12 weekly groups, 9 were selected from among the 27 sessions described by Monti et al.: relapse prevention, recreational skills, managing negative moods, relaxation training, enhancing social support networks, anger management, problem solving, communication skills, and improving intimate relationships (modified to include a discussion of safer sexual practices). The three remaining groups, developed at our site (physical health, knowing your community resources, and vocational skills training) were included to address the special medical, social, and vocational needs of inner city methadone-maintained patients. The 12-week treatment phase of the trial began the week following completion of the admission intake.
Assessments
