Although the prevalence rates of problematic cocaine use and cocaine dependence are unclear, the lifetime prevalence of cocaine use has almost doubled in the Swiss general population (aged 15–24 and 25–34 years) over the past ten years [1], which is in line with findings in many other countries in Southern and Western Europe [2]. However, the prevalence of cocaine use might be underestimated in general population surveys [3, 4]. Since 2005, resident institutions and outpatient units for the treatment of substance use disorders have reported that cocaine is more or less equally common as opiates in terms of the main problem substance upon entry into treatment [5].
It is assumed that quasi-controlled, occasional use of cocaine is much more prevalent than addicted use and that only a few users are currently in treatment [6]. Nevertheless, some cocaine users switch from controlled consumption to more problematic consumption—in the sense of use that is harmful to oneself or others—and to cocaine dependence [7]. Previous research has estimated that about one in six users who have used cocaine at least once will develop cocaine dependence [8]. For problematic users and those with dependence symptoms, appropriate interventions follow the Concurrent Cover principle (i.e., minimally invasive, low-cost interventions that enhance therapeutic intensity according to need).
Outpatient treatment that is based on Cognitive Behavioral Therapy (CBT) has been successful in treating cocaine dependence, while intense research on psychopharmacological approaches over the past three decades has not identified any compelling evidence of effective medicinal treatments [9]. Nevertheless, Swiss narcotics law allows the off-label use of prescription drugs, e.g., methylphenidate or modafinil, to treat the symptoms of cocaine dependence. However, health insurance coverage for such treatments is not guaranteed [9]. Further treatment approaches, such as Contingency Management or the Community Reinforcement Approach, which reward cocaine abstinence with money or use positive reinforcement, have primarily been reported in the United States and seem hardly applicable to European countries due to health care policy or health insurance-related differences [9, 10].
Web-based interventions that aim to reduce problematic cocaine use might fill an important gap by providing support for problematic cocaine users or those with the initial dependence symptoms who have not responded well to the present institutional treatment offerings. The Internet is a useful tool to reach hidden populations, such as illicit drug users [11]. Furthermore, web-based interventions are easy to access and show a remarkably positive cost-benefit relationship [12], which is an important advantage for Switzerland and other industrialized countries with increasing health care costs.
However, web-based interventions have primarily focused on reducing alcohol and cannabis use [13–17]. Web-based interventions to reduce problematic stimulant drug use are sparse and report mixed results [18, 19]. The first meta-analysis on the effectiveness of web-based interventions in reducing alcohol use yielded encouraging results [20]. The most promising approaches for web-based interventions that aim to reduce substance use are based on CBT, including Behavioral Self-Management (BSM), relapse prevention [21, 22] and Motivational Enhancement Therapy (MET) [19]. Web-based self-help interventions with guided individual CBT chat counseling were found to reduce alcohol use and alcohol use disorder symptoms in problematic alcohol users [23]. Similar positive outcomes have been shown in guided individual CBT for (subclinical) depression and anxiety disorders [24, 25]. Therapeutic alliance has been shown to reach high levels in the guided web-based individual cognitive-behavioral treatment of depression, generalized anxiety and social anxiety disorders, and post-traumatic stress disorder, with mixed evidence of its impact on the respective main outcomes [26–28]. The therapeutic alliance in guided real-time web-based CBT has not been investigated in the frame of preclinical or clinical substance use disorders, which could be of importance in the light of recent findings on social cognitive deficits in cocaine users. Problematic cocaine users might possess rather universal social-cognitive deficits and decreased social networks, depending on the frequency of use, compared with stimulant-naïve controls [29, 30]. It has been argued that basic social interaction deficits in cocaine users may arise from altered social reward processing [31].
In a previous study, we demonstrated the feasibility and potential effectiveness of the initial web-based self-help intervention, Snow Control (without chat), which was designed to reduce problematic cocaine use [18, 32]. Overall, treatment retention was very low. However, participants in the self-help intervention showed increased treatment retention compared with the psycho-educative control group. The factors that contributed to subject treatment retention included the low severity of cocaine dependence, age, and depression symptoms. The average number of cocaine use days per week did not change substantially, whereas the weekly quantity of cocaine use was reduced equally in both groups. Many participants set very moderate consumption goals and quit the program after achieving their rather low goals in 1–2 weeks [18]. Therefore, a thorough revision of this preliminary self-help intervention was developed; this revision considers the need for more structured goal setting, more personalized advice, and sustained motivation and accounts for potential depression symptoms with CBT for depression therapy [33] and social problem solving [34]. In addition, this revised version offers guided anonymous chat counseling to foster socially rewarding and non-cocaine-related contacts and relationships.
The present study aims to investigate and compare the effectiveness of the revised web-based self-help intervention, Snow Control 2.0, with tailored chat counseling that is based on CBT, MET, BSM, and social problem solving in reducing problematic cocaine use. More specifically, a three-arm randomized controlled trial (RCT) will be conducted to test the effects of a self-help intervention with and without chat counseling compared with those of a waiting list control group.
Study interventions
The first-arm intervention consists of three individual chat-counseling sessions that are based on MET and CBT and the web-based self-help intervention from study arm 2. These chat sessions are tailored to the data that are derived from participants’ self-help interventions. Chat counseling will explore the currently available social support for cocaine users, help improve their valuable relationships, and respond to their individual requests. The web-based self-help intervention from study arm 2 is based on classical CBT for the treatment of cocaine dependence [1], BSM [21], MET [35], CBT for depression [33], and social problem solving [34]. Study arm 3 consists of a waiting list control condition. Figure 1 presents a detailed overview of the aforementioned study arms.
Self-help intervention modules
The web-based self-help intervention (study arms one and two) is organized in two parts. Part 1 can be accessed after successful registration and completion of the baseline assessment. Part 1 has to be worked through systematically. Part 2 is presented in a clearly arranged menu (see Fig. 1), and its modules are freely accessible as soon as part 1 is completed. Nevertheless, we recommend working through the modules in the order presented below, as long as no specific module is indicated (e.g., strong craving). The participants are allowed to repeat the modules whenever needed.
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Part 1: Introduction
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o Registration process
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o Personal companion (an introduction of 6 companion profiles and the participant’s personal selection of his or her companion)
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o Examination of the pros and cons of changing cocaine consumption patterns to address motivation
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o Goal setting and introduction to e-mail reminders
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o Introduction to the cocaine consumption diary and its fully automated progress charts and statistics
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o Introduction to the “My Snow Control” folder: individuals can review their acquired module documents (e.g., the list of the top five strategies for managing cocaine cravings)
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o Introduction to the emergency button for immediate responses to frequently asked questions and access to emergency contacts
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Part 2: Modules
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o Module 1: Strategies for goal achievement
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o Module 2: Identifying your risk situations
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o Module 3: Caring about your needs: reduction of stress and depression symptoms and sleep hygiene
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o Module 4: Managing cocaine cravings
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o Module 5: Managing relapses
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o Module 6: Six-step program to tackle your problems
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o Module 7: Say “no” to bolster refusal skills
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o Module 8: Preserving achievements
Fig. 2 Main menu of the self-help study arm including the chat-window that is visible in the self-help plus plus chat study arm only. Furthermore, a glossary that explains the terms, definitions, and concepts that are used in the intervention will be provided in an appendix that can be accessed after registration. This glossary will contain information about the history of cocaine use, the short-, medium- and long-term effects of cocaine use, the physical risks of cocaine use (e.g., addiction, cardio-vascular diseases), and co-occurring mental health problems (e.g., depression, psychosis). Moreover, frequently asked questions and their corresponding answers will be presented.
Personal companion
At the beginning of the self-help intervention, six companions will be briefly introduced. Study participants choose a companion with whom they can best identify themselves. The characters vary with regard to gender, age, sexual orientation, family status, and professional circumstances to provide maximum identification. In each module, the personal companion may provide specific advice or examples of useful intervention strategies. Furthermore, the participants may switch between different personal companions to gather additional advice and examples.
Goal setting and motivation-enhancing e-mail feedback
Additional tailored motivational advice will be developed and implemented to prevent participants in study arms one and two from setting their consumption goals too low and thus quitting the intervention within the first couple of weeks, as frequently occurred in the preliminary Snow Control study [18], or from setting their goals too high and risking early relapse. Participants will be encouraged to set their overall six-week goal in the beginning and to envision reducing their weekly cocaine use by at least 40 % over the course of the six-week intervention. In a second step, tailored weekly instructions will be provided, which encourage a successive weekly reduction of 20–30 % in the first three weeks. If the planned reduction goal is not met, motivational enhancement will be set to a more realistic goal (e.g., 15–20 %). The participants who seek cocaine abstinence will be encouraged to make similar step-by-step reductions until full abstinence has been attained. To avoid severe withdrawal symptoms and potential health risks, abrupt cocaine abstinence will not be recommended, as is often recommended when attempting to quit, e.g., smoking or chewing tobacco [36]. Participants who achieve their weekly aims will receive positive feedback and will be encouraged to continue in a similar vein to achieve or even exceed their overall goals. Once participants have achieved their overall goals, they will be encouraged to maintain their reduced cocaine use or abstinence or to further reduce their use successively until week 6. Moreover, weekly motivation-enhancing e-mail reminders will be sent; these e-mails will contain feedback that is tailored to the previous weeks of the intervention and the participant’s module progress.
Extensions in the chat condition
The three additional chat counseling sessions (only in study arm 1) will support behavioral changes through MET. Participants in the chat condition can discuss the modules of the web-based self-help intervention and review the development of their consumption diary; they are also motivated to foster and review socially rewarding contacts. Social reward sensitivity is assumed to be limited in the self-help only study arm 2, which does not include sensitizing individual counseling.
The chat sessions will be structured as follows:
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Chat session 1: Starting point and objective agreement
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o Personalized feedback according to the baseline assessment and potential cocaine-related physical and mental health risks
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o Review of successful strategies for change that are related to topics other than cocaine
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o Imagining daily routines, structuring the day and managing boring situations after cocaine cessation/reduction with new rewards; exploring the aim to live with cocaine abstinence or with low cocaine use and the dissonances with its current use; and mobilizing social support and the option of inviting a relevant third party to join chat session 2
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o Review of and agreement on the overall cocaine use objective
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o Review strategies to deal with cocaine cravings and perspectives for chat session 2
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Chat session 2: Exchange of experiences, social support, and relationships
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o Exchange of experiences regarding the agreed-upon objective since the beginning of the intervention
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o Review of the patterns that relate to the consumption diary goals and achievements
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o Review and consolidation of web-based self-help modules
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o Review of social rewards prior to cocaine use
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o Experience and improvement of existing social support and relationships
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o Revision of intervention objectives and perspectives for chat session 3
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Chat session 3: Review and consolidation
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o Exchange of experiences regarding the agreed-upon objective since the beginning of the intervention
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o Review of the patterns that relate to the consumption diary goals and achievements
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o Consolidation of web-based self-help modules and identification of the best five strategies for long-term success
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o Experience of intention to change and improvement of social support and relationships
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o Definition of long-term objectives and consolidation of strategies for long-term success
Health care professionals will be assigned as online counselors, who will contact registered users during their 6-week programs to arrange three chat counseling sessions. To conveniently manage their interactions with clients, counselors will have access to a specific user management area to add arranged chat dates, define current statuses, and add personal comments about their clients. With this tool, counselors can follow their clients’ progress in reducing their cocaine use through clearly arranged charts, monitor their clients’ module progress, and look up previous chat histories. Specific lists will help counselors track their clients (e.g., a list with “all users”, “my clients”, or “my upcoming chat sessions”). All written dialogues during chat counseling sessions will be recorded in a database for further analysis.
Waiting list control condition
Participants who are randomized to the waiting list will have the opportunity to participate in the web-based self-help intervention 6 months after registration. Follow-up measures for these participants will be assessed online or through telephone interviews for those participants who cannot be reached online at the 6-month follow-up.
Technical specifications
Snow Control 2.0 is a website that is based on Drupal 7, a content management system with a responsive design for computer screens, tablets and smartphones.
Any Internet user can register an online account via www.snowcontrol.ch by providing a unique username and e-mail address. Registered users will be asked to take care to not disclose any personal information about their real identities. For this purpose, they will be advised to register an anonymous e-mail account with a third-party e-mail provider. To prevent the creation of accounts with invalid e-mail addresses, the registration process will not be complete until a verification e-mail link has been clicked and a personal password been set.
