Systematic Review of Cocaine-Treatment Interventions for Black Americans

Abstract

Evidence-based drug treatment studies that have shaped best practice in the United States demonstrate racial differences in effectiveness, with Black participants reporting worse outcomes compared to White participants. There are disproportionate cocaine-related overdose deaths impacting Black Americans, with limited information about interventions that serve them best. Culturally tailored treatment approaches, which incorporate participants’ salient identities and experiences, have shown effectiveness in meta-analyses. Thus, this qualitative systematic review used PRISMA guidelines to identify both culturally universal and culturally tailored treatment intervention studies that addressed cocaine outcomes among Black Americans. 402 articles met initial criteria, 330 were reviewed by independent coders, and k=30 treatment approaches are described in the paper. Results indicate 72% of culturally tailored interventions were effective at reducing cocaine use, compared to 47% of culturally universal interventions. Implications for provision and funding of effective cocaine treatment interventions for Black Americans are critical to researchers, practitioners, and policymakers alike.

The United States is currently facing a “triple epidemic” of overdose deaths associated with prescription opioids, heroin, and fentanyl (Ahmed et al., 2022). Amid this prominent opioid epidemic is a less-acknowledged epidemic of cocaine-related overdose deaths among Black Americans (Stevens-Watkins, 2020). While cocaine is the most used illicit stimulant used in the U.S. (Mustaquim et al., 2021), and Black and White people use cocaine at similar rates, cocaine-related overdose deaths among Black Americans are more than twice as high compared to their White counterparts, with the disparity worsening during the COVID-19 pandemic (Cano et al., 2020; Hanson & Sofia, 2021). A number of sociocultural and economic factors that disproportionately impact Black Americans account for this disparity: rising rates of cocaine laced with fentanyl analogs, racism and race-related stress (e.g., racial discrimination, racist stereotypes, stigma), economic insecurities (e.g., unemployment, unstable housing, lack of insurance and transportation), older age, health comorbidity, disproportionate police contact and incarceration, and a lack of culturally competent and quality treatment (Furr-Holden et al., 2021; Kariisa et al., 2021; Khan et al., 2023).

Psychosocial treatment approaches are currently the best and most feasible interventions for reducing morbidity and mortality rates among Black Americans who use cocaine. While medication for addiction treatment options have been developed for alcohol and opioid use disorders (Buchholz & Saxon, 2019), no pharmacological interventions have been approved for cocaine use (Czoty et al., 2016). Medications that show promise such as d-amphetamine, modafinil, and disulfiram are not yet FDA-approved (Brandt et al., 2021).

Whereas the literature suggests that certain treatment approaches, like contingency management, are the most effective for reducing cocaine use in the general population (Bentzley et al., 2021), little research to date has specifically examined the effectiveness of these interventions for Black Americans, for whom drug treatment outcomes often differ. Since unique cultural norms, values, and stressors like systemic racism precede and likely exacerbate cocaine use, interventions that are culturally tailored to Black Americans may prove more effective than culturally universal ones that do not take these factors into account (Farahmand et al., 2020). Further, many existing treatment models do not consider barriers that lower Black Americans’ participation, completion, and satisfaction with drug treatment (Mennis & Stahler, 2016; Suntai et al., 2020). An analysis of culturally tailored approaches that address these barriers and other treatment needs of Black Americans is warranted (Substance Abuse and Mental Health Services Administration (SAMHSA), 2022). This qualitative systematic review identifies and compares the effectiveness of both culturally universal and culturally tailored interventions for treating cocaine use among Black Americans. Findings will inform research and practice to address adverse cocaine use outcomes in this population.

Literature Review

Impact of Cocaine Use on Black Americans in the Opioid Epidemic

As one of the most underserved populations in the United States, Black Americans are more likely to experience cocaine-related morbidity and mortality than other racial groups (Galea & Rudenstine, 2005; Zapolski et al., 2016). Black Americans who use cocaine report higher rates of mental health problems (Zapolski et al., 2016), criminal justice involvement (Camplain et al., 2020), Hepatitis C and HIV from injection drug use (McCormick et al., 2021), and other health problems such as cognitive impairment, myocardial infarction, hypertension, atherosclerosis, and stroke (Kim & Park, 2019; Potvin et al., 2014) compared to other racial groups. These specific drug-related racial health disparities have only intensified during the COVID-19 pandemic wherein exposure to and risk of death from fentanyl analogs increased for Black Americans living in various U.S. geographic regions (Lee & Singh, 2023).

Currently, Black Americans who use cocaine are disproportionately impacted by opioid overdoses, despite having experienced the lowest rate of opioid-related deaths compared to White Americans as recently as the period from 1999 to 2010 (Furr-Holden et al., 2021). The rate of opioid-related overdose deaths among Black Americans rose exponentially after 2013, accelerating from an 8.39 annual percentage change in years 2010 to 2013 to 26.16 in years 2013 to 2018, compared to annual percentage changes of 4.34 and 13.19 respectively for White Americans (Furr-Holden et al., 2021). This striking increase is largely associated with cocaine laced with fentanyl analogs (Kariisa et al., 2021). However, in comparison to the attention focused on opioid use, there is limited discussion related to the co-use of opioids and cocaine among demographic groups with higher risk of cocaine-related overdoses (Barocas et al., 2019).

Whereas major public health measures of legislative acts, policy changes, and economic investments have been implemented to combat opioid use disorder (i.e., “doctor shopping” laws, harm reduction strategies like Naloxone distribution, and syringe service programs; Bratberg et al., 2023), similar measures have not been introduced to address cocaine use over recent years. Cocaine-related morbidities continue to rise (SAMHSA, 2019) and chronic cocaine use contributes to yearly billion-dollar healthcare costs (Czoty et al., 2016; Qureshi & Chaudhry, 2014). Thus, treating cocaine use disorder would improve Black Americans’ wellbeing while lowering societal costs. Against the backdrop of systemic racism, however, socio-structural determinants of health continue to contribute to racist inequities in the access, use, and continuity of quality treatment for substance use disorders (Gibbons et al., 2023).

Culturally Universal vs. Culturally Tailored Cocaine Treatment Interventions

Researchers and practitioners alike emphasize evidence-based approaches as the gold standard for treating substance use disorders (Tucker & Roth, 2006). Evidence-based interventions (EBIs) such as cognitive behavioral therapy (CBT), motivational interviewing (MI), and contingency management (CM) are considered model programs due to substantial evidence of their efficacy (Castro & Garfinkle, 2003).

However, their efficacy has not been proven across all groups and environments, and in some cases has been shown diminished improvements. When EBIs that were successful in controlled clinical environments were introduced in community treatment programs with spontaneous factors, they showed weaker effectiveness (Chu & Leino, 2017). In addition, the common exclusion of racially/ethnically marginalized groups from the norming samples of EBIs hinders the ability to determine effectiveness across cultural groups (Castro et al., 2010). Indeed, when racially diverse samples are included in EBI studies, results show differential substance use outcomes. For example, a meta-analysis examining the efficacy of CBT for substance use suggests that CBT had a stronger impact among White participants compared to Black and Hispanic participants across 16 studies (Windsor et al., 2015). A recent systematic review demonstrated that few randomized controlled trials (RCTs) reported substance use outcomes by race/ethnicity, but when race/ethnicity was reported, there were significant racial differences in drug treatment engagement and outcomes (Jordan et al., 2022). In comparison to White participants, Black participants had worse retention in treatment and lower rates of abstinence from cocaine and opioids following treatment (Jordan et al., 2022). Overall, the literature consistently demonstrates that EBIs for treating substance use disorders may not be as effective for certain racial groups (Matsuzaka & Knapp, 2019).

One compelling explanation for current racial disparities in substance use treatment effectiveness is that traditional treatment programs are designed to be culturally universal. They lack components addressing the unique stressors that Black Americans experience, such as racial discrimination and racially disproportionate drug sanctions (Bowser & Bilal, 2001). Black women encounter race-, gender-, and often class barriers, such as family responsibilities, that further hinder their participation in gender-insensitive drug treatment programs (Sterk et al., 2003a); for instance, many pregnant Black women avoid participating in drug treatment in fear of facing legal prosecution and child custody loss (Jones et al., 2011; Lindsay & Vuolo, 2021; Smith & Roane, 2023). Whereas pregnant White women who report using opioids are more likely to be referred to treatment, pregnant Black women who endorse cocaine use are more likely to be arrested (Harp & Bunting, 2020).

Culturally universal approaches that inform substance use treatment programs essentially adopt a racially colorblind perspective that ignores cultural differences and racialized experiences (Matsuzaka & Knapp, 2019). Psychological science in the U.S. continues to proclaim that White or Eurocentric ways of knowing, perceiving, and navigating larger society are the universal standard (Remedios, 2022). For example, many psychosocial drug treatment models like CM, CBT, and MI were developed and normed on White samples (Castro et al., 2010; Chu & Leino, 2017). As a result, culturally specific experiences of other racial/ethnic groups are lost and this creates a dearth of information on effective treatments for marginalized racial/ethnic groups (Thalmayer et al., 2021). It is critical to understand that evidence-based models like these have not been validated for all populations, either because they were normed on White samples or because the number of participants from racially/ethnically marginalized groups was too low to statistically impact results and highlight differences across groups. Therefore, there is danger in assuming that culturally universal treatment models will perform well in all contexts.

Culturally tailored models offer an obvious alternative here, but they lack the empirical validation of other models for numerous reasons (e.g., small study samples, less funding, and contemporaneous factors like poverty, exposure to violence, mental health conditions hindering participant completion). Some researchers have argued that culturally tailored interventions lack the evidence to become empirically validated treatments due to poor fidelity (Griner & Smith, 2006). This, in turn, further decreases the likelihood of support from large funding agencies. Other researchers suggest that the most useful and effective interventions rely on a mixed combination of empirical evidence and cultural flexibility (Kendall & Beidas, 2007). Two meta-analyses found that cultural adaptations of psychological interventions were four times as likely to produce remission from psychopathology for racial/ethnic marginalized groups than evidence-based, manualized treatments and/or no interventions at all (.46 average effect size across 16 studies, Griner & Smith, 2006; .45 average effect size across 76 studies, Hall et al., 2016). Given these findings and the contrasting lack of evidence that standard EBIs are equally effective for Black Americans, we argue that culturally tailored models for cocaine treatment are worthy of more research and investment. The significance of this gap in the research is highlighted by the ongoing public health crisis of racially disparate cocaine-related overdose deaths.

Generally, Black Americans are less likely to complete treatment compared to White Americans regardless of type of substance(s) used (Mennis & Stahler, 2016). However, cocaine treatment interventions can be designed to address specific needs of racially marginalized groups (i.e., through culturally tailored interventions; Castro & Garfinkle, 2003). For example, spirituality is an important component of Black culture because it informs beliefs, norms, and practices that maintain hope in the face of societal stressors like racial injustice (Newlin et al., 2002). When culture and spirituality have been integrated into treatment, it has helped Black women abstain from cocaine use for at least six months (Stahler et al., 2007). Further, Black Americans may be more inclined to accept a culture of recovery that incorporates Afrocentric values, racial identity and pride, and spirituality (Bowser & Bilal, 2001; Brown et al., 2004). Acknowledging racism and subsequent race-based stress as a possible impetus for cocaine use, may help Black clients to feel understood, thus increasing their motivation to seek substance use treatment. Prior reviews on culturally adapted EBI interventions suggest attention to language, culture, and identity is effective at reducing substance misuse among Latinx people (Hernandez Robles et al., 2018; Venner et al., 2022); these results are limited, however, as they focus on Latinx communities. To the authors’ knowledge, there is little to no research on culturally-adapted EBI interventions for treating cocaine use among Black adults. While culturally universal drug treatment approaches are clearly valuable for some, culturally tailored interventions demonstrate increased utility for racially/ethnically marginalized groups and may specifically do so for Black Americans who use cocaine.

The Current Study

Disparities in cocaine-related overdose deaths can be addressed by increasing access to, promoting, and utilizing appropriate and effective treatment approaches with vulnerable populations. There are inconsistent findings about the effectiveness of culturally universal treatment approaches for racially marginalized groups and limited evaluation of the overall effectiveness of culturally tailored interventions for cocaine use Thus, an important question to raise is: What does existing treatment literature show about the effectiveness of culturally universal and culturally tailored treatment interventions to reduce cocaine use among Black Americans? This qualitative systematic review aimed to answer this question by 1) identifying treatment intervention studies about cocaine treatment with Black Americans; 2) describing components and effectiveness of culturally universal and culturally tailored cocaine treatment approaches; and 3) making recommendations for future research and practice efforts to address the cocaine-related overdose death epidemic affecting this group.

Methods

This report is a systematic review of empirical studies using quantitative methods (i.e., experimental, quasi-experimental, cohort, longitudinal, and cross-sectional designs) for cocaine use treatment interventions among Black participants from January 1990 to January 2020. Figure 1 displays the search strategy that identifies relevant articles as recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. Studies were identified by searching through the following five databases: PubMed, Medline, PsycINFO, Academic Search Complete, and Google Scholar. The key terms (“cocaine intervention” OR “cocaine treatment” OR “cocaine treatment approach”) AND (“African American” OR “Black”) AND (“drug treatment” or “substance use treatment”) were used in the search of titles and abstracts in each database. Studies that met these criteria were included: (a) the sample was at least 75% Black for generalizability (see Montgomery et al., 2020); (b) the study reported the effects of treatment using a psychosocial and/or behavioral intervention; and (c) the study had at least one self-report or biochemically verified cocaine use primary outcome. Exclusion criteria included qualitative papers, literature and systematic reviews, meta-analyses, and studies that did not report sample racial demographics and/or cocaine use outcomes. We also excluded non-empirical articles such as commentaries and editorials. All studies were conducted in the United States and written in English.

Figure 1.

Search strategy for relevant articles as recommended by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement.

Study Selection

The initial search identified 42,526 articles through five databases (see Figure 1). All further screening was completed by human reviewers (during the 2020-2021 COVID-19 lockdowns). The first and second authors served as independent reviewers to assess titles and abstracts and determine if articles met inclusion criteria. A third reviewer (the last author) consulted in cases where the two initial reviewers were unsure or disagreed over the inclusion of an article. At the first level of review, 42,124 articles were excluded because they did not meet the inclusion criteria. In the next level of review, 72 out of 402 screened articles were excluded because they represented duplicates across the databases. A total of 330 studies were retained and qualitatively coded, resulting in the exclusion of 300 of them with rationale (e.g., non-relevance; race was not reported and/or Black American sample was not at least 75%; did not report cocaine outcomes; conceptual paper; meta-analysis) after a full review. In the end, a total of 30 studies were included in this systematic review.

Study Coding

The selected studies were reviewed to extract and code study information. The coding characteristics in the current review included: methodology (e.g., quantitative, mixed-methods, quasi-experimental, and RCTs), intervention type (e.g. culturally universal or culturally tailored), intervention approach (e.g., CBT, CM, MI, faith-based, 12-step programming, etc.), sample demographics (e.g., all Black, racially diverse), and cocaine use outcomes (e.g., days of use, days of abstinence, consequences of use, urine toxicology). Outcomes of RCTs were coded as positive (+) if the intervention treatment approach was more effective at a statistically significant level than the comparison group, as negative (−) if the intervention treatment approach was less effective at a statistically significant level than the comparison group, and no effect (=) if there were no statistically significant difference in cocaine use outcomes between comparison groups. Studies with designs that featured no randomized control groups (e.g., quasi-experimental, program evaluations, cross-sectional, etc.) were coded as either ‘yes’ or ‘no’ for treatment effectiveness. The quality of each article was evaluated using Joanna Briggs Institute checklists to determine appropriate inclusion in the current paper (Aromataris et al., 2015; Barker et al., 2023).

Results

A total of 30 studies met inclusion criteria. Identified studies have been descriptively categorized as culturally universal: CM (k = 6), MI (k = 6), CBT (k = 5), and 12-step (k = 2), or culturally tailored: culture-based (k = 2), faith-based (k = 3), sexual health-based (k = 4), and gender-based (k = 2). There was some overlap in treatment approaches, particularly with MI tenets incorporated into culturally tailored interventions; however, we settled on the categories above to describe the most salient aspects of the treatment approach(es) in culturally tailored interventions. Within each category, a description of interventions is provided followed by a narrative synthesis of strengths and weaknesses of each treatment approach for Black participants. See Tables 1 and 2 for additional details of each study.

Table 1.

Culturally Universal Treatment Intervention Studies with Predominantly Black Samples (k = 19)

Author (Year)	Participant Demographics	RCT	Treatment Type	Comparison Condition	Length-to- Follow-Up	Cocaine Measure	Study Findings	Treatment Effectiveness
Alterm an et al. (1994)	111 adult male veterans (97% Black; 0 % women)	Yes	12-step programming	Day Hospital (n=56) vs. Inpatient Rehabilitatio n (n=55)	7 months	Urine Drug Screen (UDS)	Although there was a reduction in cocaine use in both groups, no statistically significant differences in cocaine use were found between groups	(=)
Hoffma n et al. (1996)	N=184 adults (95% Black; 60% men, 40% women)	Yes	Cognitive Behavioral Therapy (Relapse Prevention)	Intensive Group Therapy vs. Standard Group Therapy	12 months	Self-reported cocaine use and UDS	There were no significant differences found by treatment condition.	(=)
McKay et al. (1997)	N=98 adult males (85% Black, 0% women)	Yes	Cognitive Behavioral Therapy (Relapse Prevention)	Standard Group Counseling (n=52) vs. Individualize d Relapse Prevention Aftercare (n=46)	3 and 6 months	Self-reported cocaine use and UDS	There were no differences in percent of days of cocaine use between groups. However, complete abstinence during study were higher in STND group than RP group. RP was more effective in limiting cocaine use during months 1-3	(−)
Maude-Griffin et al. 1998	N=128 veterans (80% Black; 98.4% men, 1.6% women)	Yes	Cognitive Behavioral Therapy vs. 12-Step Programming	CBT (n=59) vs. 12-Step (n=69)	4 weeks, 8 weeks, 12 weeks, 26 weeks	Self-reported cocaine use and UDS	Participants in CBT (44%) were statistically significantly more likely to achieve abstinence than participants in 12SF (32%) during treatment and follow up	(+)
Coviello et al. (2000)	N = 94 adult male veterans (91.5% Black; 0% women)	Yes	12-step programming with Psychosocial Group Therapy, Educational Sessions and Individual Counseling/Case Management	12hr/weekda y hospital program (DH12; n=46) vs. 6hr/week outpatient program (OP6; n=48)	4 months and 7 months	Self-reported cocaine use	Although participants across conditions reported a 52% reduction in days of cocaine use, there were no statistically significant differences in cocaine use between DH12 and OP6 groups at 7-month follow up	(=)
Milby et al. (2000)	N = 110 adults (82.7% Black; 76.3% men, 23.7% women)	Yes	Contingency Management (CM)	Behavioral day treatment + Abstinence-Contingent Housing and Work Therapy (DT+; n=56) vs. Behavioral Day Treatment Alone (DT; n=54)	2 months, 6 months	UDS	DT+ group achieved statistically greater abstinence at any week during the 2- and 6 month follow ups than DT group	(+)
Schumacher et al. (2000)	N = 141 adults (82.7% Black; 72.3% men, 27.7% women)	Yes	Contingency Management	Behavioral Day Treatment + Abstinence-Contingent Housing (DT+; n=72) vs. behavioral day treatment alone (DT; n=69)	2 months, 6 months, 12 months	UDS	DT+ group had about 13% statistically higher prevalence of cocaine abstinence than DT group	(+)
McNamara et al. (2001)	N = 128 adults (82% Black; 76.6% men, 23.4% women)	Yes	Contingency Management	Behavioral Day Treatment + Abstinence-Contingent Housing (DT+) vs. behavioral day treatment alone (DT) for dual diagnosis (DUAL; n=82) and Substance Use Only (PSUD; n=46)	2 months, 6 months, 12 months	Self-reported cocaine use; UDS	No statistically significant differences in cocaine use between treatment group (DT+ vs. DT) by diagnostic group (DUAL and PSUD) at 6-month follow up	(=)
Schumacher et al. (2003)	N =141 adults (82.7% Black; 73.2% men, 26.8% women)	Yes	Contingency Management	Day Treatment + Contingency Management (DT+; n=69) vs. Day Treatment (DT; n=58)	2 months, 6 months, 12 months	Self-reported cocaine use; UDS	DT+ group had statistically significant cocaine abstinence (9.4%) at 6-month follow-up compared to DT group (4.5%)	(+)
Rush et al. 2008	N = 865 adults (82% Black; 53% women, 47% men)	Yes	Motivational Interviewing (Recovery Management Checkups)	Recovery Management Checkups vs. Control Group for substance use only (n=295); substance + internalizing disorder (n=230); and substance + internalizing and externalizing disorders (n=340)	Quarterly RMCs or quarterly for 2 years with GAIN	Self-reported cocaine use	Participants in RMC group for substance use disorder only group was statistically and significantly more likely to have higher days of abstinence compared to control condition	(+)
DeFulio et al. (2009)	N =128 adults (88% Black; 23% men, 77% women)	Yes	Contingency Management	Abstinence-contingent employment (n=27) vs. Employment-only (control, n=24)	6-month, 12- month, 18- month, 24- month	UDS	Abstinence-contingent employment condition (81.5%) provided more cocaine-negative urine samples than employment-only (control; 54.2%) condition	(+)
McKay et al. (2010)	N = 100 adults (89% Black; 42% men, 58% women)	Yes	Cognitive Behavioral Therapy and Contingency Management	CM + CBT-RP (n=25); CM (n=25); CBT-Relapse Prevention (n=24); and TAU/IOP (n=25)	3 months, 6 months, 9 months, 12 months, 15 months, and 18 months	Self-reported cocaine use and UDS	Significant effect of CM on UDS and self-reported cocaine use, with no significant CMxRP interactions. However, secondary analyses revealed CM+RP produced statistically significantly lower rates of cocaine-positive UDS at 6- and 9-month follow ups	(+)
Ingersoll et al. (2011)	N = 54 adults (82% Black; 46.3% men,51.9% women)	Yes	Motivational Interviewing (MI)	Motivational Interviewing and Skill Building Feedback (MI+; n=19) vs. Video Information and Debriefing (Video+; n=23)	2-3 months, 5-6 months	Self-reported cocaine use	Despite statistically significant reductions in cocaine use across both conditions (32% to 14.6% (3-month) and 11.6% (6-month), no significant group differences were found	(=)
Montgomery et al. (2011)	N = 194 Black adults (75.3% men, 24.7% women)	yes	Motivational Interviewing	Motivational Enhancement Therapy (MET; n=109) vs. Counseling as Usual (CAU; n=85)	2 months, 4 months (Weeks 5-16)	Self-reported cocaine use	No statistically significant group differences in positive urine screens for MET and CAU groups during 4-week active phase	(=)
Dennis & Scott (2012)	N = 446 adults (85% Black; 54% men, 46% women)	Yes	Motivational Interviewing (Recovery Management Checkups)	Recovery Management Checkups (n=198) vs. Control Group (n=195)	16 quarterly interviews over 4 years	Self-reported cocaine use	RMC group had statistically significantly more abstinence than control group	(+)
Ondersma et al. (2013)	N = 143 postpartum women (90.6% Black; 0% men)	Yes	Motivational Interviewing	Electronic screening and brief intervention (e-SBI; n=72) vs. time-matched control (n=71) condition	3 months, 6 months	Self-reported cocaine use; UDS; Hair Analysis	Although e-SBI group participants reported fewer days of drug use at 3- and 6-month follow-up compared to control group, these differences were only significant at 3-month follow-up, and not at 6-month follow up	(=)
Burlew et al. (2013)	N = 194 Black adults (75.3% men, 24.7% women)	Yes	Motivational Interviewing (Readiness-to-Change; RTC)	Motivational Enhancement Therapy (MET; n=85) vs Counseling as Usual (CAU; n=109)	2 months, 4 months	Self-reported cocaine use	Participants with high RTC in MET group reported statistically significant fewer days of use compared to participants in CAU. Among lower RTC participants, those in the in the CAU group reported statistically significant fewer days of use compared to MET participants	(−)
Daughters et al. (2018)	N = 263 adults (94.7% Black; 70.7% men, 29.3% women)	Yes	Cognitive Behavioral Therapy	Behavioral Activation Life Enhancement Treatment for Substance Use (LETS ACT; n=142) vs. Supportive Counseling Control Group (SC; n=121)	3 month, 6 months, 12 months	Self-reported cocaine use and UDS	Post-treatment cocaine abstinence, but not days of substance use, was statistically and significantly higher for LETS ACT group compared to SC group at 3-, 6-, or 12-month follow ups	(+)
Jemison et al. (2019)	N = 16 women (81% Black; 0% men)	Yes	Contingency Management	CM + Expressive Writing (n=9) vs. CM + Neutral Writing (n=7)	3 month, 6 months	Self-reported cocaine use and UDS	Though participants in EW group provided more negative urine screens than the NW group, the EW group displayed non-significant trends towards reductions in cocaine use at 3- and 6 month follow ups	(=)

Table 2.

Culturally Tailored Cocaine Treatment Studies with Predominantly Black Samples (k = 11)

Author (Year)	Participant Demographics	RCT	Treatment Type	Comparison Condition	Length-to- Follow-Up	Cocaine Measures	Study Results	Treatment Effectiveness
Cottler et al. (1998)	N=1,434 adults (93% Black; 52% men, 48% women)	Yes	Culturally Congruent Intervention	NIDA Cooperative Agreement Standard Intervention (n=651) vs. Enhanced Intervention for HIV/AIDS risk (n=783)	3 months	Self-reported use of cocaine	Enhanced Group (85%) had statistically and significantly improved rates of cocaine use compared to Standard group (77%) at 3-month follow up	(+)
Longshore et al. (2000)	N = 269 Black adults (63.9% men, 36.1% women)	Yes	Culturally Congruent Intervention	Motivational Interviewing (n=131) vs. Standard Treatment (n=138)	3 months, 6 months, 12 months	Self-reported use of cocaine and UDS	Participants in MI group were statistically and significantly less likely to use cocaine (54%) at compared to standard group (71%) at 12-month follow up	(+)
Volpicelli et al., (2000)	N = 84 adults (96.4% Black; 100% women)	Yes	Gender-Specific Intervention (Pregnancy and Motherhood)	Case Management-Oriented Outpatient Treatment (CM; n=42) vs. Psychosocially Enhanced Treatment Program (PET; n=42)	12 months	Self-reported cocaine use and UDS	While average number of days of cocaine use decreased for both groups, the PET group had statistically significantly fewer days of cocaine use compared to CM group at 12-month follow up	(+)
Sterk et al., (2003a)	N = 265 Black women (0% men)	Yes	Culturally Congruent, Gender-Specific Intervention for HIV	NIDA Cooperative Agreement Standard Intervention (n = 114) vs. Motivation Enhanced Intervention (n=73) vs. Negotiation Enhanced Intervention (n=78)	6 months	Self-reported cocaine use	The proportion of women across conditions who used crack cocaine statistically and significantly decreased from 100% to 61.1%, with greatest reductions among women in the standard and negotiation conditions at 6-month follow up	(+)
Sterk et al., (2003b)	N = 68 Black women (0% men)	Yes	Culturally Congruent, Gender-Specific Intervention for HIV	NIDA Cooperative Agreement Standard Intervention (n=27) vs. Motivation Enhanced Intervention (n=20) vs. Negotiation Enhanced Intervention (n=21)	6-months	Self-reported cocaine use	All groups demonstrated reduction in past 30-day cocaine use at 6-month follow-up	(=)
Stahler et al., (2005)	N = 118 Black women (0% men)	No	Faith-Based	Bridges + Standard Treatment (Residential) vs. Standard Treatment	18 months	Random UDS	Although both groups reported fewer days of cocaine use, there were statistically significant group differences as the Bridges group reported 100% cocaine abstinence compared to low levels of cocaine use in the standard treatment group	Yes
Stahler et al., (2007)	N = 18 Black women (0% men)	Yes	Faith-Based	Standard Treatment + Bridges (n=8) vs. Standard Treatment with an Attention Control (n=10)	3 months, 6 months	Random UDS	Bridges group provided statistically significant more negative urine screens (75%) compared to control group (30%) at 6-month follow up	(+)
MacMaster et al., (2007)	N = 163 adults (n=131 Black; 47.5% men, 52.5% women)	No	Faith-Based	N/A	6 months, 12 months	Self-reported use of cocaine	Participants self-reported significant decrease in days of cocaine use (79% at 12-month follow-up	Yes
Wechsberg et al. (2007)	N = 443 Black adults (73.1% men, 26.9% women)	Yes	Culturally Congruent Intervention (Pre-treatment Readiness)	Motivational Interviewing Pre-Treatment (n=198) vs. Delayed Treatment Control (n=200)	3 months, 6 months	Self-reported cocaine use; UDS	Although both groups reported reduced crack cocaine use, there were no statistically significant group differences	(=)
Okpaku et al., (2010)	N = 207 women (94.7% Black; 0% men)	No	Pre-Treatment Program for HIV	N/A	6 months	Self-reported cocaine use	Participants reported statistically significant decrease (75.1%) in cocaine use at 6-month follow up	Yes
Jones et al., (2011)	N = 59 Black women (0% men)	Yes	Gender-Specific Intervention (Pregnancy and Motherhood)	Woman-focused intervention (the Women’s Co-op; n =30) vs. Treatment-as-Usual (n=29)	6 months	UDS	Although both groups reduced their cocaine use during pregnancy, there were no statistically significant group differences	(=)

Culturally Universal Cocaine Treatment Interventions

Nineteen (19) studies investigated the effectiveness of culturally universal treatment approaches for cocaine use in samples of more than 75% Black participants (see Table 1).

Description of Studies

Contingency Management.

CM interventions involve reinforcing cocaine abstinence with resources (e.g., goods, money, housing) in exchange for cocaine-free urine screenings and/or treatment compliance (McGovern & Carroll, 2003). Seven studies examined the effectiveness of CM for treating cocaine use. Five RCTs compared behavioral day treatment and abstinent-contingent housing or employment (DT+) to behavioral day treatment alone (DT) for homeless participants who use cocaine. In four of the five RCT studies in day treatment settings, participants in the DT+ conditions had a greater likelihood of self-reported positive treatment outcomes (82.7% Black participants, Schumacher et al., 2003), cocaine-negative urine screens (88% Black participants; DeFulio et al., 2009; 82.7% Black participants, Schumacher et al., 2000), and cocaine abstinence at 2- and 6-month follow-ups (82.7% Black participants, Milby et al., 2000). In the fifth study, which was intervention comparing a behavioral day treatment program (DT) to a behavioral day treatment program with an abstinent contingent housing and work therapy component (CM + DT) , neither participants with a dual diagnosis of mental health and cocaine use disorders, nor those with only given a substance use diagnosis, showed statistically significant differences in self-reported use or cocaine-negative urine screens at 6-month follow-up. However, both groups reported stable housing and full-time employment because of the intervention (82% Black participants, McNamara et al., 2001).

An RCT assessing CM, relapse prevention (RP), a combination of the two approaches (CM + RP), or treatment as usual (TAU) in an intensive outpatient program showed participants (89% Black) in the CM + RP condition self-reported less cocaine use and had more negative cocaine urine screens at 6- and 9-month follow-ups compared to participants in CM-only, RP-only, or TAU conditions (McKay et al., 2010). The authors argued the positive effects of CM + RP were evident after participants achieved stabilization and abstinence in an intensive outpatient program. Jemison and colleagues (2019) conducted a CM intervention focused on cocaine use, trauma, and HIV disease with Black women. Participants (81% Black) received cash incentives for each cocaine-negative urine screen and were randomly assigned to an expressive writing (CM + EW) or neutral writing condition (CM + NW). Though the authors noted non-significant trends (e.g., less cocaine use and cocaine-negative urine screens) in the CM + EW condition, those participants did not have better outcomes than participants in the CM + NW condition at 6-month follow-up.

Motivational Interviewing.

Six studies used an MI approach to help participants resolve ambivalence and increase motivation to change drug use behaviors (McGovern & Carroll, 2003). Two Recovery Management Check-up (RMC) interventions demonstrated that participants assigned to RMC conditions were significantly more likely to provide cocaine-negative screens, self-report more days of cocaine abstinence, return to treatment sooner, and receive more days of treatment than participants in the control conditions over years (85% Black participants, Dennis & Scott, 2012; 82% Black participants, Rush et al., 2008).

In two Motivational Enhancement Therapy (MET) interventions (100% Black participants, Burlew et al., 2013; 100% Black participants, Montgomery et al., 2011), there were no significant differences in self-reported cocaine use between intervention and control groups (Montgomery et al., 2011) unless Black participants in the MET condition had a high readiness to change (Burlew et al., 2013). Although participants with high readiness-to-change scores self-reported fewer days of cocaine use compared to participants in the TAU condition, this was not true for participants with low readiness-to-change scores (Burlew et al., 2013).

Last, a tailored computer-delivered MI intervention delivered postpartum was effective for new mothers (90.6% Black participants) who self-reported reduced cocaine use and provided more cocaine-negative urine and hair samples for analyses, even though the results did not reach significance at 6-month follow-up (Ondersma et al., 2013). Another study utilizing MI reported significant reductions in cocaine use but no statistically significant differences between intervention and control groups (82% Black participants, Ingersoll et al., 2011).

Cognitive-Behavioral Therapy.

Four studies utilized CBT to help participants challenge their dysfunctional beliefs about drug use and learn new coping skills of self-awareness and problem-solving (McGovern & Carroll, 2003). One intervention found that Black participants (80%) assigned to the CBT condition self-reported more cocaine abstinence and provided more cocaine-negative urine screens than participants in the 12-step (12SF) condition (Maude-Griffin et al., 1998). However, another RCT tested various combinations of treatment approaches over 4-months with participants (95% Black) and found that there were no significant differences found by treatment condition at 12-month follow-up (Hoffman et al., 1996).

Two CBT interventions focused on post-treatment cocaine abstinence and aftercare. Participants (94.7% Black) in a behavioral activation (BA) RCT self-reported higher cocaine abstinence and provided more cocaine-negative urine screens compared to those assigned to the supportive group counseling condition at 3, 6, and 12-month follow-up (Daughters et al., 2018). However, McKay and colleagues (1997) noted although there were no significant differences in percent of days of cocaine use between participants (85% Black) enrolled in an intensive outpatient program (IOP) who were assigned to either a standard group counseling (STND) or relapse prevention (RP) group, participants in the RP group self-reported less cocaine use and provided more cocaine-negative screens during the first three months of the six-month intervention. RP appeared to be more effective in limiting cocaine use only during months 1-3 compared to higher self-reported cocaine abstinence of participants in the STND condition at 6-month follow-up.

12-Step Programming.

Mutual help groups such as Alcoholics or Narcotics Anonymous (AA/NA) are peer-led meetings based on 12 guiding principles of physical, mental, and spiritual recovery (McGovern & Carroll, 2003). Two interventions with male veterans compared cocaine outcomes in a day hospital (DH) to inpatient hospitalization (97% Black participants; Alterman et al., 1994) or outpatient program (91.5% Black participants; Coviello et al., 2000). Both treatments required participants to participate in AA/NA; participants self-reported reduced days of cocaine use and provided more cocaine-negative urine screens, but there were no differences in cocaine abstinence between groups during or after treatment at 7-month follow-up (Alterman et al., 1994; Coviello et al., 2000).

Summary of Findings for Culturally Universal Cocaine Treatment Interventions

A total of 9 out of 19 (47%) culturally universal cocaine interventions demonstrated statistically significant differences in effectiveness with predominantly Black American samples in one or more conditions; CM and CBT were used in the largest number of intervention studies with statistically significant results. For example, several CM approaches, which reinforced abstinence and addressed participants’ basic needs of income, housing, and employment, improved cocaine outcomes (SAMHSA, 2020). Four CBT studies, which targeted a range of problems such as increasing self-awareness and developing new problem-solving skills, were also effective (SAMHSA, 2020). In contrast, MI interventions had mixed findings; only those with RMCs appeared to be effective among Black participants with cocaine dependence. Lastly, two 12-step interventions showed no statistically significant effect in reducing Black participants’ biologically verified cocaine use, although they did increase self-reported cocaine abstinence.

Culturally Tailored Cocaine Treatment Interventions

Previous research has proposed that treatment approaches providing professional support and that adequately address unique experiences of Black Americans such as racism and discrimination may foster more cocaine abstinence (Smith et al., 1993). A review of the literature identified 11 cocaine intervention studies that were culturally tailored to Black participants’ salient identities, needs, and preferences for treatment (see Table 2).

Description of Studies

Culture-Based.

One culturally tailored intervention integrated MI with the following components: Black peer counselors, a traditional meal, and a culturally relevant film about drug consequences among Black Americans. Black participants in the culturally tailored MI + needs assessment and referral condition were significantly less likely to report and provide positive urine samples for cocaine at 1-year follow-up compared to Black participants in the standard assessment and referral condition (100% Black participants, Longshore & Grills, 2000). Similarly, in a culturally congruent intervention to increase treatment motivation for solely Black participants, Wechsberg and colleagues (2007) provided participants in the intervention group with individualized drug treatment plans that incorporated problem-solving and accountability skills. The Black interventionists acknowledged various sociocultural factors and external barriers (e.g., economic instability, cultural competency, gender bias, and lack of childcare) that could hinder participants’ treatment entry. The control group received no treatment during the first six months of the intervention and were only invited to participate afterwards. Because both groups reported reduced crack cocaine use, there were no significant group differences (Wechsberg et al., 2007).

Faith-Based.

Three studies integrated spirituality into cocaine treatment by engaging with Black churches in their interventions. One study with a single-group design targeted difficult-to-reach people (80.3% Black) who used cocaine and heroin to provide drug treatment, case management, HIV/STD testing, and mental health services from a faith-based perspective (MacMaster et al., 2007). Participants in the program self-reported reduced cocaine use and frequency, with almost half who entered drug treatment (MacMaster et al., 2007). Two RCTs with solely Black participants compared standard 12-step-oriented residential treatment to residential treatment with a faith-based component (Faith Bridges; Stahler et al., 2005, 2007). Black women participants in both experimental conditions self-reported reduced drug use and provided more cocaine-negative urine samples than participants in the standard conditions (Stahler et al., 2005; Stahler et al., 2007). Additionally, participants in the Faith Bridges conditions reported more treatment satisfaction than women in the standard condition at 3- and 6-month follow-up (Stahler et al., 2005). Key components of the faith-based condition were individual counseling, daily group activities facilitating spiritual enlightenment, relationship skills, and mentorship with a Black female volunteer (Stahler et al., 2005; 2007).

Sexual Health Interventions.

Given a decades-long syndemic of sexually transmitted infections (e.g., HIV) and substance use that continue to disproportionately affect Black Americans (Edlin et al., 1994; Kerr & Jackson, 2016), three studies sought to primarily reduce cocaine use and simultaneously decrease engagement in sexual risk behaviors. Of these, two studies utilized the National Institute on Drug Abuse’s Cooperative Agreement for HIV/AIDS to compare a sexual health education standard condition to one of two culturally tailored conditions: an enhanced condition, which focused on gender-specific norms and values, power and control, and economic stressors, or a motivation condition, which focused on safer sex by way of safer drug use, and the impact of race and gender on HIV risk and protective behaviors. While some Black women in culturally tailored conditions self-reported reduced cocaine use and sexual risk behaviors at follow-up compared to Black women in standard conditions (93% Black participants, Cottler et al., 1998), the other two interventions showed Black women in each condition equally reported reduced cocaine use and sexual risk behaviors (100% Black participants, Sterk et al., 2003a; 100% Black participants, Sterk et al., 2003b).

Another study focused on reducing cocaine use among women who are at risk for contracting HIV. Okpaku and colleagues (2010) enrolled women (97% Black) who used cocaine in the Treatment Access Program (TAP) to ensure access to substance use treatment, faith-based case management, and HIV outreach. The program relied on Black female staff to provide mentorship to participants. In this study with a single-group design, approximately 75% of participants self-reported cocaine abstinence or reduced cocaine use at 6-month follow-up (Okpaku et al., 2010). Sexual risk-related behaviors such as condomless sex also decreased.

Motherhood-Based.

Two treatment interventions addressed gender-based identity through the lens of motherhood. Volpicelli and colleagues (2000) compared a culturally tailored psychosocial enhanced treatment (PET) to a case management condition among mothers (96.4% Black) who used cocaine. Participants assigned to the PET condition self-reported fewer days of cocaine use and offered more cocaine-negative urine samples compared to participants in the case management control condition. Whereas the PET condition included women-oriented group counseling modules, parenting and GED classes, and access to therapists, the case management condition offered daily group therapy and access to community services only by referral (Volpicelli et al., 2000). In a woman-focused Cognitive Orientation to Occupational Performance (Co-Op) intervention tailored for pregnant women (100% Black) enrolled in drug treatment, there were no statistically significant differences in cocaine use between participants of the intervention group and TAU group (Jones et al., 2011). However, both groups reported less cocaine use and produced more cocaine-negative urine screens at 6-month follow up.

Summary of Findings for Culturally Tailored Treatment Findings

Overall, 8 out of 11 (72%) culturally tailored treatment interventions demonstrated significant effectiveness in reducing self-reported or biologically confirmed cocaine use among Black participants. These interventions acknowledged participants’ salient gender, socioeconomic status, motherhood, and spiritual backgrounds and incorporated Black cultural values in content material. For example, interventions that addressed stressors of poverty, unemployment, unstable housing, unreliable childcare, and poor relationship dynamics helped Black women reduce their cocaine use. Further, culturally tailored approaches validated race-based stressors and promoted self- and collective-esteem to promote drug recovery (Rowe & Grills, 1993). Several studies included Black outreach managers, peer counselors, and community mentors to facilitate interventions, which may have increased some participants’ motivation and investment to reduce their cocaine use. Last, interventions that featured faith-based and sexual health components facilitated reductions in cocaine use and risk of HIV infection. Two major limitations of these culturally tailored intervention studies are that most were published more than 20 years ago and heavily relied on self-reported, rather than biologically confirmed, cocaine use.

Discussion

The current study identified and analyzed culturally universal and culturally tailored interventions for reducing cocaine use among Black Americans. Our review showed that both culturally tailored and culturally universal approaches can be effective for cocaine treatment in Black Americans. Interventions that offer incentives for abstinence, identify drug triggers, increase coping skills, and encourage changes in drug-related behaviors are generally effective in decreasing cocaine use. However, because of racial differences in drug and treatment outcomes (Jordan et al., 2022), we conclude that some culturally universal treatment approaches like MI or 12-step programs may have limited utility in reducing cocaine-related racial health disparities if they do not specifically address Black participants’ needs. For example, only MI interventions with RMCs demonstrated reductions in cocaine use among Black participants, perhaps because RMCs guided participants in recognizing cocaine dependence as a cyclic problem of relapse, reentry, and recovery that requires numerous treatment episodes (Scott et al., 2005). The lower effectiveness of other MI interventions may reflect Black participants’ need for more tailored intervention according to their readiness for change (Burlew et al., 2013). Similarly, the two 12-step interventions reviewed in the current study showed no significant difference in Black participants’ cocaine use compared to control conditions. It is possible that 12-step groups’ concepts of surrendering and powerlessness as positive elements along the journey of recovery may not translate well for people from marginalized communities who routinely experience powerlessness in negative ways (Smith et al., 1993).

Although the current study does not allow us to compare the magnitude of efficacy between the two intervention types, we note the difference in the number of studies — 72% versus 47% — that demonstrated efficacy for Black Americans of culturally tailored versus culturally universal interventions respectively. Recommendations for future research and clinical practice are discussed below.

Collaboration with Black churches to provide faith-based interventions are strongly associated with decreases in cocaine use as well as HIV risk behaviors with this group (MacMaster et al., 2007; Stahler et al., 2005; Stahler et al., 2007). The value of faith-based interventions for cocaine use may be attributable to the fact that churches are the most influential institutions in Black communities (Jordan et al., 2021). Further, through its encouragement of hope and facilitation of social support (Belgrave & Allison, 2014), spirituality can enhance one’s ability to cope with cocaine cravings and related life stressors. Among Black women, two studies showed the Faith Bridges church mentoring intervention reduced HIV risk behaviors among cocaine-using Black women (Stahler et al., 2005; Stahler et al., 2007). There were no studies identified in this review that implemented a faith-based approach for Black men exclusively. While Black women tend to be more spiritual than Black men (Holt et al., 2015), Black men are still highly religious compared to other U.S. demographics (Cox & Diamant, 2018). This limitation in the literature needs further study on the utility of tailored faith-based interventions for reducing cocaine use among Black men.

In addition to faith-based interventions, other culturally tailored approaches demonstrated consistent decreases in cocaine use among Black Americans. Key intervention elements include incorporating cultural values (i.e., racial pride, collectivism, and family) and taking an intersectional approach (i.e., integrating racialized gender roles and expectations). Surprisingly, some research suggests matching clients with therapists based on race and gender does not appear to impact cocaine outcomes (Sterling et al., 2001). However, many culturally tailored approaches incorporated community values into treatment content in conjunction with racial matching of clinicians or peers to make meaningful and sustainable change in cocaine use among this group.

Further study is needed for three primary reasons. First, despite the effectiveness of culturally tailored approaches, few empirical studies have examined cultural interventions for cocaine use among Black Americans since the early 2000s. Second, culture is dynamic; while there are core values in Black communities, interventions should be continually adapted over time as cultural norms and attitudes shift. For example, less than half of Black Americans from younger generations report regular church attendance (Mohamed et al, 2021). Additionally, only half of Black adults perceive predominantly Black churches to be as influential as they were 50 years ago (Mohamed et al., 2021). Faith-based interventions should be updated regularly to remain relevant to cultural changes and spiritual norms among Black Americans who use cocaine.

Third, cultural norms vary across subgroups within a given population (Golub et al., 2005). While some studies attended to the unique experience of Black women, few studies attended to differences in intersecting identities (e.g., age cohorts, sexual orientation, geographic region) among Black Americans who use cocaine. Research on frequent and severe cocaine use among older Black generations is warranted as this group has the highest rates of drug overdose compared to other race/ethnicity-gender cohorts (Akwe et al., 2023; Jones et al., 2023). Further, more research is needed to determine prevention and intervention needs of younger Black generations (e.g., 18-34 years old) because their initiation of cocaine use and risk for overdose due to co-use of cocaine and opioids has substantially increased in the current epidemic (Mustaquim et al., 2021). With racial disparities in the rise of cocaine use and comorbidities in recent years (John & Wu, 2017), there is a continued need for implementation and analysis of cocaine interventions designed specifically for Black Americans and targeted according to their intersectional identities.

Overall, findings from this systematic review present several implications for treatment of Black Americans who use cocaine. First, both culturally universal treatments (e.g., MI, CM, CBT) and culturally tailored treatments can be effective in reducing cocaine use in this group. However, our findings suggest that culturally tailored approaches are better at addressing the specific needs of Black Americans. Given existing racial disparities in treatment effectiveness, it may be ideal to integrate cultural needs into culturally universal approaches and/or implement evidence-based methods in the design of culturally tailored interventions. Culturally tailored approaches, which engage and validate the experiences of their participants, are uniquely positioned to address race-related stressors that may serve as triggers for drug use, such as racial discrimination (Carliner et al., 2016), as well as structural barriers, like disproportionate criminal justice involvement (Farahmand et al., 2020). These factors impact drug use among Black Americans above and beyond individual behaviors that are addressed in culturally universal treatment approaches (Galea & Vlahov, 2002).

Limitations

This systematic review has several limitations. First, study inclusion and exclusion criteria, treatment interventions, and measurements of treatment outcomes were not the same across studies; therefore, meta-analyses were unlikely to be informative and were thus not performed. Second, this review includes RCTs, quasi-experimental and cross-sectional articles, but excludes studies utilizing other methodologies that may be culturally informed such as qualitative and conceptual studies. We did not find any studies that directly compared the effectiveness of culturally universal and culturally tailored treatment approaches in one intervention; this limitation is worthy of exploration in future research.

Third, studies included in this review paper may have resulted from publication bias, where studies with favorable treatment outcomes were more likely to be published than studies with unfavorable treatment outcomes. Numerous systematic reviews have demonstrated such a publication bias within clinical research literature that may lead to an overestimation of the efficacy of interventions (Dickersin et al., 1997; Easterbrook et al., 1991; Song et al., 2010). Results from review articles indicate that publication bias is less prevalent among randomized clinical trials (Easterbrook et al., 1991; Schwab et al., 2021). While a larger proportion of studies in the current review were randomized clinical trials, it is likely that our findings were skewed due to the decreased likelihood that null findings were published. This may also be true for culturally tailored interventions because the majority of those showed effectiveness.

Last, our results may not be generalizable to other racial and ethnic groups in clinical or community settings. Further research is needed to broaden our understanding of the cultural components that will be most important to integrate in cocaine treatment among various subgroups in Black communities, including men, LGBT* individuals, and non-religious individuals. Despite these disadvantages, this paper is the one of the first to provide an overview of effective cocaine treatment approaches among Black Americans that can inform research and clinical work with this population.

Conclusion

Cocaine use remains a public health concern and disproportionately affects Black Americans, leading to poor consequences including overdose deaths. These racial disparities are exacerbated by treatment access barriers, cultural blindness, and poor treatment satisfaction. Culturally tailored treatment approaches may be able to reduce cocaine use and mitigate cocaine-related comorbidities with a level of effectiveness that current standard culturally universal approaches cannot always achieve for this population. This review paper identifies effective approaches that can be utilized in future research and practice to recruit and engage Black Americans in cocaine treatment, reduce their cocaine use, and ultimately improve their physical, emotional, and social wellbeing. By demonstrating that culturally tailored treatments are effective among Black Americans, the current systematic review hopes to encourage more investment in culturally tailored cocaine treatment intervention development and implementation.