SW1002:   Principles of Drug Addiction Treatment


   


Scientifically Based Approaches to Drug Addiction Treatment

This section presents several examples of treatment approaches and components that have been developed and tested for efficacy through research supported by the National Institute on Drug Abuse (NIDA). Each approach is designed to address certain aspects of drug addiction and its consequences for the individual, family, and society. The approaches are to be used to supplement or enhanceÑnot replaceÑexisting treatment programs.

This section is not a complete list of efficacious, scientifically-based treatment approaches. Additional approaches are under development as part of NIDA's continuing support of treatment research.


Relapse Prevention, a cognitive-behavioral therapy, was developed for the treatment of problem drinking and adapted later for cocaine addicts. Cognitive-behavioral strategies are based on the theory that learning processes play a critical role in the development of maladaptive behavioral patterns. Individuals learn to identify and correct problematic behaviors. Relapse prevention encompasses several cognitive-behavioral strategies that facilitate abstinence as well as provide help for people who experience relapse.

The relapse prevention approach to the treatment of cocaine addiction consists of a collection of strategies intended to enhance self-control. Specific techniques include exploring the positive and negative consequences of continued use, self-monitoring to recognize drug cravings early on and to identify high-risk situations for use, and developing strategies for coping with and avoiding high-risk situations and the desire to use. A central element of this treatment is anticipating the problems patients are likely to meet and helping them develop effective coping strategies.

Research indicates that the skills individuals learn through relapse prevention therapy remain after the completion of treatment. In one study, most people receiving this cognitive-behavioral approach maintained the gains they made in treatment throughout the year following treatment.

References:

Carroll, K.; Rounsaville, B.; and Keller, D. Relapse prevention strategies for the treatment of cocaine abuse. American Journal of Drug and Alcohol Abuse 17(3): 249-265, 1991.

Carroll, K.; Rounsaville, B.; Nich, C.; Gordon, L.; Wirtz, P.; and Gawin, F. One-year follow-up of psychotherapy and pharmacotherapy for cocaine dependence: delayed emergence of psychotherapy effects. Archives of General Psychiatry 51: 989-997, 1994.

Marlatt, G. and Gordon, J.R., eds. Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York: Guilford Press, 1985.


The Matrix Model provides a framework for engaging stimulant abusers in treatment and helping them achieve abstinence. Patients learn about issues critical to addiction and relapse, receive direction and support from a trained therapist, become familiar with self-help programs, and are monitored for drug use by urine testing. The program includes education for family members affected by the addiction.

The therapist functions simultaneously as teacher and coach, fostering a positive, encouraging relationship with the patient and using that relationship to reinforce positive behavior change. The interaction between the therapist and the patient is realistic and direct but not confrontational or parental. Therapists are trained to conduct treatment sessions in a way that promotes the patient's self-esteem, dignity, and self-worth. A positive relationship between patient and therapist is a critical element for patient retention.

Treatment materials draw heavily on other tested treatment approaches. Thus, this approach includes elements pertaining to the areas of relapse prevention, family and group therapies, drug education, and self-help participation. Detailed treatment manuals contain work sheets for individual sessions; other components include family educational groups, early recovery skills groups, relapse prevention groups, conjoint sessions, urine tests, 12-step programs, relapse analysis, and social support groups.

A number of projects have demonstrated that participants treated with the Matrix model demonstrate statistically significant reductions in drug and alcohol use, improvements in psychological indicators, and reduced risky sexual behaviors associated with HIV transmission. These reports, along with evidence suggesting comparable treatment response for methamphetamine users and cocaine users and demonstrated efficacy in enhancing naltrexone treatment of opiate addicts, provide a body of empirical support for the use of the model.

References:

Huber, A.; Ling, W.; Shoptaw, S.; Gulati, V.; Brethen, P.; and Rawson, R. Integrating treatments for methamphetamine abuse: A psychosocial perspective. Journal of Addictive Diseases 16: 41-50, 1997.

Rawson, R.; Shoptaw, S.; Obert, J.L.; McCann, M.; Hasson, A.; Marinelli-Casey, P.; Brethen, P.; and Ling, W. An intensive outpatient approach for cocaine abuse: The Matrix model. Journal of Substance Abuse Treatment 12(2): 117-127, 1995.


Supportive-Expressive Psychotherapy is a time-limited, focused psychotherapy that has been adapted for heroin- and cocaine-addicted individuals. The therapy has two main components:

  • Supportive techniques to help patients feel comfortable in discussing their personal experiences.
  • Expressive techniques to help patients identify and work through interpersonal relationship issues.

Special attention is paid to the role of drugs in relation to problem feelings and behaviors, and how problems may be solved without recourse to drugs.

The efficacy of individual supportive-expressive psychotherapy has been tested with patients in methadone maintenance treatment who had psychiatric problems. In a comparison with patients receiving only drug counseling, both groups fared similarly with regard to opiate use, but the supportive-expressive psychotherapy group had lower cocaine use and required less methadone. Also, the patients who received supportive-expressive psychotherapy maintained many of the gains they had made. In an earlier study, supportive-expressive psychotherapy, when added to drug counseling, improved outcomes for opiate addicts in methadone treatment with moderately severe psychiatric problems.

References:

Luborsky, L. Principles of Psychoanalytic Psychotherapy: A Manual for Supportive-Expressive (SE) Treatment. New York: Basic Books, 1984.

Woody, G.E.; McLellan, A.T.; Luborsky, L.; and O'Brien, C.P. Psychotherapy in community methadone programs: a validation study. American Journal of Psychiatry 152(9): 1302-1308, 1995.

Woody, G.E.; McLellan, A.T.; Luborsky, L.; and O'Brien, C.P. Twelve month follow-up of psychotherapy for opiate dependence. American Journal of Psychiatry 144: 590-596, 1987.

Individualized Drug Counseling focuses directly on reducing or stopping the addict's illicit drug use. It also addresses related areas of impaired functioning such as employment status, illegal activity, family/social relationsÑas well as the content and structure of the patient's recovery program. Through its emphasis on short-term behavioral goals, individualized drug counseling helps the patient develop coping strategies and tools for abstaining from drug use and then maintaining abstinence. The addiction counselor encourages 12-step participation and makes referrals for needed supplemental medical, psychiatric, employment, and other services. Individuals are encouraged to attend sessions one or two times per week.

In a study that compared opiate addicts receiving only methadone to those receiving methadone coupled with counseling, individuals who received only methadone showed minimal improvement in reducing opiate use. The addition of counseling produced significantly more improvement. The addition of onsite medical/psychiatric, employment, and family services further improved outcomes.

In another study with cocaine addicts, individualized drug counseling, together with group drug counseling, was quite effective in reducing cocaine use. Thus, it appears that this approach has great utility with both heroin and cocaine addicts in outpatient treatment.

References:

McLellan, A.T.; Arndt, I.; Metzger, D.S.; Woody, G.E.; and O'Brien, C.P. The effects of psychosocial services in substance abuse treatment. Journal of the American Medical Association 269(15): 1953-1959, 1993.

McLellan, A.T.; Woody, G.E.; Luborsky, L.; and O'Brien, C.P. Is the counselor an 'active ingredient' in substance abuse treatment? Journal of Nervous and Mental Disease 176: 423-430, 1988.

Woody, G.E.; Luborsky, L.; McLellan, A.T.; O'Brien, C.P.; Beck, A.T.; Blaine, J.; Herman, I.; and Hole, A. Psychotherapy for opiate addicts: Does it help? Archives of General Psychiatry 40: 639-645, 1983.

Crits-Cristoph, P.; Siqueland, L.; Blaine, J.; Frank, A.; Luborsky, L.; Onken, L.S.; Muenz, L.; Thase, M.E.; Weiss, R.D.; Gastfriend, D.R.; Woody, G.; Barber, J.P.; Butler, S.F.; Daley, D.; Bishop, S.; Najavits, L.M.; Lis, J.; Mercer, D.; Griffin, M.L.; Moras, K.; and Beck, A. Psychosocial treatments for cocaine dependence: Results of the NIDA Cocaine Collaborative Study. Archives of General Psychiatry (in press).


Motivational Enhancement Therapy is a client-centered counseling approach for initiating behavior change by helping clients to resolve ambivalence about engaging in treatment and stopping drug use. This approach employs strategies to evoke rapid and internally motivated change in the client, rather than guiding the client stepwise through the recovery process. This therapy consists of an initial assessment battery session, followed by two to four individual treatment sessions with a therapist. The first treatment session focuses on providing feedback generated from the initial assessment battery to stimulate discussion regarding personal substance use and to elicit self-motivational statements. Motivational interviewing principles are used to strengthen motivation and build a plan for change. Coping strategies for high-risk situations are suggested and discussed with the client. In subsequent sessions, the therapist monitors change, reviews cessation strategies being used, and continues to encourage commitment to change or sustained abstinence. Clients are sometimes encouraged to bring a significant other to sessions. This approach has been used successfully with alcoholics and with marijuana-dependent individuals.

References:

Budney, A.J.; Kandel, D.B.; Cherek, D.R.; Martin, B.R.; Stephens, R.S.; and Roffman, R. College on problems of drug dependence meeting, Puerto Rico (June 1996). Marijuana use and dependence. Drug and Alcohol Dependence 45: 1-11, 1997.

Miller, W.R. Motivational interviewing: research, practice and puzzles. Addictive Behaviors 61(6): 835-842, 1996.

Stephens, R.S.; Roffman, R.A.; and Simpson, E.E. Treating adult marijuana dependence: a test of the relapse prevention model. Journal of Consulting & Clinical Psychology, 62: 92-99, 1994.


Behavioral Therapy for Adolescents incorporates the principle that unwanted behavior can be changed by clear demonstration of the desired behavior and consistent reward of incremental steps toward achieving it. Therapeutic activities include fulfilling specific assignments, rehearsing desired behaviors, and recording and reviewing progress, with praise and privileges given for meeting assigned goals. Urine samples are collected regularly to monitor drug use. The therapy aims to equip the patient to gain three types of control:

Stimulus Control helps patients avoid situations associated with drug use and learn to spend more time in activities incompatible with drug use.

Urge Control helps patients recognize and change thoughts, feelings, and plans that lead to drug use.

Social Control involves family members and other people important in helping patients avoid drugs. A parent or significant other attends treatment sessions when possible and assists with therapy assignments and reinforcing desired behavior.

According to research studies, this therapy helps adolescents become drug free and increases their ability to remain drug free after treatment ends. Adolescents also show improvement in several other areas: employment/school attendance, family relationships, depression, institutionalization, and alcohol use. Such favorable results are attributed largely to including family members in therapy and rewarding drug abstinence as verified by urinalysis.

References:

Azrin, N.H.; Acierno, R.; Kogan, E.; Donahue, B.; Besalel, V.; and McMahon, P.T. Follow-up results of supportive versus behavioral therapy for illicit drug abuse. Behavioral Research & Therapy 34(1): 41-46, 1996.

Azrin, N.H.; McMahon, P.T.; Donahue, B.; Besalel, V.; Lapinski, K.J.; Kogan, E.; Acierno, R.; and Galloway, E. Behavioral therapy for drug abuse: a controlled treatment outcome study. Behavioral Research & Therapy 32(8): 857-866, 1994.

Azrin, N.H.; Donohue, B.; Besalel, V.A.; Kogan, E.S.; and Acierno, R. Youth drug abuse treatment: A controlled outcome study. Journal of Child & Adolescent Substance Abuse 3(3): 1-16, 1994.


Multidimensional Family Therapy (MDFT) for Adolescents is an outpatient family-based drug abuse treatment for teenagers. MDFT views adolescent drug use in terms of a network of influences (that is, individual, family, peer, community) and suggests that reducing unwanted behavior and increasing desirable behavior occur in multiple ways in different settings. Treatment includes individual and family sessions held in the clinic, in the home, or with family members at the family court, school, or other community locations.

During individual sessions, the therapist and adolescent work on important developmental tasks, such as developing decisionmaking, negotiation, and problem-solving skills. Teenagers acquire skills in communicating their thoughts and feelings to deal better with life stressors, and vocational skills. Parallel sessions are held with family members. Parents examine their particular parenting style, learning to distinguish influence from control and to have a positive and developmentally appropriate influence on their child.

References:

Diamond, G.S., and Liddle, H.A. Resolving a therapeutic impasse between parents and adolescents in Multi-dimensional Family Therapy. Journal of Consulting and Clinical Psychology 64(3): 481-488, 1996.

Schmidt, S.E.; Liddle, H.A.; and Dakof, G.A. Effects of multidimensional family therapy: Relationship of changes in parenting practices to symptom reduction in adolescent substance abuse. Journal of Family Psychology 10(1): 1-16, 1996.


Multisystemic Therapy (MST) addresses the factors associated with serious antisocial behavior in children and adolescents who abuse drugs. These factors include characteristics of the adolescent (for example, favorable attitudes toward drug use), the family (poor discipline, family conflict, parental drug abuse), peers (positive attitudes toward drug use), school (dropout, poor performance), and neighborhood (criminal subculture). By participating in intense treatment in natural environments (homes, schools, and neighborhood settings) most youths and families complete a full course of treatment. MST significantly reduces adolescent drug use during treatment and for at least 6 months after treatment. Reduced numbers of incarcerations and out-of-home placements of juveniles offset the cost of providing this intensive service and maintaining the clinicians' low caseloads.

References:

Henggeler, S.W.; Pickrel, S.G.; Brondino, M.J.; and Crouch, J.L. Eliminating (almost) treatment dropout of substance abusing or dependent delinquents through home-based multisystemic therapy. American Journal of Psychiatry 153: 427-428, 1996.

Henggeler, S.W.; Schoenwald, S.K.; Borduin, C.M.; Rowland, M.D.; and Cunningham, P. B. Multisystemic treatment of antisocial behavior in children and adolescents. New York: Guilford Press, 1998.

Schoenwald, S.K.; Ward, D.M.; Henggeler, S.W.; Pickrel, S.G.; and Patel, H. MST treatment of substance abusing or dependent adolescent offenders: Costs of reducing incarceration, inpatient, and residential placement. Journal of Child and Family Studies 5: 431-444, 1996.


Combined Behavioral and Nicotine Replacement Therapy for Nicotine Addiction consists of two main components:

  • The transdermal nicotine patch or nicotine gum reduces symptoms of withdrawal, producing better initial abstinence.
  • The behavioral component concurrently provides support and reinforcement of coping skills, yielding better long-term outcomes.

Through behavioral skills training, patients learn to avoid high-risk situations for smoking relapse early on and later to plan strategies to cope with such situations. Patients practice skills in treatment, social, and work settings. They learn other coping techniques, such as cigarette refusal skills, assertiveness, and time management. The combined treatment is based on the rationale that behavioral and pharmacological treatments operate by different yet complementary mechanisms that produce potentially additive effects.

References:

Fiore, M.C.; Kenford, S.L.; Jorenby, D.E.; Wetter, D.W.; Smith, S.S.; and Baker, T.B. Two studies of the clinical effectiveness of the nicotine patch with different counseling treatments. Chest 105: 524-533, 1994.

Hughes, J.R. Combined psychological and nicotine gum treatment for smoking: a critical review. Journal of Substance Abuse 3: 337-350, 1991.

American Psychiatric Association: Practice Guideline for the Treatment of Patients with Nicotine Dependence. American Psychiatric Association, 1996.


Community Reinforcement Approach (CRA) Plus Vouchers is an intensive 24-week outpatient therapy for treatment of cocaine addiction. The treatment goals are twofold:

  • To achieve cocaine abstinence long enough for patients to learn new life skills that will help sustain abstinence.
  • To reduce alcohol consumption for patients whose drinking is associated with cocaine use.

Patients attend one or two individual counseling sessions per week, where they focus on improving family relations, learning a variety of skills to minimize drug use, receiving vocational counseling, and developing new recreational activities and social networks. Those who also abuse alcohol receive clinic-monitored disulfiram (Antabuse) therapy. Patients submit urine samples two or three times each week and receive vouchers for cocaine-negative samples. The value of the vouchers increases with consecutive clean samples. Patients may exchange vouchers for retail goods that are consistent with a cocaine-free lifestyle.

This approach facilitates patients' engagement in treatment and systematically aids them in gaining substantial periods of cocaine abstinence. The approach has been tested in urban and rural areas and used successfully in outpatient detoxification of opiate-addicted adults and with inner-city methadone maintenance patients who have high rates of intravenous cocaine abuse.

References:

Higgins, S.T.; Budney, A.J.; Bickel, H.K.; Badger, G.; Foerg, F.; and Ogden, D. Outpatient behavioral treatment for cocaine dependence: one-year outcome. Experimental & Clinical Psychopharmacology 3(2): 205-212, 1995.

Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Foerg, F.; Donham, R.; and Badger, G. Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Archives of General Psychiatry 51: 568-576, 1994.

Silverman, K.; Higgins, S.T.; Brooner, R.K.; Montoya, I.D.; Cone, E.J.; Schuster, C.R.; and Preston, K.L. Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy. Archives of General Psychiatry 53: 409-415, 1996.


Voucher-Based Reinforcement Therapy in Methadone Maintenance Treatment helps patients achieve and maintain abstinence from illegal drugs by providing them with a voucher each time they provide a drug-free urine sample. The voucher has monetary value and can be exchanged for goods and services consistent with the goals of treat-ment. Initially, the voucher values are low, but their value increases with the number of consecutive drug-free urine specimens the individual provides. Cocaine- or heroin-positive urine specimens reset the value of the vouchers to the initial low value. The contingency of escalating incentives is designed specifically to reinforce periods of sustained drug abstinence.

Studies show that patients receiving vouchers for drug-free urine samples achieved significantly more weeks of abstinence and significantly more weeks of sustained abstinence than patients who were given vouchers independent of urinalysis results. In another study, urinalyses positive for heroin decreased significantly when the voucher program was started and increased significantly when the program was stopped.

References:

Silverman, K.; Higgins, S.; Brooner, R.; Montoya, I.; Cone, E.; Schuster, C.; and Preston, K. Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy. Archives of General Psychiatry 53: 409-415, 1996.

Silverman, K.; Wong, C.; Higgins, S.; Brooner, R.; Montoya, I.; Contoreggi, C.; Umbricht-Schneiter, A.; Schuster, C.; and Preston, K. Increasing opiate abstinence through voucher-based reinforcement therapy. Drug and Alcohol Dependence 41: 157-165, 1996.


Day Treatment With Abstinence Contingencies and Vouchers was developed to treat homeless crack addicts. For the first 2 months, participants must spend 5.5 hours daily in the program, which provides lunch and transportation to and from shelters. Interventions include individual assessment and goal setting, individual and group counseling, multiple psychoeducational groups (for example, didactic groups on community resources, housing, cocaine, and HIV/AIDS prevention; establishing and reviewing personal rehabilitation goals; relapse prevention; weekend planning), and patient-governed community meetings during which patients review contract goals and provide support and encouragement to each other. Individual counseling occurs once a week, and group therapy sessions are held three times a week. After 2 months of day treatment and at least 2 weeks of abstinence, participants graduate to a 4-month work component that pays wages that can be used to rent inexpensive, drug-free housing. A voucher system also rewards drug-free related social and recreational activities.

This innovative day treatment was compared with treatment consisting of twice-weekly individual counseling and 12-step groups, medical examinations and treatment, and referral to community resources for housing and vocational services. Innovative day treatment followed by work and housing dependent upon drug abstinence had a more positive effect on alcohol use, cocaine use, and days homeless.

References:

Milby, J.B.; Schumacher, J.E.; Raczynski, J.M.; Caldwell, E.; Engle, M.; Michael, M.; and Carr, J. Sufficient conditions for effective treatment of substance abusing homeless. Drug & Alcohol Dependence 43: 39-47, 1996.

Milby, J.B.; Schumacher, J.E.; McNamara, C.; Wallace, D.; McGill, T.; Stange, D.; and Michael, M. Abstinence contingent housing enhances day treatment for homeless cocaine abusers. National Institute on Drug Abuse Research Monograph Series 174, Problems of Drug Dependence: Proceedings of the 58th Annual Scientific Meeting. The College on Problems of Drug Dependence, Inc., 1996.


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