Scientifically Based Approaches to Drug Addiction
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
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.
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
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.
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.
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.
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.
and Gordon, J.R., eds. Relapse Prevention: Maintenance Strategies
in the Treatment of Addictive Behaviors. New York: Guilford Press,
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.
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.
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.
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.
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.
is a time-limited, focused psychotherapy that has been adapted for
heroin- and cocaine-addicted individuals. The therapy has two main
techniques to help patients feel comfortable in discussing their
techniques to help patients identify and work through interpersonal
is paid to the role of drugs in relation to problem feelings and
behaviors, and how problems may be solved without recourse to drugs.
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.
Principles of Psychoanalytic Psychotherapy: A Manual for Supportive-Expressive
(SE) Treatment. New York: Basic Books, 1984.
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.
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.
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.
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.
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.
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.
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).
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.
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.
Motivational interviewing: research, practice and puzzles. Addictive
Behaviors 61(6): 835-842, 1996.
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.
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:
Control helps patients avoid situations associated with drug
use and learn to spend more time in activities incompatible with
helps patients recognize and change thoughts, feelings, and plans
that lead to drug use.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
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.
Combined psychological and nicotine gum treatment for smoking: a
critical review. Journal of Substance Abuse 3: 337-350, 1991.
Association: Practice Guideline for the Treatment of Patients with
Nicotine Dependence. American Psychiatric Association, 1996.
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.
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.
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.
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,
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,
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.
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.
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.
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.
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.
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.
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.
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,
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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