Scientifically Based Approaches to Drug Addiction Treatment
Principles of Drug Addiction Treatment, National Institute on Drug Abuse,
October 1999
This section presents several examples of treatment approaches and components
that have been developed and tested for efficacy through research. 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 enhance - not replace - existing 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.
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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.
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 recipients 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 relations - as 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 program 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.; Metger, 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 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
and 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 other 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 and 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 and Therapy 3298): 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 and 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 decision making, 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 youth 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 and 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 with the goals of treatment. 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, urinalysis 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 two months, participants
must spend 5.5 hours daily in the program, which provides lunch and transportation
to and from shelters. Interventions include 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 two months of day treatment and at least two weeks of abstinence, participants
graduate to a four 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.;
Micheal, M.; and Carr, J. Sufficient conditions for effective treatment of
substance abusing homeless. Drug and Alcohol Dependence 43; 39-47, 1996
. Milby, J.B.; Schumacher, J.E.; McNamara, C.; Wallace, D.; McGill, T.;
Stange, D.; and Micheal, 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.
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.
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