Substance Abuse: Effective Treatments
Outreach Partnership Program 2005 Annual Meeting
Friday April 1, 2005
Melissa Racioppo, Ph.D., Program Official
Behavior Therapies Development Branch, National Institute on Drug Abuse
Dr. Racioppo presented an overview of behavioral treatments for drug abuse. She began by describing the difficulties of identifying effective treatments: What does it mean to be effective? What criteria do we use? What kinds of change processes are we trying to create with our treatments and how do those work? What are the outcomes of interest--complete abstinence or reduction in use? How long are people off drugs before we decide a treatment is worth using? In what populations do specific treatments work best? Also, most research conducted in substance-abuse populations must include people with comorbid conditions. In spite of these questions and challenges, we are at a point where there have been great achievements in behavioral treatments for drug abuse.
Contingency management, which creates incentives for new behavior, is based on the classic laws of learning: behavior that produces good effects tends to become more frequent, and behavior that produces bad effects tends to become less frequent. Applied to behaviors of drug-abusing populations, this means we use reinforcers to promote abstinence, treatment attendance, medication compliance, and engaging in prosocial rather than drug culture activities. Reinforcers include cash, goods and services, or vouchers that can be exchanged for goods and services. Some providers have offered people take-home methadone dosing or access to work. In a good contingency management program, the contingencies need to be well defined and specific, and the consequences of the behavior that is to be reinforced should be immediate. The reinforcers and consequences need to be customized for the particular individual. Some basic principles are that frequent reinforcement is best for teaching new behaviors, but variable reinforcement is best for maintaining established behaviors. Generally, the larger the reinforcer, the more effective it is in producing desired behavior. However, because we need to keep in mind that community treatment programs have limited funds, we need to establish the minimum, effective reinforcers.
There are concerns about using contingency management with drug abusers. First, do people revert to their previous behavior once reinforcement stops? Research shows some lasting effects, and we are working on better methods of sustaining effects. Second, does contingency management address the person’s root problem(s), assuming he or she lacks certain abilities or skills? A philosophical question is, should we be paying someone to do something they should be doing anyway? How can there be immediate consequences in the “real world”? Is contingency management cost-effective? Is it community-friendly, meaning can it fit into existing programs and be sustained?
Dr. Racioppo described research results from three studies of contingency management. The first, involving patients seeking treatment for marijuana dependence, used vouchers that could be earned for abstinence and exchanged for goods and services. Patients were randomly assigned to three different treatments: motivational enhancement (ME), ME plus behavioral coping skills therapy, or motivational coping skills and abstinence-based vouchers. At the end of the 14-week treatment, a significantly greater number of subjects in the voucher group were abstinent compared to the other groups.
Investigators at Johns Hopkins have come up with a creative way to use contingency management that gets around the issue of whether we should be paying people to do things they should be doing anyway. In their therapeutic workplace studies, they have linked abstinence with the reinforcer of access to work training, work and a salary. In one study of pregnant or postpartum cocaine- and opiate-dependent women, participants were randomly assigned to methadone maintenance treatment as usual (an extensive treatment at the Center for Addiction and Pregnancy), or to the abstinence-contingent therapeutic workplace. Relative to controls, the therapeutic workplace participants had better abstinence rates based on urinalysis, and these results were maintained for three years and beyond.
A study at the University of Connecticut addressed the issue of the cost of paying participants for abstinence by offering them chances to draw marked chips, from a fish bowl or some other kind of container, which could be exchanged for prizes. The chips specified prize values--small, medium or large--and the longer participants remained abstinent, the more chances they got to draw chips. The study assigned 42 methadone-maintained opiate-dependent patients who also used cocaine to 12 weeks of either standard methadone maintenance or methadone maintenance plus the “fish bowl” contingency management. Analysis of the data for each week of the program showed that the fish bowl participants had better abstinence rates from both opioids and cocaine. Also, among fish bowl participants, there was a longer time between the end of the study and first use of drugs. But what is really striking is the cost savings: the cost of the traditional treatment program is about $600 per person, but the fish bowl program cost an average of $137 per person.
Cognitive-behavioral therapy (CBT) has also been studied in drug abuse. The idea behind cognitive therapy is that our response to an event is driven by our beliefs, and the beliefs are the target of treatment. According to cognitive theory, a drug abuser’s beliefs about a stressful event can lead to drug use: for example, the person may think, I can’t handle this, I shouldn’t be feeling so lousy, I’m a failure, things will never get better, or life is hard and I deserve to party. Probably the quintessential CBT model for drug abuse was developed by Kathy Carroll and Bruce Rounsville, adapted from Alan Marlatt’s relapse prevention for alcohol use. This approach fosters motivation for abstinence, clarifies risky situations that trigger drug use, builds coping skills, helps the person change reinforcement contingencies, fosters management of painful emotions, improves interpersonal functioning and enhances social supports.
CBT uses functional analysis to bring into consciousness what might have led to drug use by looking at the triggering event, the thoughts and feelings and the behaviors that ensued, and finally, the consequences, whether positive or negative. (Other CBT treatments were described in Dr. Racioppo’s handouts and slides.)
The developer of motivational interviewing (MI) and motivational enhancement therapy (MET) describes it as sitting beside a client, looking together at a photo album of his or her life. The theory behind MI and MET capitalizes on the typical drug abuser’s ambivalence about change and on the person’s ability to see the negative side of drug abuse. In MI and MET, the therapist stimulates change by helping the client to resolve ambivalence, tries to roll with the client’s resistance to change, avoids directives, and takes a neutral stance toward change. The main difference between MI and MET is that MI lasts one or two sessions and MET is a four-session intervention. There are some concerns about studies of MI for drug abuse: the effect sizes are small, the intervention may not be generalizable from problem drinking to drug abuse, and the different versions make it hard to compare data. Also, whereas the original intent was to engage people into treatment, for various reasons, now it is being used as a stand-alone treatment.
Of all of our treatments for teen drug abuse, family therapies are the furthest along in terms of standardizing treatment, testing for outcomes, developing training methods, and getting them out into the community. Obviously, the potential for chaos increases the more people you have in treatment. One of the things that family theory attempts to do is bring some order to the chaos and provide a blueprint for how to manage a number of people in one place at once. Family systems theory focuses on patterns of interaction rather than individual pathology or causation, thus avoiding the issue of blame. Structural theory, another hallmark of some family therapies, sets out how a healthy family should look and behave. There should be hierarchy (the parents in charge) and boundaries (closeness but not too much closeness or distance). Strategic theory, a part of some family therapies, assumes that the family can reorganize in a healthy way, once the change process is begun. Reframing, an important piece of family interventions, is a sophisticated form of positive thinking. In therapy, if a family has a high degree of anger, the anger might be reframed as dealing with pain or loss; if a high degree of conflict, feeling passion. A crisis can be reframed as an opportunity for change, etc. Multiple studies demonstrate that family therapy not only decreases drug abuse but improves family functioning and increases engagement and retention in treatment.
In conclusion, NIDA’s ongoing work includes supporting the development of new treatments, boosting effect sizes and identifying the mechanisms of action of treatments. To persuade people to adopt treatments in their communities, it is important to be able to say with confidence which treatments, or parts of treatments, will make a difference.
Questions and Answers
On the question of trauma as it relates to substance abuse, Dr. Racioppo said that NIDA researchers are developing treatments that take into account the individual’s history of trauma. One approach, called “Seeking Safety,” by Lisa Nagivitz, is a variation on CBT. Although it appears that the results are approximately the same as those obtained with general CBT, there may be a need to develop an approach specifically targeted to adolescents.
Disclaimer
* This document is intended to summarize a speaker’s presentation at the NIMH Outreach Partnership Program’s Annual Meeting and is not an official statement or opinion of the NIMH. This information is in the public domain and may be used or reproduced for educational purposes without additional permission from the NIMH.
