Scientifically
Based Approches 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 main-tained 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 metha-done 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 functioningÑsuch
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 areasÑemployment/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.
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