Scientifically
Based Approches to Drug Addiction Treatment
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 resource, 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 resource 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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