Durability of Cognitive-Behavioral Therapy Efficacy for Substance Abusers
Bruce J. Rounsaville, M.D.

SUMMARY: Dr. Bruce Rounsaville reviews the evidence for Cognitive Behavioral Therapy’s (CBT) enduring effects, presents findings on the potentially mediational role of homework completion and skill acquisition, and proposes strategies for maximizing the efficacy of CBT. Based on social learning theories of substance use disorders, CBT focuses on implementation of effective coping skills for recognizing, avoiding, and coping with situations that increase risk of drug use. CBT’s efficacy is supported by randomized clinical trials of patients with dependence on alcohol, nicotine, cocaine, and marijuana. A particularly distinctive CBT characteristic is that benefits appear not only to be durable but to become stronger after treatment ends. Rounsaville suggests that efficacy may be enhanced by augmenting CBT with contingency management interventions focused on treatment retention and homework compliance.

HIV Risk Reduction and Substance Abuse Treatment
George E. Woody, M.D.

SUMMARY: Dr. George Woody’s presentation reviewed studies showing that behavioral treatments for persons with a wide range of substance use disorders reduce HIV risk. Behavioral treatments explored include: individual drug counseling, group drug counseling, cognitive therapy, and supportive-expressive therapy. Studies have consistently shown that methadone maintenance reduces HIV risk. The contribution of drug counseling and psychotherapy beyond that achieved with methadone alone has not been well studied but it would be expected to have additional effects. No effective pharmacotherapy is available for cocaine, amphetamine, or other stimulant dependence, but behavioral treatments, particularly drug counseling, have been shown to be associated with reductions in HIV risk behavior, mainly due to reduction in unprotected sex. HIV-risk reduction in alcohol treatment has not been well studied but reduction in unprotected sex is likely.

Low-Cost Contingency Management in Community Settings
Nancy M. Petry, Ph.D.

SUMMARY: Dr. Nancy Petry presented a series of studies demonstrating the efficacy of contingency management when implemented with a range of substance abusing patients in community-based treatment settings. Specifically, studies comparing the voucher and prize systems were described, as well as studies evaluating magnitudes of prize reinforcers and the adaptation of this technique for use in group treatment format. In addition, studies comparing different targets of reinforcement (drug abstinence, compliance with goal-related activities, and attendance at treatment) were reviewed.

Cognitive-Behavioral Therapy and Naltrexone for Cocaine Dependence
Joy M. Schmitz, Ph.D.

SUMMARY: Dr. Joy Schmitz evaluated the effects of naltrexone (NTX) and cognitive-behavioral therapy (CBT) for cocaine dependence (Study 1) and cocaine-alcohol dependence (Study 2). Both studies utilized a full factorial design in which randomized subjects received one of four treatment conditions for 12 weeks: NTX and CBT; NTX and drug counseling (DC); placebo and CBT; placebo and DC. NTX was 50mg per day or a matching placebo, administered in double-blind fashion. The CBT focused on coping skills training and relapse prevention, while the DC emphasized education and support. Results from Study 1 revealed a significant three-way interaction (time X medication X therapy), suggesting less cocaine use over time among subjects receiving CBT and 50mg NTX. In contrast, Study 2 results suggested initial improvement in the CBT (vs. DC) group, but failed to support a medication effect. Together, these studies address the potential value and limitations of combined NTX-CBT treatment.

Behavioral Family Counseling and Naltrexone Compliance for Male Opioid-Dependent Patients
William S. Fals-Stewart, Ph.D.

SUMMARY: Dr. William Fals-Stewart examined the effects of using family members to observe naltrexone ingestion by opioid-dependent patients as part of a medication compliance contract. Men entering treatment for opioid dependence who were living with a family member were randomly assigned to one of two 24-week treatments: (1) behavioral family counseling (BFC) plus individual treatment (patients had both individual and family sessions and took naltrexone daily in presence of family member) or (2) individual-based treatment only (IBT; patients were prescribed naltrexone and were asked in counseling sessions about compliance, but there was no family involvement). Results showed that BFC patients, compared with their IBT counterparts, ingested more doses of naltrexone; attended more scheduled treatment sessions; had more days abstinent from opioids and other drugs during treatment and during the year after treatment; and had fewer drug-related, legal, and family problems at 1-year followup. Fals-Stewart concluded that family-involved medication contracts can enhance naltrexone compliance among opioid-dependent patients, leading to improved treatment response and outcomes.