Cognitive-Behavioral Therapy

Cognitive-behavioral therapies (CBTs), among the most frequently evaluated approaches used to treat substance use disorders, have been shown to be effective in several clinical trials of cocaine-dependent individuals and other types of substance users. The theoretical background and goals of this approach, the fundamentals of implementing CBT with substance users, and a brief review of the evidence supporting its effectiveness with drug abusers will be presented.

Presentation Conclusions

1. CBTs are based on social learning and behavioral theories of drug abuse.

2. The basic approach of CBT can be summarized as "recognize, avoid, and cope."

3. Treatment is organized around a functional analysis of substance use; i.e., understanding substance use with respect to its antecedents and consequences.

4. Skill training is focused on strategies for coping with craving, fostering motivation to change, managing thoughts about drugs, developing problemsolving skills, planning for and managing high-risk situations, identifying apparently irrelevant decisions, and cultivating drug refusal skills.

5. Basic principles of CBT are that: (a) basic skills should be mastered before more complex ones are given, (b) material presented by the therapist should be matched to patient needs, (c) repetition fosters the development of skills, (d) practice is needed for mastery of skills, (e) the patient is an active participant in treatment, and (f) skills taught are generalizable to a variety of problem areas.

Community Reinforcement Approach to Treatment

The community reinforcement approach (CRA) is an intensive behavioral treatment for drug abuse. Initially demonstrated to be an efficacious intervention for severe alcoholism, CRA was later adapted for and shown to be efficacious in the treatment of cocaine dependence. The basic features of CRA will be outlined, with special attention to its use in outpatient treatment of cocaine dependence.

Presentation Conclusions

1. CRA is an effective treatment.

2. CRA can be adopted in part or as a whole.

3. CRA can be used with a wide range of substance abusers.

4. CRA is based on extensive scientific evidence regarding determinants of drug abuse and effective treatment.

How to Treat If You Only Have Three or Four Sessions

Regardless of the ongoing debate about the optimal intensity of treatment, many practical factors necessitate addressing substance abuse within a relatively short period of time. The average length of stay in outpatient drug abuse treatment is quite brief. Managed care continues to limit the duration of care. Substance abuse is most likely to be seen not in specialty clinics but in general healthcare settings where time is short. The good news is that, even if only a few sessions are conducted, it is possible to make a clinically significant difference. This presentation will discuss the essential characteristics of effective brief treatment for alcohol and other drug problems.

Presentation Conclusions

1. A supportive, empathic counseling style is one of the most important predictors of successful treatment outcomes.

2. Though tempting to use when time is short, confrontational approaches are associated with poor outcomes.

3. There are at least six common elements of effective brief treatment, summarized by the acronym FRAMES (feedback, responsibility, advise, menu, empathy, self-efficacy).

4. Motivational interviewing is a client-centered yet directive approach for resolving ambivalence and enhancing commitment to change.

5. Clinical trials consistently support the efficacy of brief treatment.

Family Therapy

Findings from four major family therapy research programs have shown that, by using somewhat different approaches to family therapy when working with different ethnic groups, family therapy is a highly effective treatment for drug-abusing adolescents. Data will be presented from each of these four programs that demonstrate the efficacy of family therapy and the apparent generalizability across populations, as well as intervention sites.

While most drug treatments emphasize the individual as the target of intervention, the defining characteristic of family therapy is the transformation of family interactions. Repetitive patterns of family interactions are the focus of treatment. Changing these patterns results in diminished antisocial behavior, including adolescents' drug abuse.

Presentation Conclusions

1. Family therapy is an effective treatment for adolescent drug abuse.

2. While different family therapy approaches have somewhat different emphases, the defining characteristic of all family approaches is the transformation of repetitive patterns of family interactions.

3. Because family therapy is drastically different from individual approaches, specialized training is required. It is as complex to learn family therapy as it is to learn supportive-expressive psychotherapies.

4. Family therapy can work with a broad range of family and social network configurations.

5. Family therapy approaches have developed specific interventions for engaging and keeping reluctant, unmotivated adolescents and family members in treatment.

HIV Risk Reduction: Sex, Drugs, and the Importance of Context

Human immunodeficiency virus (HIV) risk behaviors as observed in both the field and in treatment settings will be discussed, with special emphasis on the importance of considering context in the development of effective harm reduction programs for drug abusers and their sexual partners. Bleach and condom use, the female condom, needle exchanges, single-use syringes, peer interventions, motivating behavior change, reducing barriers to treatment, and treatment as prevention will also be discussed.

Presentation Conclusions

1. Communicating appropriate harm reduction messages to drug abusers is complicated by: the hidden and stigmatized nature of the problem, the chaos that accompanies drug abuse, the struggle to survive in impoverished environments, and the cultural and situational diversity of the target population.

2. Researchers need to carefully consider context in developing harm reduction messages. For example, in a study of female sexual partners of injecting drug users, individuals reporting monogamous relationships were much more likely to be infected by HIV than were those reporting the exchange of sex with multiple partners for money or drugs. In this specific instance, monogamy increases the probability of exposure to HIV, thus highlighting the need to specifically develop and tailor the risk reduction message to the situation.

3. It is important to view HIV transmission from a social network rather than an individual perspective.

4. Effective treatments for substance abuse will prevent HIV infection by decreasing the frequency of higher risk behaviors, and perhaps by altering the social drug-using environment.

5. It is wrong to assume that drug abusers do not care and will not change. Small changes can yield bigger results if they are supported, but this process takes a great deal of time, effort, patience, and money.

Individual Addiction Counseling

The discussion will begin by describing a model of individual drug counseling that was used in the recently completed Multisite Cocaine Collaborative Study sponsored by the National Institute on Drug Abuse (NIDA). The training and supervision practices employed and the means by which counselors' adherence and competence were evaluated will be described. The philosophy and methods of this model will be compared and contrasted with other models of addiction counseling and psychotherapy. Modifications that could be made to adapt this treatment for use with alcohol and opiate dependence will be reviewed, with relevant research findings integrated into the discussion.

Presentation Conclusions

1. This approach addresses the symptoms of drug dependence and related areas of impaired functioning and the content and structure of the client's ongoing recovery program. It is a time-limited approach that focuses on behavioral change, educates about 12-step ideology and tools for recovery, and encourages self-help participation.

2. Adequate training and ongoing supervision are as important as the counseling approach itself in providing effective drug treatment. In this approach, counselors' adherence and competence were evaluated from audiotapes of sessions, based on a rating scale developed for this purpose, and their ratings were used as a supervision tool.

3. Treatment should be tailored to directly address specific drug dependencies. While the content of the counseling will be similar regardless of the particular drug, the intensity, frequency, and length of treatment will often need to vary to effectively provide for different drug dependencies.

4. Current research supports the use of addiction counseling for treatment of drug dependence, in some cases with adjunctive pharmacotherapy, depending on the particular drug addiction.

Group Drug Counseling

The development and use of a group drug counseling (GDC) model of treatment in a multisite clinical trial for treatment of cocaine dependency will be reviewed. Training and selection of group counselors, goals of the group, structure and content of the group sessions, and the use of supporting interactive recovery materials for patients will be discussed. Applying this GDC model to community drug and alcohol programs will be examined.

Presentation Conclusions

1. Manual-driven group drug counseling is a cost-effective way of providing treatment services to clients with drug use disorders.

2. Time-limited, structured psychoeducational groups work best in the early months of treatment; semistructured, problemsolving groups work best in the later months of treatment.

3. When group drug counseling is provided in addition to individual drug counseling, client outcomes are better compared to providing only a single treatment.

4. Clients generally prefer individual sessions in addition to group sessions, particularly those with high levels of social anxiety.

5. Group drug counseling strategies can be easily adapted to a variety of drug and alcohol treatment contexts and address the full range of different types of drug use disorders.

Treatment of Medically Ill Individuals

The prevalence of concurrent medical disorders among substance-dependent persons and the extent to which illicit or psychoactive substance use is related to the development of these medical disorders will be examined. Clinical and public health significance of the medical consequences of substance abuse will be emphasized. The challenge of providing medical care to substance-dependent persons and the difficulty of furnishing substance abuse treatment to medically ill substance abusers will also be explored.

Presentation Conclusions

1. There is a wide spectrum of concurrent medical disorders among substance-dependent persons.

2. Many of the concurrent medical disorders are related to the lifestyles of substance-dependent persons, but not necessarily to the physiologic or pharmacologic effects of the psychoactive substance.

3. Prevention, early identification, and treatment of concurrent medical disorders have significant benefit.

4. Collaboration between substance abuse treatment providers and medical and psychiatric care providers has the best potential of achieving successful clinical outcomes.

Ethnic/Cultural Issues in Drug Addiction Treatment

This presentation will focus on ethnic and cultural issues impacting drug addiction treatment in minority populations. Issues to be discussed are cultural and ethnic attitudes regarding drug use; the impact of ethnic identity development on drug use; cultural and ethnic attitudes toward drug abuse treatment; gender differences in drug use and in response to drug treatment in minority populations; ethnic differences in response to drug treatment; ecological variables impacting drug treatment; and effective strategies of drug treatment for minority populations.

Presentation Conclusions

1. Understand the importance of culture and ethnicity to patterns of drug use and drug treatment.

2. Understand the potential impact of gender differences and differences between ethnic groups on drug use and treatment.

3. Identify effective strategies of drug treatment for ethnic minority groups.

Alternative/Complementary Therapies

Using complementary/alternative medicine (CAM) therapies for treating drug addiction is the focus of this presentation. Therapies for which some controlled research has been performed will be discussed with regard to opiate, alcohol, cocaine, and nicotine addictions. Special emphasis will be on acupuncture research relating to the areas of alcohol and cocaine abuse. Methodologic problems confronting researchers who are attempting to more precisely define the role of CAM therapies in the treatment of drug addiction will be identified, and future directions will be explored.

Presentation Conclusions

1. Some preliminary reports and early research efforts show promise for treating substance abuse with CAM therapies.

2. Incorporating CAM into mainstream substance abuse treatment programming is outstripping the research required to justify it.

3. Many therapies require more rigorous investigation, but current research paradigms are inadequate.

4. To date, there is no definitive evidence that CAM therapies are or are not effective in treating drug addiction.

Detoxification

Successful opioid detoxification is a function of safety and minimal discomfort as well as retention and progress to longer term treatment. Methadone withdrawal is most common, but rebound mild withdrawal symptoms lasting over 1 month are frequently associated with relapse. The -2 agonist clonidine is associated with less "rebound," but also less symptom suppression and more side effects. Combined clonidine and naltrexone produce a marked shortening of time (to 48 to 72 hours) and higher completion rate, but there is more discomfort and more intensive monitoring. Withdrawal can be reduced to 5 to 6 hours under intravenous midazolam sedation or general anesthesia (e.g., propofol) with clonidine premedication and increasing doses of naltrexone. Advantages include very high completion rates and ability to reach addicts who fear any withdrawal discomfort. Disadvantages include anesthesia risks, less elimination of postwithdrawal discomfort than claimed, and high cost. Rapid detoxification using buprenorphine, naltrexone, and clonidine may be almost as effective as the anesthesia method, but with fewer risks.

Presentation Conclusions

1. Detoxification from opiates is usually only the first step into treatment, rather than the treatment itself.

2. A variety of methods exists, each with advantages and disadvantages. Successful detoxification is a function of safety, minimal discomfort and retention, and progress to longer term treatment.

3. Newer, rapid methods using clonidine and naltrexone, preceded by buprenorphine, may ultimately prove to be easiest and most successful.

4. The psychosocial approaches with these various medications need to be improved to increase the percentage of those who continue in treatment.

New Medications

New medications are available for opioid and stimulant dependence, including nicotine, and for comorbid psychiatric and substance abuse disorders, most notably alcoholism. For opioids, substitution pharmaco-therapies such as buprenorphine address both cost-effective detoxification and relapse prevention. Stimulant dependence continues to benefit from specific pharmacotherapies for comorbid disorders such as schizophrenia with atypical antipsychotics, depression with tricyclics, and possibly attention deficit disorder with bupropion. Nicotine dependence has benefited from nicotine patches in combination with bupropion and naltrexone. Comorbid alcoholism, which occurs in 70 percent of cocaine users, improves with naltrexone treatment, and disulfiram (Antabuse) has reduced cocaine abuse.

Presentation Conclusions

1. With less severe withdrawal facilitating detoxification, Schedule 4 (not Schedule 2) Food and Drug Administration control, and longer action facilitating less than daily dosing, buprenorphine is an alternative to methadone for opioid dependence.

2. Opioid detoxification using buprenorphine with naltrexone and clonidine or lofexidine is more cost-effective than other outpatient approaches.

3. Stimulant dependence benefits from pharmacotherapy of comorbid psychopathology.

4. Nicotine abstinence is facilitated by combining nicotine patches with bupropion and naltrexone.

5. Comorbid alcoholism in stimulant abusers is well treated with naltrexone or disulfiram.

Methadone and LAAM Treatment

A brief definition of the medical problems that are common in untreated heroin addicts and, to a lesser extent, in patients with other addictive diseases will be presented, along with those aspects of physiology that become disordered in cycles of addiction. The negative impact of short-acting opiates (such as heroin) on physiology, including modulation of the hypothalamic-pituitary-gonadal function, hypothalamic-pituitary-adrenal function, gastrointestinal function, and immune function will be briefly summarized. The central focus will present those areas where treatment has been shown to be extremely effective in decreasing exposure to diseases, facilitating appropriate prevention and treatment of diseases, and allowing normalization of aspects of physiology that have been disrupted during cycles of addiction. Emphasis will be on the three most common diseases in heroin addicts: (1) HIV-1 infection progressing to AIDS, (2) hepatitis B infection with or without complications with hepatitis delta and hepatitis C infection, and (3) mental health disorders, especially comorbidity with anxiety and depression.

Presentation Conclusions

1. Effective treatments for each of the addictive diseases allow improvement in general health status.

2. The most extensive studies have been conducted in active heroin addicts before and during short- and long-term methadone maintenance treatment. It has been shown that such treatment allows significant improvement in overall health status.

3. It has been shown that during effective methadone maintenance treatment, and during other treatments for this and other addictions, the use of unsterile needles and injection equipment is significantly reduced, which in turn leads to decreased exposure to infectious diseases including HIV-1, hepatitis B, hepatitis delta, and hepatitis C.

4. Normalization of immune function, which has been disrupted during cycles of heroin addiction, due to different direct as well as indirect factors, becomes normalized during chronic long-term methadone maintenance treatment, which in turn may contribute to clearing of viruses such as hepatitis B antigenemia and to improvement in overall immune function.

5. Disrupting the stress responsive and reproductive biological axis, which is common during cycles of heroin addiction, cocaine addiction, and alcoholism, becomes normalized during methadone maintenance treatment. It partially (or fully) improves during abstinence-based treatment for cocaine dependency and alcoholism.

Improving Access to Drug Abuse Treatment Services

A summary of what is known about access to drug abuse treatment services and clients' use of medical and social services will be presented. Changes in treatment intensity and duration over the past several years and changes in clients' use of key medical and social services will be reviewed. Ways to improve access to services will be discussed, with special focus on the organizational factors (including managed care, treatment unit ownership, staffing patterns, and regulation) that affect access to and use of various treatment services.

Presentation Conclusions

1. Successful drug abuse treatment depends not only on treatment intensity and duration but also on clients' use of medical and social services.

2. Treatment intensity, duration, and medical and social services have decreased in the past several years.

3. Many factors affect this decrease, including some types of managed care.

4. Several organizational factorsÑclient-staff ratios, public ownership of treatment units, professional staffing, and the Joint Commission for the Accreditation of Healthcare Organizations (JCAHO) accreditationÑcan promote access to and use of services.

Impact of Managed Care on Drug Abuse Treatment

Debate on the potential for positive and negative effects from the expansion of managed care intensifies as States follow commercial purchasers and use managed care techniques for publicly funded substance abuse treatment. If public funds are poorly managed, or if the system is designed poorly, vital and necessary services could be jeopardized in the name of cost control. Services research can help policymakers, providers, and consumers assess the effects of managed care strategies and improve program design. This presentation will offer an overview of managed care, identify opportunities and challenges associated with public sector managed care, examine three strategies used for managed behavioral healthcare initiatives, and conclude with an assessment of policy lessons and services research needs. Presentation Conclusions

1. There are many opportunities to improve the quality of substance abuse treatment services.

2. Successful managed care programs appear to have the benefit of leadership that has clear vision, skillful implementation, and sufficient flexibility to make alterations. Most importantly, policymakers demonstrate a capacity to be assertive purchasers of serviceÑthey manage managed care.

3. There are multiple models of managed care, and each dimension can be modified and crafted to fit the unique implementation. It is critical to monitor the effects of managed care on the organization, financing, and delivery of services for the treatment of alcohol and drug abuse and dependence.

4. The relationships between Medicaid and non-Medicaid systems of care should be examined. The potential for undesired cross-subsidization should be assessed and monitored. Cost-shifting opportunities should be identified and reported.

5. Careful services research can contribute to better managed care design, implementation, and evaluation.