Evidence-Based Approaches to Drug Addiction Treatment
Behavioral Therapies
Behavioral treatments help engage people in drug abuse treatment, provide incentives for them to remain abstinent, modify their attitudes and behaviors related to drug abuse, and increase their life skills to handle stressful circumstances and environmental cues that may trigger intense craving for drugs and prompt another cycle of compulsive abuse. Below are a number of behavioral therapies shown to be effective in addressing substance abuse (effectiveness with particular drugs is denoted in parentheses).
Cognitive-Behavioral Therapy
(Alcohol, Marijuana, Cocaine, Methamphetamine, Nicotine)
Cognitive-behavioral therapy was developed as a method to prevent relapse when treating problem drinking, and later was adapted for cocaine-addicted individuals. 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 by applying a range of different skills that can be used to stop drug abuse and to address a range of other problems that often co-occur with it.
Cognitive-behavioral therapy generally 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 highrisk 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 likely problems and helping patients develop effective coping strategies.
Research indicates that the skills individuals learn through cognitive-behavioral approaches remain after the completion of treatment. In several studies, most people receiving a cognitive-behavioral approach maintained the gains they made in treatment throughout the following year.
Current research focuses on how to produce even more powerful effects by combining cognitive-behavioral therapy with medications for drug abuse and with other types of behavioral therapies. Researchers are also evaluating how best to train treatment providers to deliver cognitive-behavioral therapy.
Further Reading:
Carroll, K., et al. Efficacy of disulfiram and cognitive behavior therapy in cocaine-dependent outpatients: A randomized placebo-controlled trial. Archives of General Psychiatry 61(3):264-272, 2004.
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(12):989-997, 1994.
Carroll, K.; Sholomskas, D.; Syracuse, G.; Ball, S.A.; Nuro, K.; and Fenton, L.R. We don't train in vain: A dissemination trial of three strategies of training clinicians in cognitive-behavioral therapy. Journal of Consulting and Clinical Psychology 73(1):106-115, 2005.
Carroll, K.M., et al. The use of contingency management and motivational/skills-building therapy to treat young adults with marijuana dependence. Journal of Consulting and Clinical Psychology 74(5):955-966, 2006.
Community Reinforcement Approach Plus Vouchers (Alcohol, Cocaine)
Community Reinforcement Approach (CRA) Plus Vouchers is an intensive 24-week outpatient therapy for treatment of cocaine and alcohol addiction. The treatment goals are twofold:
- To maintain abstinence long enough for patients to learn new life skills to help sustain it
- To reduce alcohol consumption for patients whose drinking is associated with cocaine use
Patients attend one or two individual counseling sessions each 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 cocainenegative 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 treatment of opioid-addicted adults and with inner-city methadone maintenance patients with high rates of intravenous cocaine abuse.
Further Reading:
Higgins, S.T., et al. Community reinforcement therapy for cocaine-dependent outpatients. Archives of General Psychiatry 60(10):1043-1052, 2003.
Roozen, H.G.; Boulogne, J.J.; van Tulder, M.W.; van den Brink, W.; De Jong, C.A.J.; and Kerhof, J.F.M. A systemic review of the effectiveness of the community reinforcement approach in alcohol, cocaine and opioid addiction. Drug and Alcohol Dependence 74(1):1-13, 2004.
Silverman, K., et al. Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy. Archives of General Psychiatry 53(5):409-415, 1996.
Smith, J.E.; Meyers, R.J.; and Delaney, H.D. The community reinforcement approach with homeless alcohol-dependent individuals. Journal of Consulting and Clinical Psychology 66(3):541-548, 1998.
Stahler, G.J., et al. Development and initial demonstration of a community-based intervention for homeless, cocaineusing, African-American women. Journal of Substance Abuse Treatment 28(2):171-179, 2005.
Contingency Management Interventions/Motivational Incentives
(Alcohol, Stimulants, Opioids, Marijuana, Nicotine)
Research has demonstrated the effectiveness of treatment approaches using contingency management principles, which involve giving patients in drug treatment the chance to earn low-cost incentives in exchange for drug-free urine samples. These incentives include prizes given immediately or vouchers exchangeable for food items, movie passes, and other personal goods. Studies conducted in both methadone programs and psychosocial counseling treatment programs demonstrate that incentive-based interventions are highly effective in increasing treatment retention and promoting abstinence from drugs.
Some concerns have been raised that a prize-based contingency management intervention could promote gambling—as it contains an element of chance—and that pathological gambling and substance use disorders can be comorbid. However, studies have shown no differences in gambling over time between those assigned to the contingency management conditions and those in the usual care groups, indicating that this prize-based contingency management procedure did not promote gambling behavior.
Further Reading:
Budney, A.J.; Moore, B.A.; Rocha, H.L.; and Higgins, S.T. Clinical trial of abstinence-based vouchers and cognitivebehavioral therapy for cannabis dependence. Journal of Consulting and Clinical Psychology 74(2):307-316, 2006.
Budney, A.J.; Roffman, R.; Stephens, R.S.; and Walker, D. Marijuana dependence and its treatment. Addiction Science & Clinical Practice 4(1):4-16, 2007.
Elkashef, A.; Vocci, F.; Huestis, M.; Haney, M.; Budney, A.; Gruber, A.; and el-Guebaly, N. Marijuana neurobiology and treatment. Substance Abuse 29(3):17-29, 2008.
Peirce, J.M., et al. Effects of lower-cost incentives on stimulant abstinence in methadone maintenance treatment: A National Drug Abuse Treatment Clinical Trials Network study. Archives of General Psychiatry 63(2):201-208, 2006.
Petry, N.M., et al. Effect of prize-based incentives on outcomes in stimulant abusers in outpatient psychosocial treatment programs: A National Drug Abuse Treatment Clinical Trials Network study. Archives of General Psychiatry 62(10):1148-1156, 2005.
Petry, N.M., et al. Prize-based contingency management does not increase gambling. Drug and Alcohol Dependence 83(3):269-273, 2006.
Prendergast, M.; Podus, D.; Finney, J.; Greenwell, L.; and Roll, J. Contingency management for treatment of substance use disorders: A meta-analysis. Addiction 101(11):1546-1560, 2006.
Roll, J.M., et al. Contingency management for the treatment of methamphetamine use disorders. The American Journal of Psychiatry 163(11):1993-1999, 2006.
Motivational Enhancement Therapy
(Alcohol, Marijuana, Nicotine)
Motivational Enhancement Therapy (MET) is a patientcentered counseling approach for initiating behavior change by helping individuals resolve ambivalence about engaging in treatment and stopping drug use. This approach employs strategies to evoke rapid and internally motivated change, rather than guiding people 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. In the first treatment session, the therapist provides feedback to the initial assessment battery, stimulating discussion about personal substance use and eliciting 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 patient. In subsequent sessions, the therapist monitors change, reviews cessation strategies being used, and continues to encourage commitment to change or sustained abstinence. Patients sometimes are encouraged to bring a significant other to sessions.
Research on MET suggests that its effects depend on the type of drug used by participants and on the goal of the intervention. This approach has been used successfully with alcoholics to improve both treatment engagement and treatment outcomes (e.g., reductions in problem drinking). MET has also been used successfully with adult marijuana-dependent individuals in combination with cognitive-behavioral therapy, comprising a more comprehensive treatment approach. The results of MET are mixed for participants abusing other drugs (e.g., heroin, cocaine, nicotine, etc.) and for adolescents who tend to use multiple drugs. In general, MET seems to be more effective for engaging drug abusers in treatment than for producing changes in drug use.
Further Reading:
Baker, A., et al. Evaluation of a motivational interview for substance use with psychiatric in-patient services. Addiction 97(10):1329-1337, 2002.
Haug, N.A.; Svikis, D.S.; and Diclemente, C. Motivational enhancement therapy for nicotine dependence in methadone-maintained pregnant women. Psychology of Addictive Behaviors 18(3):289-292, 2004.
Marijuana Treatment Project Research Group. Brief treatments for cannabis dependence: Findings from a randomized multisite trial. Journal of Consulting and Clinical Psychology 72(3):455-466, 2004.
Miller, W.R.; Yahne, C.E.; and Tonigan, J.S. Motivational interviewing in drug abuse services: A randomized trial. Journal of Consulting and Clinical Psychology 71(4):754-763, 2003.
Stotts, A.L.; Diclemente, C.C.; and Dolan-Mullen, P. One-to-one: A motivational intervention for resistant pregnant smokers. Addictive Behaviors 27(2):275-292, 2002.
The Matrix Model (Stimulants)
The Matrix Model provides a framework for engaging stimulant (e.g., methamphetamine and cocaine) 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 through urine testing.
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 authentic 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 critical to patient retention.
Treatment materials draw heavily on other tested treatment approaches and, thus, include elements of relapse prevention, family and group therapies, drug education, and self-help participation. Detailed treatment manuals contain worksheets for individual sessions; other components include family education groups, early recovery skills groups, relapse prevention groups, combined sessions, urine tests, 12-step programs, relapse analysis, and social support groups.
A number of studies have demonstrated that participants treated using the Matrix Model show statistically significant reductions in drug and alcohol use, improvements in psychological indicators, and reduced risky sexual behaviors associated with HIV transmission.
Further Reading:
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(4):41-50, 1997.
Rawson, R., et al. An intensive outpatient approach for cocaine abuse: The Matrix model. Journal of Substance Abuse Treatment 12(2):117-127, 1995.
Rawson, R.A., et al. A comparison of contingency management and cognitive-behavioral approaches during methadone maintenance treatment for cocaine dependence. Archives of General Psychiatry 59(9):817-824, 2002.
12-Step Facilitation Therapy
(Alcohol, Stimulants, Opiates)
Twelve-step facilitation therapy is an active engagement strategy designed to increase the likelihood of a substance abuser becoming affiliated with and actively involved in 12-step self-help groups and, thus, promote abstinence. Three key aspects predominate: acceptance, which includes the realization that drug addiction is a chronic, progressive disease over which one has no control, that life has become unmanageable because of drugs, that willpower alone is insufficient to overcome the problem, and that abstinence is the only alternative; surrender, which involves giving oneself over to a higher power, accepting the fellowship and support structure of other recovering addicted individuals, and following the recovery activities laid out by the 12-step program; and active involvement in 12-step meetings and related activities. While the efficacy of 12-step programs (and 12-step facilitation) in treating alcohol dependence has been established, the research on other abused drugs is more preliminary but promising for helping drug abusers sustain recovery. NIDA has recognized the need for more research in this area and is currently funding a community-based study to examine the impact of 12-step facilitation therapy for methamphetamine and cocaine abusers.
Further Reading:
Carroll, K.M.; Nich, C.; Ball, S.A.; McCance, E.; Frankforter, T.L.; and Rounsaville, B.J. One-year follow-up of disulfiram and psychotherapy for cocainealcohol users: Sustained effects of treatment. Addiction 95(9):1335-1349, 2000.
Donovan D.M., and Wells E.A. "Tweaking 12-step": The potential role of 12-Step self-help group involvement in methamphetamine recovery. Addiction 102(Suppl. 1):121-129, 2007.
Project MATCH Research Group. Matching alcoholism treatments to client heterogeneity: Project MATCH posttreatment drinking outcomes. Journal of Studies on Alcohol 58(1)7-29, 1997.
Behavioral Couples Therapy
Behavioral Couples Therapy (BCT) is a therapy for drug abusers with partners. BCT uses a sobriety/ abstinence contract and behavioral principles to reinforce abstinence from drugs and alcohol. It has been studied as an add-on to individual and group therapy and typically involves 12 weekly couple sessions, lasting approximately 60 minutes each. Many studies support BCT's efficacy with alcoholic men and their spouses; four studies support its efficacy with drug-abusing men and women and their significant others. BCT also has been shown to produce higher treatment attendance, naltrexone adherence, and rates of abstinence than individual treatment, along with fewer drug-related, legal, and family problems at 1-year followup.
Recent research has focused on making BCT more community-friendly by adapting the therapy for delivery in fewer sessions and in a group format. Research is also being done to demonstrate cost-effectiveness and to test therapy effectiveness according to therapist training.
Further Reading:
Fals-Stewart, W.; Klosterman, K.; Yates, B.T.; O'Farrell, T.J.; and Birchler, G.R. Brief relationship therapy for alcoholism: A randomized clinical trial examining clinical efficacy and cost-effectiveness. Psychology of Addictive Behaviors 19(4):363-371, 2005.
Fals-Stewart, W.; O'Farrell, T.J.; and Birchler, G.R. Behavioral couples therapy for male methadone maintenance patients: Effects on drug-using behavior and relationship adjustment. Behavior Therapy 32(2):391-411, 2001.
Kelley, M. L., and Fals-Stewart, W. Couples- versus individual-based therapy for alcohol and drug abuse: Effects on children's psychosocial functioning. Journal of Consulting and Clinical Psychology 70(2):417-427, 2002.
Klostermann, K.; Fals-Stewart, W.; and Yates, B.T. Behavioral couples therapy for substance abuse: A cost analysis. Alcoholism: Clinical Experimental Research 28(Suppl.):164A, 2004.
Winters, J.; Fals-Stewart, W.; O'Farrell, T.J.; Birchler, G.R; and Kelley, M.L. Behavioral couples therapy for female substance-abusing patients: Effects on substance use and relationship adjustment. Journal of Consulting and Clinical Psychology 70(2):344-355, 2002.
Behavioral Treatments for Adolescents
Drug-abusing and addicted adolescents have unique treatment needs. Research has shown that treatments designed for and tested in adult populations often need to be modified to be effective in adolescents. Family involvement is a particularly important component for interventions targeting youth. Below are examples of behavioral interventions that employ these principles and have shown efficacy for treating addiction in youth.
Multisystemic Therapy
Multisystemic Therapy (MST) addresses the factors associated with serious antisocial behavior in children and adolescents who abuse alcohol and other drugs. These factors include characteristics of the child or adolescent (e.g., 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 intensive 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. Fewer incarcerations and out-of-home juvenile placements offset the cost of providing this intensive service and maintaining the clinicians' low caseloads.
Further Reading:
Henggeler, S.W.; Clingempeel, W.G.; Brondino, M.J.; and Pickrel, S.G. Four-year follow-up of multisystemic therapy with substance-abusing and substance-dependent juvenile offenders. Journal of the American Academy of Child and Adolescent Psychiatry 41(7):868-874, 2002.
Henggeler, S.W., et al. Home-based multisystemic therapy as an alternative to the hospitalization of youths in psychiatric crisis: Clinical outcomes. Journal of the American Academy of Child and Adolescent Psychiatry 38(11):1331-1339, 1999.
Henggeler, S.W.; Halliday-Boykins, C.A.; Cunningham, P.B.; Randall, J.; Shapiro, S.B.; and Chapman, J.E. Juvenile drug court: Enhancing outcomes by integrating evidence-based treatments. Journal of Consulting and Clinical Psychology 74(1):42-54, 2006.
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. The American Journal of Psychiatry 153(3):427-428, 1996.
Huey, S.J.; Henggeler, S.W.; Brondino, M.J.; and Pickrel, S.G. Mechanisms of change in multisystemic therapy: Reducing delinquent behavior through therapist adherence and improved family functioning. Journal of Consulting and Clinical Psychology 68(3):451-467, 2000.
Multidimensional Family Therapy for Adolescents
Multidimensional Family Therapy (MDFT) for adolescents is an outpatient family- based alcohol and other drug abuse treatment for teenagers. MDFT views adolescent drug use in terms of a network of influences (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 problemsolving skills. Teenagers acquire vocational skills and skills in communicating their thoughts and feelings to deal better with life stressors. Parallel sessions are held with family members. Parents examine their particular parenting styles, learning to distinguish influence from control and to have a positive and developmentally appropriate influence on their children.
Further Reading:
Dennis, M., et al. The Cannabis Youth Treatment (CYT) Study: Main findings from two randomized clinical trials. Journal of Substance Abuse Treatment 27(3):197-213, 2004.
Liddle, H.A.; Dakof, G.A.; Parker, K.; Diamond, G.S.; Barrett, K;, and Tejeda, M. Multidimensional family therapy for adolescent drug abuse: Results of a randomized clinical trial. The American Journal of Drug and Alcohol Abuse 27(4):651-688, 2001.
Liddle, H.A., and Hogue, A. Multidimensional family therapy for adolescent substance abuse. In E.F. Wagner and H.B. Waldron (eds.), Innovations in Adolescent Substance Abuse Interventions. London: Pergamon/Elsevier Science, pp. 227-261, 2001.
Liddle, H.A.; Rowe, C.L.; Dakof, G.A.; Ungaro, R.A.; and Henderson, C.E. Early intervention for adolescent substance abuse: Pretreatment to posttreatment outcomes of a randomized clinical trial comparing multidimensional family therapy and peer group treatment. Journal of Psychoactive Drugs 36(1):49-63, 2004.
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.
Brief Strategic Family Therapy
Brief Strategic Family Therapy (BSFT) targets family interactions that are thought to maintain or exacerbate adolescent drug abuse and other co-occurring problem behaviors. Such problem behaviors include conduct problems at home and at school, oppositional behavior, delinquency, associating with antisocial peers, aggressive and violent behavior, and risky sexual behavior. BSFT is based on a family systems approach to treatment, where family members' behaviors are assumed to be interdependent such that the symptoms of any one member (the drug-abusing adolescent, for example) are indicative, at least in part, of what else is going on in the family system. The role of the BSFT counselor is to identify the patterns of family interaction that are associated with the adolescent's behavior problems and to assist in changing those problem-maintaining family patterns. BSFT is meant to be a flexible approach that can be adapted to a broad range of family situations in various settings (mental health clinics, drug abuse treatment programs, other social service settings, and families' homes) and in various treatment modalities (as a primary outpatient intervention, in combination with residential or day treatment, and as an aftercare/continuing-care service to residential treatment).
Further Reading:
Coatsworth, J.D.; Santisteban, D.A.; McBride, C.K.; and Szapocznik, J. Brief Strategic Family Therapy versus community control: Engagement, retention, and an exploration of the moderating role of adolescent severity. Family Process 40(3):313-332, 2001.
Santisteban, D.A.; Coatsworth, J.D.; Perez-Vidal, A.; Mitrani, V.; Jean-Gilles, M.; and Szapocznik, J. Brief Structural/Strategic Family Therapy with African- American and Hispanic high-risk youth. Journal of Community Psychology 25(5):453-471, 1997.
Santisteban, D.A.; Suarez-Morales, L.; Robbins, M.S.; and Szapocznik, J. Brief strategic family therapy: Lessons learned in efficacy research and challenges to blending research and practice. Family Process 45(2):259-271, 2006.
Santisteban, D.A.; Szapocznik, J.; Perez-Vidal, A.; Kurtines, W.M.; Murray, E.J.; and Laperriere, A. Efficacy of intervention for engaging youth and families into treatment and some variables that may contribute to differential effectiveness. Journal of Family Psychology 10(1):35-44, 1996.
Szapocznik, J., et al. Engaging adolescent drug abusers and their families in treatment: A strategic structural systems approach. Journal of Consulting and Clinical Psychology 56(4):552-557, 1988.
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