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Behavioral Treatments for Drug Abuse and Dependence, 137 PDF

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National Institute on Drug Abuse RESEARCH MONOGRAPH SERIES Behavioral Treatments for Drug Abuse and Dependence 137 U.S. Department of Health and Human Services • Public Health Service • National Institutes of Health Behavioral Treatments for Drug Abuse and Dependence Editors: Lisa Simon Onken, Ph.D. Jack D. Blaine, M.D. John J. Boren, Ph.D. NIDA Research Monograph 137 1993 US. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service National Institutes of Health National Institute on Drug Abuse 5600 Fishers Lane Rockville, MD 20857 ACKNOWLEDGMENT This monograph is based on the papers from a technical review on “Behavioral Treatments on Drug Abuse and Dependence” held in 1992. The review meeting was sponsored by the National Institute on Drug Abuse. COPYRIGHT STATUS The National Institute on Drug Abuse has obtained permission from the copyright holders to reproduce certain previously published material as noted in the text. Further reproduction of this copyrighted material is permitted only as part of a reprinting of the entire publication or chapter. For any other use, the copyright holder’s permission is required. All other material in this volume except quoted passages from copyrighted sources is in the public domain and may be used or reproduced without permission from the Institute or the authors. Citation of the source is appreciated. Opinions expressed in this volume are those of the authors and do not necessarily reflect the opinions or official policy of the National Institute on Drug Abuse or any other part of the Department of Health and Human Services. The U.S. Government does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this publication are used only because they are considered essential in the context of the studies reported herein. National Institute of Drug Abuse NIH Publication No. 93-3684 Printed 1993 NIDA Research Monographs are indexed in the Index Medicus. They are selectively included in the coverage of American Statistics Index, Biosciences Information Service, Chemical Abstracts, Current Contents, Psychological Abstracts, and Psychopharmacology Abstracts. ii Contents Page Behavioral Treatments for Drug Abuse and Dependence: Progress, Potential, and Promise . . . . . . . . . . . . . . . . . . . . . . . . . 1 Lisa Simon Onken, Jack D. Blaine, and John J. Boren Advancing the Application of Behavioral Treatment Approaches for Drug Dependence . . . . . . . . . . . . . . . . . . . . . . . . 5 Charles R. Schuster and Kenneth Silverman Contingency Management in Methadone Treatment: The Case for Positive Incentives . . . . . . . . . . . . . . . . . . . . . . . . 19 Maxine L. Stitzer, Martin Y. Iguchi, Michael Kidorf, and George E. Bigelow Clinicwide and Individualized Behavioral Interventions in Drug Dependence Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 John Grabowski, Howard Rhoades, Ronith Elk, Joy Schmitz, and Daniel Creson Cue Reactivity and Cue Reactivity Interventions in Drug Dependence . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73 Anna Rose Childress, Anita V. Hole, Ronald N. Ehrman, Steven J. Robbins, A. Thomas McLellan, and Charles P. O’Brien Treatment of Cocaine Dependence Through the Principles of Behavior Analysis and Behavioral Pharmacology . . . . . . . . . . . . 97 Stephen T. Higgins and Alan J. Budney Cognitive Therapy of Substance Abuse: Theoretical Rationale . . 123 Fred D. Wright, Aaron T. Beck, Cory F. Newman, and Bruce S. Liese Harm Reduction: Application to Alcohol Abuse Problems . . . . . 147 G. Alan Marlatt, Julian M. Somers, and Susan F. Tapert iii Behavioral Treatments for Drug Problems: Lessons From the Alcohol Treatment Outcome Literature . . . . . . . . . . . . 167 William R. Miller Multisystemic Treatment of Serious Juvenile Offenders: Implications for the Treatment of Substance-Abusing Youths . . . 181 Scott W. Henggeler Dialectical Behavior Therapy for Treatment of Borderline Personality Disorder: Implications for the Treatment of Substance Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 201 Marsha M. Linehan Substance Abuse Research: Outcome Measurement Conundrums 217 Karla Moras Between-Group Therapy Outcome Research: Design and Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 249 T.D. Borkovec When Clinical Trials Fail: A Guide to Disaggregation . . . . . . . 291 Kenneth I. Howard, Merton S. Krause, and John S. Lyons Behavioral Treatments for Drug Problems: Where Do We Go From Here? . . . . . . . . . . . . . . . . . . . . . . . . 303 William R. Miller iv Behavioral Treatments for Drug Abuse and Dependence: Progress, Potential, and Promise Lisa Simon Onken, Jack D. Blaine, and John J. Boren This monograph is a product of a National Institute on Drug Abuse technical review meeting, “Behavioral Treatments for Drug Abuse and Dependence,” held in Bethesda, Maryland, on September 1 and 2, 1992. The meeting was chaired by the editors of this monograph. The participants included Drs. Thomas D. Borkovec, Anna Rose Childress, John Grabowski, Scott W. Henggeler, Stephen T. Higgins, Kenneth I. Howard, Marsha M. Linehan, G. Alan Marlatt, William R. Miller, Karla Moras, Charles R. Schuster, Maxine Stitzer, and Fred Wright. In the past decade, behavioral treatment researchers have explored the efficacy of numerous behavioral interventions for drug dependent individuals and have made considerable progress. Research studies on behavioral treatments for drug dependence were presented by scientists who do state-of-the-art research in this area: Drs. Stitzer, Childress, Grabowski, and Higgins. In her presentation and in the chapter she wrote with Drs. Iguchi, Kildorf, and Bigelow, Dr. Stitzer reviewed the research on the use of positive versus negative contingencies with methadone maintenance patients and presented the advantages of using positive incentives. Cognitive therapy for substance abuse was clearly described by Dr. Wright at the technical review and again in the chapter written by Drs. Wright, Beck, Newman, and Liese. Dr. Childress reviewed the work she has done on cue exposure with opiate and cocaine addicts. In her chapter, she and her coauthors, Drs. Hole, Ehrman, Robbins, McLellan, and O’Brien, alert the field to the need for providing patients with active strategies for managing their drug problems in addition to the passive cue exposure strategies used in the laboratory. Dr. Grabowski pointed out that even when clinics do not define them as such, all clinics use clinicwide behavioral interventions, commonly thought of as the rules of the clinic. Dr. Grabowski and his coauthors, Drs. Rhoades, Elk, Schmitz, and Creson, reviewed the ways in which these clinicwide and individualized contingencies can impact 1 positively on drug dependence treatment. Dr. Higgins showed how community reinforcement, an approach that controls and utilizes reinforcers in multiple aspects of the cocaine-dependent individual’s life, can increase the ability to achieve and maintain cocaine abstinence. Dr. Higgins’ approach, described in the chapter by Drs. Higgins and Budney and originally developed by Hunt and Azrin (1973) for use with alcoholics, holds great promise for the treatment of cocaine addiction. The work of the fine behavioral treatment researchers at the technical review has, in many ways, set the standard for behavioral drug dependence treatment research. Significant progress has been made in the past 20 years in alcoholism treatment. As Dr. Higgins has shown, some of the treatments known to work well for alcoholics may work well for persons addicted to other drugs. Familiarity with the literature on behavioral treatments for alcohol dependence can greatly improve our ability to develop effective treatments for drug dependence. The research on behavioral treatments for alcohol dependence has been comprehensively reviewed by Dr. Miller and is a significant contribution to this monograph. In the same spirit, Dr. Marlatt and his colleagues, who are alcoholism behavioral treatment researchers, have written a piece on harm reduction. Their perspective challenges the conventional wisdom regarding drug dependence treatment (i.e., that anything short of complete drug abstinence is a failure). Whether or not one agrees, unconventional perspectives may provide an impetus for framing a problem in a different way, ultimately leading to new approaches toward solving problems. The editors hope and believe that the contributions made to this monograph will spark new ideas regarding the behavioral treatment of drug dependence. Dr. Henggeler presented his research findings on the treatment of antisocial adolescents with multisystemic therapy. Dr. Linehan has developed dialectical behavior therapy for parasuicidal individuals who meet criteria for borderline personality disorder. Both Dr. Henggeler’s and Dr. Linehan’s populations are well known for being difficult to treat. Both populations are also well known for their substantial comorbid drug dependence problems. The treatments that Drs. Henggeler and Linehan have developed for their respective populations are truly remarkable. The editors believe that they will 2 provide invaluable insights into the treatment of the drug dependent individual. Methodological issues were highlighted at the technical review by Drs. Borkovec, Moras, and Howard. In this monograph, Dr. Borkovec explicates methodological and design guidelines for between-group behavioral treatment research. One of the difficulties in doing good behavioral drug dependence treatment research is obtaining valid and reliable measurements of outcome. Dr. Moras has clearly described strategies that may be used to maximize the ability to do this. Dr. Howard, in his inimitable way, maintains that although clinical researchers routinely design studies to determine main effects, they typically end up rummaging through the data when main effects do not appear looking for information (interactions) to explain the results. Did the men respond to treatment and the women not? Did the people who had spouses do well and the people without them poorly? In their contribution to this monograph, Drs. Howard, Krause, and Lyons have provided straightforward before-the-fact strategies to enable researchers to disaggregate the data after the fact. The points that these fine methodologists have made are well taken, and the editors of this publication are confident that they will serve to enhance the quality of behavioral drug dependence treatment research. Dr. Schuster provided insights as to why behavioral treatments are not more readily utilized outside of research settings. In their contribution to the monograph, Drs. Schuster and Silverman have enumerated concrete suggestions to facilitate the utilization of behavioral treatment methods in drug dependence treatment settings. Dr. Miller, with a combination of incisive thinking and humor, provided a commentary on the points that were made at the meeting. As is strikingly apparent in his second chapter and the final chapter to this monograph, he is able to cut to the heart of problems, making the complicated and muddled appear obvious and clear. The insights of Drs. Schuster and Miller are greatly appreciated and, the editors are sure, will make invaluable contributions to this field. The editors of this monograph would like to extend our thanks to Drs. Harry Haverkos and Robert Battjes, Director and Deputy Director of the Division of Clinical Research, respectively, who made the technical review that sparked this monograph possible. We also would 3 like to thank the fine group of technical review participants who contributed to this monograph. Finally, we would like to inform the field of NIDA’s dedication to supporting research in this area. NIDA has launched a major initiative in this area, the Behavioral Therapies Initiative, that affirms a continuing interest in expanding the support of fine research on behavioral treatments for drug dependence. REFERENCE Hunt, G.M., and Azrin, N. A community reinforcement approach to alcoholism. Behav Res Ther 11:91-104, 1973. AUTHORS Lisa Simon Onken, Ph.D. Research Psychologist Jack D. Blaine, M.D. Chief Clinical and Experimental Therapeutics Branch Division of Clinical Research National Institute on Drug Abuse Parklawn Building, Room 10A- John J. Boren, Ph.D. Chief Behavioral Pharmacology Branch Division of Clinical Research National Institute on Drug Abuse Parklawn Building, Room l0A- 5600 Fishers Lane Rockville, MD 20857 4 Advancing the Application of Behavioral Treatment Approaches for Drug Dependence Charles R. Schuster and Kenneth Silverman Over the past 30 years, a range of behavioral interventions for drug dependence have been found effective in diminishing drug use (Childress et al. 1985; Stitzer et al. 1985, 1989); unfortunately, those interventions have not been widely adopted by treatment providers. The purpose of this chapter is to discuss methods that might facilitate the widespread applications of behavioral treatment interventions that have been shown to be efficacious in controlled studies. This topic, which has been referred to as knowledge utilization, is not a problem confined to the drug abuse treatment field but rather is an issue that is common to all science-based applied activities, from engineering to medicine. This is basically a problem of how behavioral change can be best achieved, not in clients seeking treatment but rather in treatment practitioners and in the researchers who are developing, evaluating, and disseminating the new treatment approaches. Why is this area of importance to both researchers and practitioners? First, utilization of new behavioral interventions could result in significant improvement in the success of prevention or treatment practitioners. In addition, the public, the legislatures, and the insurance companies that pay for treatment increasingly are demanding accountability, asking, “Does it work? Are there more cost-effective procedures?” It is also of importance to researchers, whose support ultimately rests on the perception of society, and especially Congress, that research does have some practical value. It is true that fundamental research is of importance for knowledge generation in its own right; humans are unique in their inquisitiveness about how the world works, and societies should support scientists whose work allows us all to vicariously express this need. However, it is also a fact that society is increasingly demanding accountability, asking, 5

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“Behavioral Treatments on Drug Abuse and Dependence” held in 1992. Cognitive Therapy of Substance Abuse: Theoretical Rationale . versus 11 percent and 5 percent in drug abuse counseling. (figure 2, lower panel). 104
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