NIDA Research Monograph Series #137: Behavioral Treatments for Drug Abuse and Dependence

335 Pages·1993·2.4 MB·English

by  Onken, Lisa Simon (editor), Blaine, Jack D. (editor), Boren, John J. (editor)

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,
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