Behavioral Therapies For Drug Abuse

BEHAVIORAL THERAPIES FOR DRUG ABUSE
SUBMITTED BY : NEHA
MPHARM PHARMACEUTICAL CHEMISTRY
IDC COURSE
INTRODUCTION
 The past three decades have been marked by
tremendous progress in behavioral therapies for drug
abuse and dependence, as well as advances in the
conceptualization of approaches to development of
behavioral therapies.
 Cognitive behavior therapy, contingency
management, couples and family therapy, and a
variety of other types of behavioral treatment have
been shown to be potent interventions for several
forms of drug addiction, and scientific progress has
also been greatly facilitated by the articulation of a
systematic approach to the development, evaluation,
and dissemination of behavioral therapies.
HISTORY
 By the mid to late 1980s, there were a number of behavioral
treatments that had been shown to be efficacious in the
treatment of a variety of mental disorders, including depressive,
panic, and obsessive compulsive disorders. However, the
methodological rigor and specificity that were characteristic of
these studies were not yet apparent in drug abuse treatment
studies, with a few exceptions
 Although behavioral approaches were universally available in
drug abuse treatment programs by the late 1980s (9), there was
continued pessimism in the field regarding the efficacy of
behavioral therapies for drug use disorders
 In the early 1990s, studies in which behavioral therapies,
therapist training, study populations, and objective
outcome measures were carefully specified and in which
participants were randomly assigned to experimental and
control or comparison conditions began to appear more
frequently in the drug abuse treatment literature
THE STAGE MODEL AND RECONCEPTUALIZATION
OF BEHAVIORAL THERAPIES DEVELOPMENT
In 1992, the National Institute on Drug Abuse (NIDA) began to offer comprehensive support for a
broader range of scientific activity in behavioral treatment development, spanning from origination
and initial testing of novel behavioral therapies to their dissemination in community settings. Three
stages were defined:
1) Stage I - consists of pilot/feasibility testing for new and untested
treatments, including preparation of treatment manuals, development of a training program, and
development of adherence/competence measures for new and untested treatments, as well as
translation of findings from basic science to clinical applications. innovative in that it permits greater
creativity by allowing investigators to develop entirely new
therapies or to adapt or improve existing therapies
2) Stage II, consists principally of efficacy testing to evaluate treatments that are fully developed and
have shown promise or efficacy in earlier studies determine if a treatment can be effective, clarify
how and why it works, and identify
its essential components, it does not address whether a
treatment will work in clinical practice
3) Stage III, which is aimed principally at issues of transportability of approaches to community
settings . By providing a scientific framework and support not only for efficacy testing at Stage II but
for the development of novel approaches at Stage I and a wide range of dissemination/diffusion
research at Stage III, this pro gram expanded both the range and the rigor of clinical behavioral
science. produce all of the necessary knowledge to proceed to and conduct what is usually considered
traditional “effectiveness” research, that is, an evaluation
of whether an approach is effective when implemented by
community-based clinicians in clinical settings.
BEHAVIORAL THERAPIES FOR DRUG ABUSE
AND DEPENDENCE
Primary focus on the broader categories of
treatment that effective in Stage II randomized
clinical trials (including contingency management,
cognitive behavior approaches, motivational
interviewing, and family/couples approaches) and
on the major categories of drug dependence
(opoids, cocaine, and marijuana dependence).
Space limitations preclude a more comprehensive
review of this burgeoning literature; hence, a
number of important studies, populations (e.g.,
adolescents, smokers)
Contingency Management Therapies
•Contingency management, in which patients receive incentives or rewards
for meeting specific behavioral goals has particularly strong, consistent, and
robust empirical support across a range of types of drug use.
•Contingency management approaches are based on principles of behavioral
pharmacology and operant conditioning, in which behavior that is followed
by positive consequences is more likely to be repeated.
•Voucher-based incentives have been shown to be effective in improving
retention and abstinence in outpatient opioid detoxification (26), in reducing
smoking as well as illicit substance use among opioid addicts in a methadone
maintenance program (27), in reducing the frequency of marijuana use (28),
and in improving medication compliance among opioid-dependent individuals
treated with naltrexone maintenance
Consistent findings of effectiveness in contingency management
interventions are compelling, some limitations have been noted.
1) The effects tend to weaken after the contingencies are terminated. This
problem might be addressed by evaluating combinations of contingency
management with approaches that have more enduring effects, for example,
by transferring rewards from monetary reinforcers to behaviors that are, in
and of themselves, reinforcing or by exploring novel discontinuation
strategies, such as lengthening periods between reinforcement or offering
more intermittent reinforcements.
2) The cost of providing rewards and administering contingency management
systems has been a barrier to the adoption of these approaches by the
clinical community
3) Because a substantial proportion of substance abusers does not respond
to contingency management, there is a need to understand and address
individual differences in response to these approaches.
Cognitive Behavior and Skills Training Therapies
Cognitive behavior approaches, such as relapse prevention, are grounded in

social learning theories and principles of operant conditioning. The defining
features of these approaches are
1) an emphasis on functional analysis of drug use, i.e., understanding drug

use within the context of its antecedents and consequences
2) skillstraining, through which the individual learns to recognize the
situations or states in which he or she is most vulnerable to drug use, avoid
those high-risk situation. Several research groups have demonstrated the
efficacy of cognitive behavior therapy in the treatment of cocaine-
dependent outpatients, particularly depressed and more severely dependent
cocaine users (, and have shown that cognitive behavior therapy is
compatible and possibly has additive effects when combined with
pharmacotherapies.
This feature may be a factor in emerging evidence for the long-term
durability of the effects of cognitive behavior therapy. Several studies have
demonstrated that cognitive behavior therapy’s effects are durable and that
continuing improvement may occur even after the end of treatment
 Extending the work on cognitive behavior therapy’s durability to panic
disorder patients, two studies found that the addition of group cognitive
behavior therapy to slow tapering of alprazolam or clonazepam
for patients who were attempting to discontinue the benzodiazepine
resulted in higher rates of successful discontinuation, compared with
the use of slow tapering alone .
*Cognitive behavior interventions have also been evaluated as a component
of multimodal treatment packages.
Motivational interviewing
 based on principles of motivational psychology and is intended to enhance
the individual’s intrinsic motivation for change.
 Motivational interviewing approaches have strong empirical support for
use in treating alcohol users, with several studies showing significant and
durable effects.
 A combination of motivational interviewing with behavioral skills training
wasfound to reduce HIV risk behaviors among low-income urban women.
 These trials include studies of the effects of motivational interviewing on
drug use outcomes among inpatients and outpatients entering community-
based treatment.
 There is stronger support for motivational interviewing combined with
other evidence-based
therapies for drug abusers, although the combination of
treatments precludes attribution of benefit to any single component.
Couples and Family Treatments
Couples and family treatments is that they treat drug-using individuals in
the context of family and social systems in which substance use may develop
or be maintained. The engagement of the individual’s social networks in
treatment can be a powerful predictor of change, and thus the inclusion of
family members in treatment may be helpful in reducing attrition family-
based approaches are quite diverse, and it is unlikely that all are equally
effective. Moreover, many family-based approaches combine a variety of
techniques, including family and individual therapies, skills training, and
communication training .
•Behavioral couples therapy and behavioral family counseling combine
abstinence contracts and behavioral principles to reinforce abstinence from
drugs; these approaches require the participation of a non-substance-abusing
spouse or cohabitating partner. These findings highlight the
possibility that effective treatment of substance-using parents may
ameliorate and conceivably prevent problems in their children.
•Azrin’s family behavior therapy, which combines behavioral contracting
with contingency management, was found to be more effective than
supportive counseling in a series of comparisons involving adolescents with
substance use disorders with and without conduct disorder
•Multisystemic therapy is a manual-based approach that addresses multiple
determinants of drug use and antisocial behavior and is intended to promote
more family involvement by engaging family members as collaborators in
treatment, emphasizing the strengths of youths and their families
DRUG COUNSELLING
Researchers have specified the elements of drug counseling approaches in
detailed manuals for therapists and have evaluated these approaches in
clinical trials.
EG; A multisite randomized clinical trial of psychotherapeutic treatments for
cocaine dependence provided evidence of the effectiveness of a manual-
guided individual drug counseling approach that combined drug counseling and
relapse prevention techniques . Data from this study also indicated that the
reductions in cocaine use were associated with sharp decreases in the
frequency of HIV risk behaviors underscoring the view that effective drug
abuse treatment constitutes effective HIV prevention
HIV Risk Reduction
Behavioral therapies have been demonstrated to be effective in reducing HIV
risk behaviors and promoting health in intravenous drug users enrolled in
methadone maintenance programs. Two randomized clinical trials found that
the Holistic Harm Reduction Program, developed to reduce HIV risk behaviors,
illicit drug use, and transmission of infectious diseases (e.g., HIV, hepatitis B
and C), reduced illicit drug use and risky sexual behavior
and, among HIV-positive participants, improved adherence to antiretroviral
treatment . Although these findings are promising, this approach has been
evaluated in a fairly narrow range of populations and requires replication in
other settings and other groups of drug users.
Future Directions
There are many ways to improve behavioral therapies at all three stages of
treatment development.
Stage I
Research at this stage has the potential for a high yield from evaluation of
clinical strategies that have not yet been subject to empirical evaluation,
from the adaptation of effective treatments used for other disorders, and
from translation of concepts from basic science to clinical applications. Basic
neuroscience and basic research on behavioral, cognitive, affective, and
social factors offer rich and relatively untapped sources of information on
behavior and behavior change.
Stage II,
Renewed emphasis is needed on improving understanding of the mechanisms
of action in treatments with established efficacy, not only to enhance their
effectiveness but also to increase the efficiency of treatment
delivery. Currently underutilized strategies for investigating mechanisms of
action include
1) evaluating novel combinations of behavioral therapies or psychotherapy/
pharmacotherapy combinations, both to enhance treatment efficacy and
to offset weaknesses of a single approach
2) investigating individual differences in treatment response and in
treatment moderators by using novel methods that may in the near future
include subtyping and predictor analyses involving neuroimaging, stress-
response paradigms, and genetics
3) developing strategies to investigate sequenced interventions, in
which treatments or treatment components are delivered
on the basis of the individual drug user’s characteristics,
including previous treatment response, neurocognitive
functioning, and family history.
Stage III
Promising strategies include evaluation of the means by which efficacious
treatments can be reduced in duration, complexity, and cost. Projects to
make behavioral treatments more “community friendly” are needed for
treatments that show efficacy but are not deemed feasible for use by
treatment providers or the treatment system.
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BEHAVIORAL THERAPIES FOR DRUG ABUSE

Cognitive behavior approaches, such as relapse prevention, are grounded in

1) an emphasis on functional analysis of drug use, i.e., understanding drug

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