Chapter 7. Evolution in Addiction Treatment Concepts and Methods

 

FORCES LEADING TO A CHANGED APPROACH TO ADDICTION TREATMENT

There has always been broad recognition that alcohol and drug abuse are partly or fully responsible

for such serious public health and public safety problems as traffic accidents, street crime,

transmission of infectious diseases, child abuse and neglect, and excessive use of medical services.

During the 1970s, addiction treatments gained prominence as a social response to these

addiction-related problems. This was because addiction treatments were less expensive than the

available alternatives (e.g., jail or hospitalization) and because there was social compassion for the

many addicted veterans of the Vietnam War whose substance use problems were seen as a result

of that war.

Because of concern for patients as well as concern over the pressing public health and safety

problems associated with addiction, treatments were predominantly hospital based or residential

(Musto 1973), focused upon bringing total abstinence from all substances, and designed to develop

a sense of “right living” (De Leon 2000) among those affected and bringing an end to the

“addiction lifestyle.” Concurrent with the increase in public willingness to treat addiction, not just

punish it, came substantial increases in federal funding for research on addiction within the

National Institutes of Health (White 1998, 2004).

Although cure for addiction was virtually never discussed as a treatment goal, the treatment

system was structured, delivered, insured, and evaluated under this tacit expectation (McLellan et

1. 2005; White 1998). Specifically, almost all treatments were time limited; proximal goals for

providers were to bring patients to graduation or completion of care; and evaluations were

conducted 6 or 12 months after treatment completion, with “1-year abstinence rates” being the

implicit standard of evaluation within the field (see McLellan 2002).

However, by the last decade of the twentieth century, there was broad dissatisfaction with the

country’s response to drug abuse problems. Increased surveillance, interdiction, and criminal

penalties had not reduced drug availability appreciably (see SAMHSA 2002). In addition, a series of

new drug epidemics, including crack cocaine starting in the 1980s and methamphetamine and

pharmaceutical opioids starting in the 1990s, brought new public demands for an effective

approach to the “drug problem.”

The country’s response to drug abuse problems also revealed a general dissatisfaction with the

effectiveness of treatments for addiction (“Editorial Commentary” 1997). The addiction treatment

field had not met either public expectations for reduction of addiction-related problems or its own

intentions to produce lasting abstinence among those treated. Indeed, a majority of patients,

including court-ordered patients, were leaving care prematurely, and relapse rates, even for those

who completed care, were generally more than 50% by 6 months (for reviews see McLellan and

Meyers 2004; Prendergast et al. 1998). Moreover, the costs of health care in general and addiction

care specifically were seen as catastrophic by employers, prompting them to engage various

managed care intermediaries to reduce the “runaway increases” in care utilization and costs

(Institute of Medicine 1997, 1998). By the end of the century, the cost-containment effects of

managed care had eliminated or drastically reduced most residential care to less than 10% of all

care provided by 2000 (Institute of Medicine 1997, 1998, 2006; McKusick et al. 1998).

The author of this chapter is supported by ongoing National Institute on Drug Abuse Health Services Research

grants and by an unrestricted grant from the Robert Wood Johnson Foundation.

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At this writing, the addiction problems facing the United States are somewhat different but no less

significant than at other points over the past 50 years. The public is still demanding action to

address substance abuse and the related problems, and the experience garnered in recent decades

has offered some hard-learned lessons as well as four promising new research findings, discussed

in the text that follows, that have set the stage for a new model of care for addiction.

A Continuing Care Perspective

The research of Drs. M. Douglas Anglin, Yih-Ing Hser, Christine E. Grella, and their University of

California, Los Angeles, colleagues was among the first to examine the lifetime trajectory of those

with addiction problems, putting perspective on the effects of any single treatment episode. Their

findings indicated that most addicted individuals had “addiction careers” of 20 years or more in

which relatively brief episodes of treatment and incarceration gradually led to increasingly long

periods of abstinence (Anglin et al. 1997; Hser et al. 1997, 2003). This work showed the chronic

and complex nature of addiction; showed that problems of crime, unemployment, mental illness,

and infectious disease were not all etiologically linked to the addiction; and helped to reset

expectations about the nature and extent of benefits that might be expected from any single

treatment episode. Abstinence by itself was not likely to result in substantial reductions in the

associated public health and safety problems, and without a reduction in those problems,

abstinence was not likely to be sustained.

A Staged Model of Treatment

Since 1985, Simpson et al. (1999) followed and researched a very large sample of publicly treated

patients during and after an index treatment episode. These researchers measured the nature and

amount of treatment elements and services actually delivered during standard care. With these

measures and state-of-the-art statistical modeling, they ultimately arrived at a multistage model of

care that provided a new perspective on the way treatments might be expected to provide benefits.

Rather than consider treatment as a single box containing a fixed set of ingredients, they identified

a staged care model in which each stage of the treatment episode had definable behavioral goals

for the patient that would prepare him or her to do well in the subsequent stage of care (Simpson

2004). This model of care suggests the benefits of extending treatment over a greater period of

time and offers an evidence-based method of evaluating a patient’s (and a treatment program’s)

progress in attaining those goals.

Parallels With Other Chronic Illnesses

In a contemporaneous set of studies at the Treatment Research Institute and at the University of

Pennsylvania School of Medicine, my colleagues and I examined parallels between addiction and

chronic medical illnesses such as hypertension, diabetes, and asthma (see McLellan 2002; McLellan

et al. 2000; O’Brien and McLellan 1996). This research showed that although there were differences

among these illnesses, there were significant similarities in terms of the behavioral factors

associated with the onset of all the illnesses, the genetic influences associated with vulnerability to

these illnesses, and remarkably, the rates of treatment compliance (30%–50%) and relapse

(30%–70%). The similarity of findings were striking to the point that they led to broad efforts to

reconsider the manner in which addiction treatments were conceptualized, delivered, and

evaluated.

Monitoring to Extend Treatment Benefits

A final set of research findings combines with the others to suggest a different approach to

addiction treatment. Researchers such as Stout et al. (1999), Dennis et al. (2003), and McKay

(McKay 2001, 2005; McKay et al. 1999) have shown that traditional addiction treatments can be

significantly improved and sustained by simple efforts to re-contact patients for brief monitoring

and support sessions after their discharge from formal care. Stout et al. (1999) were the first to

show that brief monitoring phone calls, done as part of the research and evaluation efforts, had the

unexpected effects of increasing and sustaining the abstinence rates of those contacted.Print: Chapter 7. Evolution in Addiction Treatment Concepts and Methods http://www.psychiatryonline.com/popup.aspx?aID=345616&print=yes…

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This finding was examined very thoroughly by McKay (2005) in both alcohol- and

cocaine-dependent samples following intensive outpatient treatments. Again, they found that

simple telephone monitoring contacts at 1-month intervals after treatment discharge were as

effective or more effective than more sophisticated (and more costly) therapy sessions. A more

intensive clinical procedure designed to achieve the same effects has been initiated by Dennis et al.

(2003). In this recovery check-up procedure, periodic, postdischarge home visits to patients are

designed for the dual purpose of evaluating the status of the patients and, when appropriate,

reengaging them into care as a means of forestalling significant drug-related problems and a

severe and costly relapse. Evaluations of the intervention have shown it is effective and

cost-efficient at prolonging quality of life, reducing costs, and sustaining recovery.

A NEW APPROACH TO ADDICTION TREATMENT

The work just described has combined to influence contemporary thought about and approaches to

addiction and addiction treatment. There is now increasing acceptance that many (but not all) of

those with serious addiction problems develop a chronic form of the disorder, one that is best

served by a long-term clinical approach, with staged behavioral goals as suggested by Simpson

(2004) and using components of care that have been shown to address the expensive

addiction-related problems that are so significant to the public and so related to readdiction in the

patient. Substantial research has shown that brain changes associated with addiction may persist

for years following cessation of use (Volkow et al. 1992). In addition, drug cravings and high-risk

situations (drug-using friends, emotional problems, stressful life events) may be lifelong issues for

those in recovery to deal with. Thus, treatment of addiction, like the treatment of so many other

illnesses, is now seen as a key part of a longer-term effort to help patients develop effective and

rewarding self-management strategies over the long term (see Wagner et al. 1996). Treatment

efforts are now more likely to supplement traditional abstinence-oriented counseling with specific

efforts to equip patients with effective self-management strategies and to support those strategies

through linkage to mutual help organizations such as Alcoholics Anonymous (AA) and through

periodic contacts from the treatment organization in the manner suggested by the research of

McKay, Dennis, and their colleagues.

As addiction care has begun to take on the elements of “disease management” (Bodenheimer et al.

2002; Wagner et al. 1996) and as research has provided new clinical options such as medications,

therapies, and support services, new clinical information systems have been developed to assist

care delivery (Carise et al. 2005) and to simultaneously evaluate client progress, modifying the

nature of care as needed to ensure continued progress (see McLellan et al. 2005). This is referred

to as adaptive care in other areas of health care, and it is likely to become more prevalent in the

future of addiction care (McKay 2005).

It must be said that at this writing this “new approach” is still in the formative stage, and most

care continues to be provided in traditional ways, predominantly in outpatient settings by specialty

care providers (Institute of Medicine 2006; SAMHSA 2002). At the same time, there has been

pressure from regulators (e.g., Joint Commission on Accreditation of Healthcare Organizations,

state licensing) to incorporate evidence-based components of care into these programs that will

promote a continuing care approach and improve the engagement and retention of patients for at

least 1 year. Within the staged care model proposed by Simpson (2004), programs are encouraged

to use components of care that have been developed and studied in an empirical manner—the

so-called evidence-based components of care.

Thus, the remainder of this chapter considers three categories of these components—medications,

therapies, and services—as part of a broader approach to addiction treatment. The review is

restricted to those components that have shown evidence of effectiveness in at least two

randomized, controlled experiments (compared with placebo or standard care). This standard of

evidence has been used by the U.S. Food and Drug Administration (FDA) as a key determinant for

decision making. Thanks to unprecedented research support, there are now many medications,

therapies, and support services that have met this standard of evidence. The number of thesePrint: Chapter 7. Evolution in Addiction Treatment Concepts and Methods http://www.psychiatryonline.com/popup.aspx?aID=345616&print=yes…

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makes it difficult to fully account for all within the page limitations of this chapter. Thus, this

chapter concentrates upon those that have shown both experimental evidence of effectiveness and

evidence of applicability in real-world trials.

Three Stages of Addiction Treatment

Prior to a review of research evidence on the effective components of treatment, it is important to

differentiate the three phases of treatment (detoxification/stabilization, rehabilitation, and

continuing care) because they have distinctly different goals and may apply different methods.

These have been adapted from the Simpson model (Simpson 2004) but are somewhat truncated for

ease of description.

Detoxification/Stabilization

The detoxification and/or stabilization phase of treatment is designed for people who experience

frank withdrawal symptoms or significant physiological or emotional instability after a period of

prolonged abuse of drugs. The most significant withdrawal occurs in alcohol, opioid, or

sedative/tranquilizer dependence; a characteristic rebound physiological withdrawal syndrome is

experienced usually about 8–30 hours after the last dose of the drug (depending on the drug,

dosage, and period of use). Users of amphetamine, marijuana, and cocaine often also experience

substantial emotional and physiological symptoms and often require a period of stabilizing

treatment.

The purpose of this phase of treatment is not to produce lasting sobriety, but rather to prepare an

unstable patient to do well in the subsequent rehabilitation phase of treatment. The major

components of this phase of care include medications to relieve physiological and emotional

symptoms and to reduce craving for the abused substance(s). These medications are typically

accompanied by rest and motivational forms of therapy—usually in the context of a residential or

hospital setting. On its own, detoxification is unlikely to be effective in helping patients achieve

lasting recovery; this phase is better seen as a preparation for continued rehabilitation.

Rehabilitation

The rehabilitation stage of treatment is appropriate for patients who no longer experience the

acute physiological or emotional effects of recent substance abuse. In turn, the goals of this phase

of treatment are to prevent a return to active substance use, to assist the patient in developing

control over urges to abuse drugs, and to help the patient gain improved personal health and social

functioning.

Professional opinions vary widely regarding the underlying reasons for the loss of control over

alcohol and/or drug use typically seen in treated patients. In turn, there is an equally wide range of

treatment strategies and treatment components designed to correct or ameliorate the hypothesized

underlying problems. Strategies have included such diverse elements as medications for psychiatric

disorders; medications to relieve drug craving; group and individual counseling and therapy

sessions to provide insight, guidance, and support for behavioral changes; and participation in

peer-led, mutual-support groups (e.g., AA, Narcotics Anonymous) to provide continued support for

abstinence (for reviews, see Moos 2003; Simpson 2004).

Short-term residential rehabilitation programs are typically delivered over 30–90 days; residential

therapeutic community programs usually range from 3 months to 1 year; outpatient,

abstinence-oriented counseling programs run from 30 to 120 days; and methadone maintenance

programs can have an indefinite time period. Many of the more intensive forms of outpatient

treatment (e.g., intensive outpatient and day hospital) begin with full- or half-day sessions five or

more times per week for approximately 1 month. As the rehabilitation progresses, the intensity of

the treatment reduces to shorter sessions of 1–2 hours delivered twice per week and then tapering

to once per week.

Regardless of the specific setting, modality, philosophy, or methods of rehabilitation, all forms of

rehabilitation-oriented treatments for addiction have the following four goals: 1) to maintainPrint: Chapter 7. Evolution in Addiction Treatment Concepts and Methods http://www.psychiatryonline.com/popup.aspx?aID=345616&print=yes…

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physiological and emotional improvements initiated during detoxification/stabilization; 2) to

enhance and sustain reductions in alcohol and drug use (most rehabilitation programs suggest a

goal of complete abstinence); 3) to teach, model, and support behaviors that lead to improved

personal health, improved social function, and reduced threats to public health and public safety;

and 4) to teach and motivate behavioral and lifestyle changes that are incompatible with substance

abuse.

Continuing care

The continuing care stage of treatment is the final stage of the substance abuse treatment process

and is appropriate for patients who have achieved the major goals of rehabilitation. It is designed

to provide continuing support for the behavioral changes achieved during detoxification and

rehabilitation as well as monitoring to detect early threats to relapse. All aftercare is delivered in

outpatient settings or by telephone, typically in tapering doses of group or individual counseling

sessions (weekly to monthly) over a period of approximately 1 year, typically in association with

parallel activities in self-help groups. Continuing care is less formalized than earlier stages and has

only recently received research attention. Most of the medications, therapies, and services that

have been applied and studied in the rehabilitation phase of treatment are also appropriate in the

aftercare phase of treatment, but telephone and Internet forms of continuing care and monitoring

are also under investigation.

Review of Effective Treatment Components

Here I focus on the research findings from studies of rehabilitation—and to a lesser extent,

continuing care—rather than detoxification. Studies of detoxification methods, adolescent

treatments, or smoking cessation treatments were not included.

As indicated previously, the components of care presented here derive from that larger body of

research in which at least two randomized, controlled trials showed effectiveness of the focal

component and there had been at least one large study in an important, real-world setting and

population in which the component appeared to improve the outcome of care. The review began

with all research studies published in English since 1986 that studied a medication, therapy, or

other adjunctive service as part of the rehabilitation or continuing care stages and in which the

component of care was expected to promote or extend the cessation of substance use (this last

factor is quite important). Of course individuals who present for addiction treatment typically have

a range of medical, employment, family, legal, and psychiatric problems—the so-called

addiction-related problems. Many medications have shown significant effects in reducing some of

the important general medical conditions (e.g., pain, diabetes, hypertension, infectious diseases)

and the specific psychiatric disorders (e.g., depression, anxiety, attention-deficit/hyperactivity

disorder, posttraumatic stress disorder) that are so prevalent among addicted patients. Because of

space considerations, only medications and therapies that focus upon the goals of initiating and

sustaining abstinence from substance use are considered here.

Medications

There are now many medications that have shown effectiveness in reducing craving for and relapse

to alcohol and other drugs. A review of the now more than 200 randomly controlled trials of various

types of addiction treatments is beyond the scope of this paper (for a review see O’Brien and

McKay 2002). What follows here is a brief overview of those medications that have the

best-developed evidence base at this writing and are most widely used. In this regard, although

there are an increasing number of effective new medications available, their use is still infrequent

in part because of the lack of studies documenting their long-term effects and particularly due to

state regulatory restrictions and poor insurance coverage (Institute of Medicine 2006). Thus, the

appropriate use of medications in the treatment of substance dependence disorders is among the

most important topics for future research in the treatment field (for a review see Finkelstein and

Ramos 2002).

Medications for opioid addictionPrint: Chapter 7. Evolution in Addiction Treatment Concepts and Methods http://www.psychiatryonline.com/popup.aspx?aID=345616&print=yes…

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Methadone

Methadone has been used effectively as a maintenance medication because of its oral

administration, slow onset of action, and long half-life. Thirty years of studies on the effectiveness

of methadone reliably report major reductions in opiate use, crime, and the spread of infectious

diseases associated with heroin dependence (O’Brien and McKay 2002). The medication is also very

cost effective (Zarkin et al. 2005). Despite the overwhelming research evidence, both the

medication and the methadone maintenance modality continue to have a poor public image.

Buprenorphine

Buprenorphine, a partial agonist, was approved in 2002 by the FDA for treatment of opioid

dependence in general practice settings. Buprenorphine is administered sublingually and is also

effective in reducing opiate craving for 24–36 hours. The partial agonist action of buprenorphine

has some advantages over methadone, such as few or no withdrawal symptoms upon

discontinuation and lower risk of overdose even if combined with other opiates (see O’Brien and

McKay 2002). The fears of diversion that accompanied the release of the medication for

office-based practice have not been borne out, likely because of the three policy efforts that were

put into place to minimize these risks: First, only certified physicians who complete an instructional

course and agree to be listed on a national registry of providers are able to prescribe the

medication. Second, physician caseloads were restricted to 30 patients until late 2006, when

demand for the medication—combined with the safety record to that point—led to a change to a

100-patient caseload. Finally, the manufacturer of the medication agreed to develop a combined

formulation (Suboxone) that included naloxone with the buprenorphine to prevent injection use of

the medication. At this writing the use of this medication has increased steadily in response to its

acceptance by patients, its efficacy in reducing withdrawal symptoms and preventing new opioid

use, and the low level of individual and community side effects.

Naltrexone

Naltrexone (Trexan) is an orally administered opioid antagonist that blocks opioid effects through

competitive binding for 48–72 hours. Naltrexone was designed for use as a maintenance

medication, but compliance has been generally poor, with most field studies showing retention

rates of less than 20%. Because of this, the medication has been primarily used in two populations

of opioid- addicted individuals—professional groups and criminal justice patients—wherein the

threat of significant personal loss appears to sustain motivation to take the medication. For

example, naltrexone has been used effectively in the monitored treatment of physicians, lawyers,

nurses, and other professionals for whom maintaining a license to practice is contingent upon

maintaining abstinence (DuPont et al., in press). Similarly, the medication has been used

effectively with opioid-dependent probationers and parolees, again under close monitoring, for

whom re-incarceration will result upon a return to opioid use (Cornish et al. 1998). It remains to be

seen whether these findings affect the willingness of the criminal justice system to request or even

require the medication.

Medications for alcohol dependence

Disulfiram

Disulfiram (Antabuse) has been used in the treatment of alcohol dependence for three decades. It

produces vomiting, facial flushing, and headaches following a drink of alcohol through interference

with the metabolism of acetaldehyde, which is an intermediate byproduct of alcohol metabolism.

Because of the unpleasantness of these effects, there has been very poor compliance with the

medication among patients (O’Brien 2005; Wesson 2006) and reluctance on the part of physicians

to prescribe it because of fear of a serious cross-reaction if alcohol is ingested. Nonetheless, field

studies and substantial clinical experience suggest that the medication can be effective in blocking

alcohol drinking for selected individuals over extended periods of time (Bien et al. 1993; BrewerPrint: Chapter 7. Evolution in Addiction Treatment Concepts and Methods http://www.psychiatryonline.com/popup.aspx?aID=345616&print=yes…

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1992).

Naltrexone

Naltrexone (Revia) was approved by the FDA in 1994 for reducing drinking among

alcohol-dependent patients, without producing unpleasant physiological effects were alcohol to be

consumed. It blocks alcohol-mediated stimulation of endogenous opioids, thus blunting some of

alcohol’s pleasurable effects. At this writing, there have been more than 20 field studies of the

medication in a variety of clinical samples (O’Brien 2005). Overall, these studies have shown a

statistically significant—and modestly clinically significant—response compared with placebo or

with standard outpatient treatment involving no medication. O’Malley et al. (1996) found that the

best candidates for the medication include those with high levels of alcohol dependence, a familial

history of alcohol dependence, significant cravings for alcohol, and lower educational levels.

Because of problems with compliance with the oral form of the medication, there have been efforts

to develop depot or sustained-release formulations of the medication, culminating in the FDA

approval of an injectable product (Vivitrol) in early 2006 that provides clinically effective blood

levels of the medication for at least 30 days. Early findings with this formulation indicated that

more than 85% of those given the initial injection returned for five additional monthly injections;

that side effects were modest and not long lasting; and that the effectiveness was substantially

greater than placebo injections (Garbutt et al. 2005). At this writing, this form of the medication

has only recently been made available, and time will tell whether it is more desirable or effective in

practice than the oral form of the medication.

Acamprosate

In 2004, a new alcohol-blocking agent called acamprosate (Campral) was approved by the FDA to

block craving and return to alcohol abuse. Although acamprosate acts on different receptors than

naltrexone, the clinical results have been remarkably similar—but also somewhat less potent—in

most trials. The most recent trial of naltrexone and acamprosate provided alone or in combination

showed only modest effects for acamprosate versus placebo (Anton et al. 2006); only naltrexone

(orally administered) showed significant enhancement of abstinence rates.

Medications for stimulant dependence

During the 1980s and 1990s many medications have been tried in the treatment of cocaine

dependence. At this writing, there are no medications that have been approved for the treatment of

cocaine dependence or any other stimulant dependence. However, there are many trials in process,

and one medication, disulfiram, has shown replicated positive effects in randomized trials with

cocaine-dependent patients (O’Brien 2005; Vocci and Elkashef 2005). Disulfiram, a medication

traditionally used in the treatment of alcohol dependence, has been found to be effective in

promoting cocaine abstinence (Carroll et al. 1998, 2004). Originally, it was thought that because

alcohol use is often a trigger for cocaine craving, disulfiram’s ability to prevent alcohol ingestion

also prevented triggering situations that led to cocaine use (Carroll et al. 1998). However, basic

pharmacological studies showed a direct effect of disulfiram on the metabolism of

cocaine—reducing one of the active metabolites and thereby reducing the reinforcing properties of

the drug (Carroll et al. 2004). No medication has shown positive effects in controlled trials with

methamphetamine-dependent patients.

THERAPIES

Great progress has been made in the development and evaluation of new therapies in the

treatment of alcohol addiction and other drug addictions (Woody et al. 1990). As in the case of

medication development, this area of research has followed a three-stage process (Rounsaville et

1. 2001), including pre-testing of the underlying concept and procedures as well as manual

development; randomized trials in controlled settings; and finally, field trials, usually in multiple

sites. A complete review of all therapy trials is beyond the scope of this chapter (for complete

reviews see Carroll and Onken 2005; Woody 2003). Reviewed here are four therapies that havePrint: Chapter 7. Evolution in Addiction Treatment Concepts and Methods http://www.psychiatryonline.com/popup.aspx?aID=345616&print=yes…

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been developed and tested in the previously described manner with significant benefits over

treatment as usual.

Brief Therapies

The past decade has seen the development and testing of several brief therapies typically

consisting of more than one session but fewer than six sessions. One-session interventions are

considered advice (see Bien et al. 1993 for a review). Brief therapies are designed to promote

problem recognition among reluctant or unaware substance abusers, to foster a sense of

willingness and ability to address the problem, and often to promote engagement in treatment.

These brief therapies have been tested extensively in more than 100 trials with alcohol- and other

drug-dependent individuals, usually as a strategy for encouraging non-treatment-seeking

individuals to enter into formal treatment but also as a treatment intervention (see Bien et al.

1993; Moyer et al. 2002 for reviews). Studies of non-treatment-seeking individuals typically show

small to medium effect sizes compared with no intervention at all, with the best effects seen for

individuals with less severe forms of addiction (Moyer et al. 2002). Studies of brief interventions

have been particularly interesting because they typically have shown posttreatment outcomes that

are not different from those seen among individuals with more extensive treatments (Moyer et al.

2002; Project MATCH Research Group 1997; Saitz et al. 2005). Because of their brevity and low

reliance on treatment compliance, brief interventions have been particularly attractive to primary

care physicians dealing with alcohol-dependent individuals in family medicine or emergency

medical settings (Saitz et al. 2005)

Structured Therapies

Cognitive-behavioral therapy

Cognitive-behavioral therapy (CBT) in the treatment of addictions emphasizes the role of thinking

in determining both craving for drugs and the ensuing drug seeking and use. Put simply, the

therapy is based on the findings that thoughts as well as people and situations cause the feelings

and behaviors associated with relapse, and in turn, it is possible with therapy to change thoughts

about and reactions to relapse-provoking situations. There are several approaches to, or variations

on, CBT, including rational emotive behavior therapy, rational behavior therapy, rational living

therapy, cognitive therapy, and dialectical behavior therapy. In the addiction field, most of the

versions studied have been adapted from Marlatt and Gordon’s (1985) relapse prevention

treatment for problem drinking. As studied in most research trials, the therapy is usually individual

(but also group), delivered in 8–16 weekly sessions. Change in thinking about and reactions to

relapse-provoking situations requires practice and time. Thus, one of the hallmarks of CBT is

homework assignments to provide practice in the cognitive techniques learned during the formal

sessions.

CBT may be the most studied of all the therapies in addiction, perhaps because of the very carefully

developed manuals whose purposes are to train and guide the provision of the therapy (Kadden et

1. 1997; National Institute on Drug Abuse 1998). Studies of CBT with cocaine-dependent patients

have shown general acceptance by patients (attendance at more than 50% of planned sessions)

and better posttreatment rates of abstinence than for patients given no therapy or group

counseling alone (see Carroll and Onken 2005; Carroll et al. 1994; Morgenstern et al. 2001a for

review). Similarly, CBT has also been associated with generally good engagement and

posttreatment outcomes among alcohol-dependent patients (Balldin et al. 2003). Although the

evidence for the effectiveness of this therapy is quite consistent across trials and field studies, the

effects have been generally modest in clinical impact (Crits-Christoph et al. 1999; Leichsenring and

Leibing 2003; Morgenstern and Longabough 2000; Ouimette et al. 1997).

Marital, family, and couples therapies

Since the early 1990s there have been more than 60 studies in which marital, family, or couples

therapies have been provided to reduce substance abuse or substance abuse–related problems,Print: Chapter 7. Evolution in Addiction Treatment Concepts and Methods http://www.psychiatryonline.com/popup.aspx?aID=345616&print=yes…

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such as violence. In a recent review of controlled studies of this type in alcohol-dependent patients,

marital and family therapy and particularly behavioral couples therapy was significantly more

effective than individual treatments at inducing and sustaining abstinence, improving relationship

functioning, and reducing domestic violence and emotional problems of children (O’Farrell and

Fals-Stewart 2003). Similar reductions in substance use and partner violence have also been seen

in controlled trials of marital, family, or couples therapy with opiate- and cocaine-dependent

patients (Fals-Stewart et al. 2001, 2002; Higgins et al. 1994b).

Behavioral couples therapy

Behavioral couples therapy treats the substance-abusing patient with his or her spouse to arrange

a daily “sobriety contract” in which the patient states his or her intent not to drink or use drugs,

and the spouse expresses support for the patient’s efforts to stay abstinent. Behavioral couples

therapy also teaches communication and non-substance-associated positive activities for couples.

Findings show that this approach produces greater abstinence and better relationship functioning

than typical individual-based treatment and also reduces social costs and domestic violence

(McCrady et al. 1999; O’Farrell and Fals-Stewart 2002, 2003; Winters et al. 2002).

Community reinforcement and family training

Community reinforcement and family training (CRAFT) is based on a combination of standard

functional analysis of behavior and principles of reinforcement. The therapy was developed to teach

and promote the practice of these principles by members of a household. Specifically, families who

learn the CRAFT intervention are taught skills for modifying a loved one’s alcohol- or drug-using

behavior and for enhancing treatment engagement (Smith et al. 2001). The intervention has been

generally well accepted by families, and several studies have shown that CRAFT produces greater

likelihood of entry and engagement of substance-abusing family members and greater likelihood of

posttreatment abstinence than standard treatments (Kirby et al. 1999; Meyers et al. 2002). In

addition, families of the substance abusers in these studies show significantly less depression,

anxiety, anger, and physical abuse than families of patients who received standard treatment

(Meyers et al. 2002; Smith et al. 2001).

Twelve-step facilitation therapy

Twelve-step facilitation therapy (TSF) was originally developed as a practical control condition to

be implemented by counselors and to be compared with theoretically derived therapies

implemented by trained therapists in a controlled trial with alcohol-dependent patients (i.e.,

Project MATCH). It is a structured therapy designed to engage reluctant patients to consider the

effects of their substance use on their lives and the lives of their loved ones and to ultimately begin

to take steps to deal with the problems through the 12 steps and 12 traditions of AA (Nowinski et

1. 1994). TSF is typically delivered as a time-limited (12- to 15-session) intervention, either as an

individual treatment or as group treatment (Maude-Griffin et al. 1998). In either format, TSF is a

highly structured intervention; sessions begin with a review of the patient’s recovery week,

including any 12-step meetings attended, episodes of substance use, and urges to drink or use

drugs. Each session concludes with assignments to recovery-oriented tasks such as readings from

the AA literature and attending AA meetings, which the patient agrees to undertake between

sessions. One aspect of TSF that clearly separates it from other therapies is its active promotion of

spirituality as a key to lasting recovery. In this context spirituality is considered a force that

provides direction and meaning to one’s life.

The evidence for effectiveness of TSF was first shown in the large, multisite National Institute on

Alcohol Abuse and Alcoholism’s Project MATCH study of alcohol-dependent patients (Project MATCH

Research Group 1997). There were no overall differences among the three therapies tested in that

study over the 3-year period, but as designed, the TSF group was more successful in getting

patients involved with AA and was in turn more effective in getting patients to be abstinent from

alcohol than either of the other two groups (Tonigan et al. 2000). Additional studies have

confirmed the effectiveness of this therapy versus usual care. For example, in a randomized,Print: Chapter 7. Evolution in Addiction Treatment Concepts and Methods http://www.psychiatryonline.com/popup.aspx?aID=345616&print=yes…

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controlled study of disulfiram and TSF in the treatment of cocaine and alcohol dependence (Carroll

et al. 1998), both disulfiram and TSF were independently associated with significantly better

retention in treatment as well as longer duration of abstinence from alcohol and cocaine use than

was found with the control therapy. The study found that the best outcomes were for the groups

that received combined TSF and disulfiram. Similar results were found by Thevos et al. (2001) with

alcoholic women who received TSF over 12 weeks in a random assignment comparison with

motivational counseling. Women who received CBT or TSF had better outcomes than women who

received the control condition (Thevos et al. 2001).

Individual drug counseling

Similar in several ways to TSF, the drug dependence treatment field has employed a structured

form of individual counseling that uses many of the same practical elements, but not a formal

spiritual component (Woody et al. 1990). Individual counseling to foster abstinence and general

adjustment, delivered in a structured manner over 12–24 sessions, has been extensively studied.

In almost all studies, patients who received this form of counseling (even those who initially did

not want it) had better during- and posttreatment outcomes (Fiorentine and Anglin 1997; McLellan

et al. 1988), with those who attended a greater frequency of sessions typically showing the best

results (McLellan 2002; Moos 2003; Simpson 2004). Importantly, there are very few studies that

have shown positive effects from group drug counseling. Indeed, in one large trial among

cocaine-dependent patients it was only individual counseling and not group counseling that was

associated with improved outcomes (Crits-Christoph et al. 1999). This is important in that group

drug counseling is by far the most prevalent component of treatment in the national treatment

system (SAMHSA 2002).

Adjunctive Interventions and Services

Although medications and formal therapies to bring about and sustain cessation of substance use

have been the most extensively studied components of care, there are additional types of

interventions and services that have also been shown to be effective in initiating and sustaining

abstinence from alcohol and other substances.

Voucher-based reinforcement of abstinence

Higgins et al. (1993, 1994a, 1994b) brought laboratory principles of behavioral change to the

treatment of cocaine dependence. In a now classic set of studies in a clinical laboratory setting,

cocaine-dependent patients seeking outpatient treatment were randomly assigned to receive either

standard drug counseling and referral to AA or a multicomponent behavioral treatment in which

vouchers for desirable goods and services, provided by community shops and stores, were provided

contingent upon drug-negative urine tests. The voucher-based reinforcement of abstinence

retained more patients in treatment, produced more abstinent patients and longer periods of

abstinence, and produced greater improvements in personal function than the standard counseling

approach. In the decade since the publication of these early studies, the technique of providing

positive reinforcement that is contingent upon drug-free urine tests has been replicated and

extended in alcohol-, cocaine-, opiate-, or methamphetamine-dependent patients—all with similarly

positive findings (Higgins et al. 1994a). Moreover, because voucher-based reinforcements have

been criticized for their expense and administrative problems, investigators have tested partial

reinforcement schedules using a lottery system in which drug-free urine tests afford patients an

opportunity to draw for a range of prizes of small to large value (Petry 2000). This procedure has

reduced costs in real-world settings and appears to provide an enjoyable and treatment-compatible

means of delivering the reinforcers. A very promising extension of the voucher-based

reinforcement procedure has been developed and studied by Silverman et al. (1996, 1998). These

investigators operate a data entry center where recovering patients may learn data entry skills and

earn wages for data entry, contingent upon their providing a drug-free urine sample. This

procedure appears to be practical and potentially useful as a means of extending the principles of

contingency management practices into real-world settings.Print: Chapter 7. Evolution in Addiction Treatment Concepts and Methods http://www.psychiatryonline.com/popup.aspx?aID=345616&print=yes…

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Clinical case management and wraparound services

Most patients admitted to substance abuse treatment have significant problems in one or more

areas of life function, such as medical status, employment, family relations, and/or psychiatric

function (McLellan and Weisner 1996). The severity of these addiction-related problems generally

is predictive of response during treatment as well as posttreatment outcome (i.e., more or worse

problems predict early dropout and poor response). Studies have documented that specialized

services—also called wraparound services—such as primary medical care, housing, employment

training, psychiatric care, and parenting assistance for these addiction-related problems can be

effective adjuncts to standard addiction-focused care in either residential or outpatient settings

and in either the rehabilitative or continuing care stages of treatment.

From a conceptual or clinical perspective, there has been debate regarding whether patients should

first acquire stable sobriety so that they will be more likely to follow through with treatment plans

incorporating these services, or whether these services should be provided early in the course of

rehabilitative care to increase the attractiveness and impact of that care and in turn increase

patient engagement. There is no definitive answer to this question at this writing. From a practical

perspective, most specialty care treatment programs do not have access to many of the types of

professional services that would be useful to their clients, and for this reason most field studies of

so-called wraparound services have employed clinical case managers to link patients to available

services in the community, to take patients to those services and encourage follow-through, and to

advocate on the part of the patients for access and availability of the services (McLellan et al.

1998). Studies of case management with alcohol- and drug-addicted patients show mixed results.

Although there are clearly many studies that have found improved patient function with the

addition of case management to standard addiction services, the effectiveness of this form of care

management seems to be more related to the availability and attractiveness of the services that

are being managed than to the theoretical or methodological aspects of the case management

process itself (see McLellan et al. 1998 for review). For these reasons, this review treats special

services as the active ingredients and case management as the vehicle for linking those services to

the patient. It must be admitted that case management and service provision are inextricably

linked, and it could be argued that clinical case management itself should be discussed as an

evidence-based form of care delivery.

A study by Milby et al. (1996) illustrated the importance of providing supplemental social support

services to homeless, substance-dependent (typically cocaine and alcohol) individuals who sought

health care services (not explicitly drug abuse treatment) from the Birmingham Health Care for the

Homeless Coalition. In that study, 176 subjects were recruited and randomized into usual care

(primarily 12-step group counseling) and enhanced (addition of employment, housing, and

psychiatric services to usual care) conditions conducted in separate facilities. Enhanced care

patients attended therapy more regularly and at 6-month follow-up were two times more likely to

be employed and four times less likely to be homeless than the usual care patients. It appears that

the supplemental services included as part of addiction treatment were associated with significant

and broad improvements.

Not all studies of wraparound services have required clinical case management. Similar findings

have been seen from adding wraparound services to standard addiction treatment through special

computer systems or special training of counselors. Better outcomes have been seen when the

services were matched to the problems presented by the patients and when those services were

requested by the patients. The effects of adding specialized health and social services to standard

addiction treatments typically show improvements of 20%–40% over standard care, and these

findings have been seen in Veterans Administration patients (McLellan et al. 1993), in publicly

supported inner-city treatment programs (Hser et al. 1997; McLellan et al. 1997), among patients

in the Kaiser Permanente health care system (Weisner et al. 2001), among welfare to work clients

(Gutman et al. 2003), and in criminal justice settings (Cornish et al. 1998; Inciardi et al. 1997).

In a recent example, Carise et al. (2005) developed a computer-assisted method of teachingPrint: Chapter 7. Evolution in Addiction Treatment Concepts and Methods http://www.psychiatryonline.com/popup.aspx?aID=345616&print=yes…

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counselors to link the problems presented by patients during treatment admission to free or

low-cost community health and social services (derived from the United Way’s First Call for Help).

These researchers performed a randomized, controlled field trial comparing patients from 10

outpatient programs. Half of the subjects received essentially standard care, while the counselors

in the other programs were shown how to use the computer linking procedure. Results showed that

patients of counselors who had been trained to link community services to the admission problems

were more likely to receive services, the services were more likely to match the problems

presented at admission, and the patients were more likely to engage and complete care and less

likely to have positive urine tests during treatment.

Linking Patients to Alcoholics Anonymous

In contemporary substance abuse treatment, AA has become synonymous with the continuing care

stage of treatment. Virtually all alcohol dependence rehabilitation programs and most cocaine

dependence rehabilitation programs refer patients to AA programs with instructions to get a

sponsor, “share and chair” at meetings, and attend 90 meetings in 90 days as a continued

commitment to sobriety. Research studies conducted to date have generally found that only about

25%–35% of those who attend one meeting of AA go on to active participation (e.g., attend 90

meetings, acquire a sponsor). However, for those who do attend, there is every indication that this

peer support component of rehabilitation is valuable for maintaining rehabilitation (for a review,

see Humphreys 2003; Humphreys et al. 2004).

Although there has always been consensual clinical agreement about the value of AA and other

peer support forms of treatment, there is increasing evidence showing that patients who have an

AA sponsor or who have participated in the fellowship activities have much better abstinence

records than patients who have received the same rehabilitation treatments but have not continued

in AA. There are now many controlled studies and large field studies of AA participation showing

that participation in posttreatment self-help groups is related to better outcome among cocaine- or

alcohol-dependent individuals (McLatchie and Lomp 1988; Morgenstern et al. 2001b).

POSTTREATMENT MONITORING

Substance abuse treatment may be the only area of medical care in which there is specialty care

without corresponding primary care. That is, substance abuse patients are very rarely referred to

specialty care from a primary care physician (less than 4% of all substance abuse admissions), and

perhaps more importantly in this context, almost none of those who complete specialty care

addiction treatment are referred back to a primary care physician for continuing care management.

There are few clinicians who believe that patients who complete specialty care are truly cured of

their addiction. Most realize the need for some form of continuing care, but as has been indicated,

AA has been essentially the only option for that continuing care. In this regard, clinical researchers

have been studying alternative methods for extending the positive effects of outpatient

rehabilitative care. Consistent with a disease management perspective, several groups have shown

the clinical benefits associated with either brief telephone monitoring telephone calls, e-mail and

Internet contact, or home visits on a decreasing schedule of frequency for 6–12 months after

completion of outpatient addiction rehabilitation (see McKay 2005 for review).

McKay and his colleagues have been studying alcohol- and cocaine-dependent patients during and

following their participation in a 4-week intensive outpatient program. They employed research

assistants to deliver several forms of brief, clinically oriented telephone monitoring calls for 24

months following the end of the intervention. In almost all cases, those who received the brief,

inexpensive monitoring calls achieved better substance use outcomes (McKay et al. 1997, 1999).

McKay is currently evaluating a longer-term, telephone-based adaptive alcoholism treatment

package in a study funded by the National Institute on Alcohol Abuse and Alcoholism (McKay 2001,

2005). In this study, patients who achieve initial engagement and stabilization in the intensive

outpatient program are randomized to standard care only, 18 months of monitoring and feedback

by telephone, or an 18-month telephone-based, adaptive, stepped-care protocol that also provides

motivational interviewing, CBT relapse prevention, or return to the intensive program, as needed.Print: Chapter 7. Evolution in Addiction Treatment Concepts and Methods http://www.psychiatryonline.com/popup.aspx?aID=345616&print=yes…

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ORGANIZATIONAL INFRASTRUCTURE OF THE ADDICTION TREATMENT

SYSTEM

Almost all addiction treatment in this country is provided by specialty sector programs funded

primarily through the State Block grant, the Department of Veterans Affairs, Medicaid, private

medical insurance, and other sources (SAMHSA 2002). Most of this care is carved out from general

health plans and is provided by these specialty programs through myriad reimbursement

arrangements—but more than 70% of care involves government funds rather than private

insurance (McKusick et al. 1998). Thus, efforts to improve addiction treatment through

implementation of some of the evidence-based components of care reviewed here will be governed

in a significant way by the ability of the specialty care system to absorb or adopt these new

treatment methods.

In this regard, the substance abuse treatment system has been particularly affected by the general

rise in costs of health care. Because of these growing costs, employers and government purchasers

have turned to managed care organizations to reduce their health care expenditures. Although cost

reduction and treatment streamlining efforts have affected all areas of health care, it is widely

acknowledged that the addiction and mental health treatment systems have been

disproportionately affected (Institute of Medicine 2006). For example, in 1990 there were more

than 16,000 substance abuse treatment facilities operating in the United States; approximately

55% of those were residential or inpatient hospital, approximately 15% were methadone

maintenance programs, and about 30% were outpatient programs. Figures from 2002 indicate that

there are now fewer than 14,000 programs; only 10% are residential or inpatient hospital, about

12% are methadone maintenance programs, and approximately 78% are abstinence-oriented

outpatient programs (SAMHSA 1997, 2002). Despite a widely perceived growth in need for

substance abuse treatment, there are fewer programs in operation and fewer patients in treatment

today than there were in 1990 (for a review see McLellan and Meyers 2004).

In addition to outright closure, administrative restructuring is also quite prevalent, with about

20%–30% of programs undergoing some form of organizational takeover each year, leaving them

under a different administrative structure. Perhaps because of this high level of reorganization,

directors of these programs also change regularly. Less than half of program directors surveyed in

a recent national sample had been in their jobs for even a year (McLellan et al. 2003). This does not

mean that they are new employees. Indeed, at least 80% of program directors had been working

within their program prior to their appointment as director, usually in a clinical position. About

20% of those program directors had no college degree, half to two-thirds had bachelor’s degrees,

and about 20% had master’s degrees. Less than 2% were physicians.

Beyond their administrative structures, the nature of treatment staffs and the composition of

contemporary treatments are also indications of readiness to adopt and ability to provide

evidence-based treatments. In this regard, the modal treatment program in the United States

employs 6–10 counselors, each treating an active caseload of 50–80 clients. Apart from counselors,

there are very few other professional disciplines represented in most of these programs. For

example, only about 50% of the nation’s treatment programs have even a part-time physician on

staff. If methadone maintenance programs are excluded from this group, the proportion drops to

about 35%. In fact, only about 50% of U.S. addiction treatment programs even perform an on-site

physical examination at intake (Institute of Medicine 2006). Outside of methadone programs, less

than 15% of programs employ a nurse, and even fewer employ even a part-time social worker or

psychologist. Annual turnover rates for these staff are in the 50% range—approximately the same

as seen in the fast food industry (McLellan et al. 2003).

Only about 30% of programs have access to well-developed clinical information systems and

Internet services. Another 20% have no electronic information services of any type. The remaining

50% have some form of computerized administrative information system dedicated to billing or

administrative record keeping available for the administrative staff—but very few have an

integrated clinical information system for use by the majority of treatment staff (for a review see

McLellan and Meyers 2004).Print: Chapter 7. Evolution in Addiction Treatment Concepts and Methods http://www.psychiatryonline.com/popup.aspx?aID=345616&print=yes…

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As might be expected from the staffing complement in these programs, the great majority of what

goes on in treatment programs is some form of group counseling. Essentially all treatment

programs in the United States employ group counseling but only about 40% provide individual

counseling. Typical types of groups include orientation groups (in which patients introduce

themselves and learn about group therapy), relapse prevention groups, and general drug education

groups. Although some reports of national surveys of drug abuse treatment program directors have

suggested that a wide range of services are available through the programs, most studies of

patients in treatment reveal that very few patients actually receive medical or social services

beyond general counseling. In summary, these data confirm the already widely acknowledged gap

between the type of evidence-based, quality services that could be delivered and the kind of care

that is possible to deliver given the current infrastructure. Given the existing infrastructure, it is

doubtful if any of the medications reviewed here could be prescribed or administered in most of the

treatment programs. Similarly, given the level of training and background needed to effectively

provide most of the evidence-based therapies reviewed here, only a minority of existing programs

have the staffing and training capabilities to adopt these therapies. Thus, it is disheartening to end

this quite positive summary of promising evidence-based clinical practices with the stark but

unfortunately realistic conclusion that most of them simply cannot be staffed or delivered in a

sustainable manner within the contemporary treatment system.

KEY POINTS

Addiction treatment is best considered as at least three separate stages—each with distinct goals and

methods: 1) detoxification or stabilization is designed to eliminate the acute effects of substance use and

prepare the patient for life change; 2) rehabilitation is designed to continue the initial abstinence and to help

the patient develop a life that will be enjoyable without substances; and 3) continuing care follows formal

treatment and consists of mutual help groups (usually Alcoholic Anonymous [AA]), professional therapy as

needed, and often telephone monitoring calls designed to prevent relapse.

Within the rehabilitation and continuing care stages of treatment there is now an impressive array of

treatment components that have shown U.S. Food and Drug Administration–level evidence of effectiveness.

Medications include naltrexone, buprenorphine, and methadone for opiate dependence; naltrexone,

acamprosate, and disulfiram for alcohol dependence; and disulfiram for cocaine dependence.

Therapies include cognitive-behavioral therapy; motivational enhancement therapy, behavioral couples

therapy, 12-step facilitation, community reinforcement and family training, and individual drug counseling.

Adjunctive interventions and services include voucher-based reinforcement for abstinence, clinical case

management and wraparound social services, linking of patients to AA, and posttreatment monitoring

(telephone, Internet, and home visit).

Despite these very promising new developments, most addiction treatment is delivered within a specialty

care treatment system that does not have the personnel, information management, or administrative support

to implement most of these practices. Although there will be a continuing need for new and more

sophisticated treatment interventions and components, there is a pressing need for financial and

organizational development to permit the treatment system to provide the kind of quality care that is now

possible.

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