Evidence-Based Treatment

1. Evidence-Based Treatment Community Reinforcement Approach (CRA) Robert J. Meyers, Ph.D. Jane Ellen Smith, Ph.D. University of New Mexico

2. Early CRA Studies Hunt & Azrin, 1973 Azrin, 1976 Azrin, Sisson, Meyers, & Godley, 1982

3. Hunt & Azrin 1973 • inpatient alcoholics • job finding counseling • behavioral/marital tx • social/leisure counseling • reinforcer access counseling • social club • home visits • [total 50 hrs per client]

4. Results: 6 month follow-up

5. inpatient alcoholics disulfiram w/compliance protocol problem prevention rehearsal buddy system early warning mood monitoring some group tx ~70% as aftercare home visits [Average 30 contact hrs] Azrin 1976: New & Improved CRA

6. CRA new & improved: Results

7. 43 outpatient alcoholics 3 groups: traditional tx only traditional tx + disulfiram compliance CRA only increased use of positive reinforcement sobriety sampling immed. disulfiram drink refusal training +/- functional analysis job club phone contacts [Average: 5 tx sessions] 1st CRA Outpatient Study (Azrin, Sisson, Meyers, & Godley, 1982)

8. Results of 1982 study 6 month follow-up Disulfiram only group % days abs = 74% CRA + % days abs = 97% Traditional group % day abs = 45%

9. CRA with Homeless Alcohol-Dependent Individuals PI: Jane Ellen Smith Co-PI: Robert J. Meyers Funded by: NIAAA

10. Primary Questions Addressed: • Is CRA > a day shelter’s standard program for treating drinking problems among homeless individuals? • What are the effects of the 2 treatments on the non-drinking variables (employment, housing)?

11. CRA Group Group Sessions • Problem-Solving • Communication Skills • Drink-Refusal • Independent Living Skills • Goal Setting/Community Meeting • Social Club • Disulfiram Compliance Individual Sessions • Job Finding • Case Management • Couples Therapy

12. Standard Treatment Group • Day Shelter Program • Project Share • Alcoholics Anonymous Meetings • 12-Step Counselor • Job Service Program • VA Benefits Advisor • Project CARE

13. Grant-Provided Housing • All participants were housed • Normal stay: 3 months • Extended stays: if job and $ saved • Random breathalyzer tests

14. Drinks Per Week By Condition --- Standard --- CRA Median SECs 2 Month 4 Mont 6 Month 9 Month 12 Month Follow-Up Period

15. Percent Homeless By Condition CRA Standard Percent 2 Month 4 Month 6 Month 9 Month 12 Month Follow-up Periods

16. Percent Employed By Condition CRA Standard Percent Intake 2 Month 4 Month 6 Month 9 Month 12 Month Follow-up Period

17. Limitations of the Study • Not comparable “doses” of treatment • Some CRA participants still drinking heavily • Only moderate improvement in employment • Cost of housing

18. CRA with Homeless Alcoholic Women • Why women only? • Treatments: • Case Management • CRA • CRA + contingency-managed computer training

19. Summaries of Adult Treatment Research for Alcohol Use Disorders Meta-analyses and Reviews

20. Evidence of Effectiveness: Meta-analyses Holder et al., ’91Miller et al., ’95 Social skills training Brief intervention Self-control training Social skills training Brief motivational tx MET Behavioral Marital tx CRA CRA Behavioral contract Stress management Aversion tx

21. Evidence of Effectiveness (cont’d) Finney et al., ‘96Miller et al., ’03 CRA Brief Intervention Social skills training Motivational Enhancement Behavioral Marital tx Acamprosate Disulfiram Implants CRA Other marital tx Self-Change (bibliotherapy) Stress Management Naltrexone

22. CRA for Illicit Drugs: Adult Studies Cocaine Higgins et al. (1991; 1993; 1994; 1995; 2000) Heroin Bickel et al. (1997) Abbott et al. (1998)

23. Adolescent CRA

24. Godley et al. (2002) • Continuing care study (after residential treatment) • UCC (usual continuing care) or ACRA + case mgmt • 114 adolescents • 90% = marijuana dependent at intake • 57% = alcohol dependent • 82% = involved w/ juvenile justice system

25. Results: 3 months ACRA significantly > UCC in terms of: • abstinence from marijuana • reduced alcohol use

26. Cannabis Youth Treatment (CYT) Study (Dennis et al., 2004) • Outpatient treatment for marijuana • Trial 1:MET/CBT5; MET/CBT12; FSN • Trial 2: MET/CBT5; ACRA; MDFT • 600 adolescents • Hi rate of illegal activities

27. Results: 12 months Measures: (1) days of abstinence (from drugs & alcohol) (2) “in recovery” = living in community (not jail) + no use + no past month substance problems General Findings: All treatments significantly improved pre-post; no significant tx comparison differences

28. Best overall “in recovery” rates = ACRA (34%; next best = MET/CBT5 at 27%) • Best # of abstinent days for Trial 2 = ACRA (73% of days during the year; best for Trial 1= MET/CBT5 at 74%) • Most cost-effective? ACRA

29. UNM CASAA’s Street Youth Program: Project STAR

30. Percent days of substance use Significant interaction between time (pre to 6 months) and group using number of treatment sessions as covariate (F (1, 81) = 9.10, p < .01).

31. Percentage of days off the street Trend toward interaction between time (pre to 6 months) and group using number of treatment sessions as covariate (F (1, 81) = 3.09, p =. 08).

32. What does not work! • Educational films and lectures • General alcoholism counseling • Psychotherapy • Confrontational counseling • Antipsychotic medication • Psychotherapy, group process • Insight therapy

33. Why Isn’t CRA Used More? • Disease Model • Limited accessibility • It’s hard to teach an old dog new tricks • “We already do that” • CRA isn’t “sexy”