Assessment and Treatment of Addictive Behaviors Carl W. Lejuez, PhD

1. Assessment and Treatment of Addictive BehaviorsCarl W. Lejuez, PhD Lecture 6 Drug Treatment

2. Drug Treatment: Cost Effective? • Yes! • Less expensive than alternatives, such as not treating addicts or simply incarcerating addicts • 1 year of methadone maintenance is about $4,700 per patient • 1 full year of imprisonment costs about $18,400 per person • Every $1 invested in addiction treatment programs yields a return of between $4 and $7 in reduced drug-related crime, criminal justice costs, and theft alone • Costs reduced due to drops in health care expenses, interpersonal conflicts, improvements in workplace productivity, and reductions in drug-related accidents

3. Initial Considerations • Due to heterogeneity of drug problems, detailed initial assessment is crucial • Should assess how they made it to treatment – are they self-referred or by the will of others including court mandate • Multidimensional Outcomes • Abstinence doesn’t guarantee improvement in social, occupational, etc functioning • Relapse often a part of long-term success • Relapse rate on 1st attempt seeking treatment < 25% • Common treatments often have little empirical support

4. Basics of Treatment • In addition to stopping drug use, the goal of treatment is to return the individual to productive functioning in the family, workplace, and community • Measures of effectiveness: • criminal behavior • family functioning • Employability • medical condition • Overall, treatment of addiction is as successful as treatment of other chronic diseases, such as diabetes, hypertension, and asthma

5. Basics of Treatment • Treatment reduces drug use by 40 – 60% & significantly decreases criminal activity during & after treatment • For example, a study of therapeutic community treatment for drug offenders demonstrated that arrests for violent and nonviolent criminal acts were reduced by 40 percent or more • Methadone treatment has been shown to decrease criminal behavior by as much as 50 percent. • Research shows that drug addiction treatment reduces the risk of HIV infection and that interventions to prevent HIV are much less costly than treating HIV-related illnesses.

6. Basics of Treatment • Important Considerations: • No single treatment is appropriate for all individuals • An individual's treatment and services plan must be assessed continually and modified as necessary to ensure that the plan meets the person's changing needs • Counseling and other behavioral therapies are critical components of effective treatment for addiction • Medications are an important element of treatment for many patients • Medical detoxification is an important first step to most drug addiction treatments

7. Basics of Treatment • Medical Detoxification: • Detoxification alone is rarely sufficient to help addicts achieve long-term abstinence • Medical detoxification safely manages the acute physical symptoms of withdrawal associated with stopping drug use. • Strongly indicated precursor to effective drug addiction treatment

8. Types of Treatment Pharmacological Treatment Medication can be used to accomplish a number of goals: • Prevention of overdose • Suppression of withdrawal • Reduction of cravings • Reduction of psychiatric symptoms • Heroin: Methadone, LAAM, Naltrexone, Buprenorphine • Alcohol: Disulfiram (Antabuse), Benzodiazepines • No FDA approved medications for treatment for the following: • Cocaine • LSD • PCP • Marijuana • Methamphetamine and other stimulants • Inhalants • Anabolic steroids

9. Types of Treatment Behavioral Treatment Assumption : Drug Taking is a special case of operant behavior maintained by the reinforcing effects of the drugs. Evidence:Human and animal self-administration studies repeatedly demonstrate that various psychoactive drugs serve as positive reinforcers.Variables that control other operant behaviors—such as reinforcer magnitude, response requirement, and the availability of alternative reinforcers—also control drug taking.Numerous treatment studies have demonstrated that contingency management procedures can effectively reduce drug use Examples: Contingency Management Interventions Behavioral Activation**

10. Types of Treatment Multisystemic and Social Support Treatments • These treatment programs attend to abstinence as well as other aspects of the individual’s needs based on the theory that sobriety can not be maintained in a vacuum • Areas Addressed include: medical attention, occupational training, educational training (GED), housing, family relationships, exposure to community resources, social support, etc. • Examples: • Out-patient treatment Programs • Residential Programs • Therapeutic Communities • NA/AA/Narconon

11. Types of Treatment Psychotherapy • Useful for providing patients with individualized therapy • Provides more privacy than group setting • Enables patient to address problems that may be only peripherally related to drug use • Enables patient to address other mental health issues Examples: • Individualized Drug Counseling • Motivational Enhancement Therapy • Relapse Prevention

12. Treatment Duration • Individuals progress through drug addiction treatment at various speeds, but Good outcomes are contingent on adequate lengths of treatment. • residential or outpatient treatment, participation for less than 90 days is of limited or no effectiveness, and treatments lasting significantly longer often are indicated. • For methadone maintenance, 12 months of treatment is the minimum, and some opiate-addicted individuals will continue to benefit from methadone maintenance treatment over a period of years. • Successful outcomes may require multiple treatment experience. Many addicted individuals have multiple episodes of treatment, often with a cumulative impact.

13. Pharmacological Treatments

14. Agonist Maintenance Treatment • For opiate addicts usually is conducted in outpatient settings, often called methadone treatment programs • These programs use a long-acting orally administered synthetic opiate medication • usually methadone or LAAM • sustained period at a dosage sufficient to prevent opiate withdrawal, block the effects of illicit opiate use, and decrease opiate craving • Patients stabilized on opiate agonists can engage more readily in counseling and other behavioral interventions • Most effective opiate agonist maintenance programs include individual and/or group counseling, as well as provision/referral to other needed medical, psychological, & social services.

15. Agonist Maintenance Treatment • As used in maintenance treatment, methadone and LAAM are not heroin substitutes • Pharmacological effects are markedly different from those of heroin. • Far more gradual onsets of action than heroin • No rush • Wears off much more slowly than heroin • No sudden crash • Euphoric effects of heroin are significantly blocked • No marked fluctuations experienced by brain and body • Reduced craving for heroin

16. Narcotic Antagonist Treatment Using Naltrexone • For opiate addicts, usually conducted in outpatient settings although initiation of the medication often begins after medical detoxification in a residential setting • Naltrexone is a long-acting synthetic opiate antagonist with few side effects that is taken orally either daily or three times a week for a sustained period of time • Individuals must be medically detoxified and opiate-free for several days before naltrexone can be taken to prevent precipitating an opiate abstinence syndrome. When used this way, all the effects of self-administered opiates, including euphoria, are completely blocked.

17. Narcotic Antagonist Treatment Using Naltrexone • Theory: repeated lack of the desired opiate effects, as well as the perceived futility of using the opiate, will gradually result in breaking the habit of opiate addiction • Naltrexone itself has no subjective effects or potential for abuse and is not addicting. • Patient noncompliance is a common problem. • Most useful for highly motivated, recently detoxified patients who desire total abstinence because of external circumstances, including impaired professionals, parolees, probationers, and work-release prisoners

18. Other Medications for Heroin Dependence • Buprenorphine has recently been approved for maintenance treatment. • Does not require daily administration, an advantage over methadone. • Like methadone and LAAM, Buprenorphine suppress withdrawal, reduce cravings, and prevent users from getting high from heroin • Another potential answer: prescription Heroin • Why prescribe heroin? • Methadone does not work for everyone • Might bring more people into treatment • Reduce some of the harm associated with heroin • Undermine the black market

19. Cocaine Vaccine TA-CD is a combination of the cocaine molecule and a large protein • Triggers the generation of antibodies. • If cocaine is taken: • Antibodies combine with cocaine molecules to form a complex that is too big to cross the blood-brain barrier. • Initial trails have indicated TA-CD is safe and effective in reducing cocaine intake in rats • A single human study has shown that the drug was well tolerated (low side effects) and safe in humans. • Awaiting FDA approval for use as a treatment of cocaine dependence

20. Behavioral Treatment

21. Contingency Management Programs • Based on idea that in any particular instance, benefits of drug use often are immediate & certain, whereas negatives often are delayed & often uncertain • Also focuses on fact that benefits for nonuse often are delayed and uncertain • Basic Procedures • Drug use and abstinence are readily detected • Drug abstinence is readily reinforced • Drug use results in a loss of reinforcement • Reinforcement derived from non-drug sources is increased to compete with the reinforcing effects of drug use(Higgins et al., 1991)

22. Voucher-Based Reinforcement Therapy in Methadone Maintenance Treatment • Provision of a voucher for each drug-free urine sample • Voucher has monetary value and can be exchanged for goods and services consistent with treatment goals • Initially, voucher values are low, but value increases with the number of consecutive drug-free urine specimens • Cocaine- or heroin-positive urine specimens reset the value • Escalating contingency to reinforce sustained drug abstinence. • Patients receiving vouchers for drug-free urine achieved significantly longer abstinence than patients who were given vouchers independent of urinalysis results.

23. Community Reinforcement Approach (CRA) Plus Vouchers • Intensive 24-week outpatient therapy for treatment of cocaine • To achieve cocaine abstinence long enough for patients to learn new life skills that will help sustain abstinence • To reduce alcohol consumption for patients whose drinking is associated with cocaine use. • Patients attend one or two individual counseling sessions per week, where they focus on improving family relations, learning a variety of skills to minimize drug use, receiving vocational counseling, and developing new recreational activities and social networks.

24. CRA Plus Vouchers • Those who also abuse alcohol receive clinic-monitored disulfiram (Antabuse) therapy • Patients submit urine samples two or three times each week & receive vouchers for cocaine-negative samples • The value of the vouchers increases with consecutive clean samples. Exchange vouchers for retail goods • Facilitates patients' engagement in treatment and aids in gaining substantial periods of cocaine abstinence. • Tested in urban and rural areas and used successfully in outpatient detoxification of opiate-addicted adults and with inner-city methadone maintenance patients who have high rates of intravenous cocaine abuse.

25. Multisystemic and Social Support Treatments

26. Outpatient Treatment • Outpatient Drug-Free Treatment • Varies in the types and intensity of services offered. • Costs less than residential or inpatient treatment • Most suitable for individuals who are employed or who have extensive social supports. • Low-intensity programs: focus is on drug education and admonition. • Intensive day treatment: comparable to residential programs in services and effectiveness • Group counseling is emphasized • Medical or mental health problems may also be treated

27. Long-Term Residential • Provides care 24 hours per day, generally in nonhospital settings • The best-known residential treatment model is the therapeutic community (TC), but residential treatment may also employ other models, such as cognitive-behavioral therapy

28. Therapeutic Communities • Residential programs with planned stays of 6-12 months • TCs focus on the "resocialization" of the individual and use the program's entire "community," • including other residents, staff, and the social context, as active components of treatment • Addiction is viewed in the context of an individual's social and psychological deficits • treatment focuses on developing personal accountability and responsibility and socially productive lives. • Highly structured and at times be confrontational • activities designed to help residents examine damaging beliefs, self-concepts, and patterns of behavior and to adopt new, more harmonious and constructive ways to interact with others

29. Therapeutic Communities • Many TCs are quite comprehensive and can include employment training and other support services on site. • Compared with patients in other forms of drug treatment, the typical TC resident has more severe problems, with more co-occurring mental health problems and more criminal involvement. • Research shows that TCs can be modified to treat individuals with special needs, including adolescents, women, those with severe mental disorders, and individuals in the criminal justice system

30. Narcotics Anonymous • Begin in 1953, based on AA • NA's earliest self-titled pamphlet, known among members as "the White Booklet," describes Narcotics Anonymous as: • "a nonprofit fellowship or society of men and women for whom drugs had become a major problem . . . who meet regularly to help each other stay clean… We are not interested in what or how much you used…but only in what you want to do about your problem and how we can help.“ • Membership is open to any drug addict • regardless of the particular drug or combination of drugs used. • When adapting AA's First Step, the word "addiction" was substituted for "alcohol,“ • Removed drug-specific language • Continued focus on disease concept of addiction

31. Demographics of NA • Male/female ratio: 58% male, 42% female • Ages from 16 to 69 years, with an average of 37 years • Ethnicity: 56% Caucasian, 28% African-American, 4% Hispanic, 11% other • Employment status: 76% employed full-time, 9% part-time, 5% homemakers, 4% disabled, 1% retired, and 5% unemployed • Continuous abstinence/recovery: ranged from less than one year to 35 years, with a mean average of 5.5 years

32. Narconon The Narconon Treatment Residential Treatment Program • The Narconon program is designed to get drug or alcohol abusers off drugs and back in control of their lives. • Narconon was founded in the Arizona State Prison by an inmate and former heroin addict, William Benitez. • The original group of ten inmates expanded to over one hundred within the first year • In 1972 the program was made available to the public with the opening of the first street program in Los Angeles. • Today there are Narconon centers throughout the Western world, in Canada, France, Germany, the Netherlands, Italy, Spain, Denmark, Sweden, Switzerland and Australia, as well as across the United States.

33. Narconon • PHASE I Drug-Free Withdrawal: Narconon provides a safe, 24-hour care procedure for a drug free withdrawal. An individual in withdrawal is under the careful supervision of a Withdrawal Specialist 24 hours a day until the physical and mental discomfort associated with drug and alcohol withdrawal is no longer present. • PHASE II Learning Improvement Course: This course provides the student with the ability to study and retain knowledge along with the ability to recognize and overcome obstructions in the study and learning process. The Communications and Perception Course: This course utilizes exact procedures, which focus the student’s attention onto the present, as opposed to being stuck in past experiences. It improves the student’s perception of his environment, and gets the student into better communication with others.

34. Narconon • PHASE III Ups and Downs in Life Course: In this course, students learn the characteristics of social and anti-social personalities in order to evaluate objectively and choose those people in their lives who need to be avoided Personal Values and Integrity Course: This course restores to the clients his basic sense of right and wrong, and the ability to live honestly again. Values and purposes are recovered and strengthened. Students often experience a strong feeling of relief, and a newfound feeling of freedom and self-respect because of this course. • PHASE IV The Changing Conditions in Life Course: This course gives the student the exact formulas to use to evaluate objectively and improve conditions having to do with himself, his family, the groups he belongs to, and other areas of life. The Way to Happiness Course: This course introduces the student to a common sense moral code that he can use in living a new drug and alcohol-free life.

35. Narconon Final Program Review • A comprehensive review to ensure the student has thoroughly completed all phases of the program. • Additional course work is assigned based on specific student needs to prepare the student to deal with life situations after graduation from the program.

36. Narconon Follow-up Program • A comprehensive long-term follow-up program is designed and implemented to assist the student through the first year of recovery. This is accomplished through regular contact with the student and family members. • The entire Narconon program takes between 3-5 months to complete. The difference in time depends on each individual and what is required for them.

37. Psychotherapy Treatments

38. Individualized Drug Counseling • Focuses directly on reducing or stopping the addict's illicit drug use • Addresses related areas of impaired functioning—such as employment status, illegal activity, family/social relations • Emphasis on short-term behavioral goals • Development and application of coping strategies and tools for maintaining abstinence • The addiction counselor • Encourages 12-step participation • Makes referrals for needed supplemental medical, psychiatric, employment, and other services • Individuals are encouraged to attend sessions one or two times per week

39. Motivational Enhancement Therapy • Client-centered counseling approach for initiating behavior change by helping clients to resolve ambivalence about engaging in treatment and stopping drug use. • Employs strategies to evoke rapid and internally motivated change in the client, rather than guiding the client stepwise through the recovery process. • Consists of an initial assessment battery session, followed by two to four individual treatment sessions with a therapist. • The first treatment session provides feedback generated from assessment battery to stimulate discussion regarding personal substance use and to elicit self-motivational statements. • Motivational interviewing principles are used to strengthen motivation and build a plan for change. • Coping strategies for high-risk situations are suggested and discussed with the client. • This approach has been used successfully with alcoholics and with marijuana-dependent individuals.

40. Confrontation vs. Motivation Enhancement

41. Other Techniques • Application of Marlatt’s Relapse Prevention for alcohol • Cue Exposure • Extinction

42. Alcohol Treatment

43. Factors that affect treatment success • Current level of dependence • Medical Problems • Treatment History • Previous Quit Attempts • Social Support Systems • Personal resources • Other psychological problems • Attitudes about treatment

44. Detoxification • Sx begin 5-12 hrs after drinking stopped and may last up to 72 hrs • 4 detox alternatives • Inpatient medical • Partial hospital medical • Inpatient nonmedical • Outpatient medical

45. Treatment Modalities • Self-help groups • Individual treatment • Group therapy • Couples therapy • Family therapy • In most cases, can occur as inpatient or outpatient

46. Treatment Approaches

47. Marlatt’s Relapse Prevention Model • Coping & Skills Training • Drinking conceptualized in terms of deficits in interpersonal and coping skills • Condition more adaptive responses to drinking cues • Focus on new coping skills • Functional analysis, relapse prevention, cue exposure, refusal skills

48. Relapse Prevention Cognitive-behavioral therapy • Developed for the treatment of problem drinking by Marlatt • Adapted for cocaine and other drugs more recently • Based on the theory that learning processes play a critical role in the development of maladaptive behavioral patterns • Individuals learn to identify and correct problematic behaviors • Includes several cognitive-behavioral strategies that facilitate abstinence and provide help for people who experience relapse • Techniques include: • Exploring the positive and negative consequences of continued drinking • Self-monitoring to recognize cravings early on and to identify high-risk situations for use • Avoiding high-risk situations • Developing strategies for coping with avoidable high-risk situations

49. Community Reinforcement Approach • Based in Cognitive/Behavioral theory • Sobriety through use of support systems: • Examine interaction of environment & drinking • Uses skills training • Functional analysis • Mood monitoring • Vocational counseling • Drink refusal training • Compliance monitoring • Buddy systems • Can be limited by high cost of implementation, including time, $$$, and participation of others

50. Motivational Enhancement • Developed by Miller • Brief intervention tradition • Nonconfrontational • Client-centered • Focus on motivation/readiness to change • Techniques include: • Feedback of risk/impairment • Responsibility for change • Advice to change • Menu of alternative change options • Therapist empathy • Facilitation of client self-efficacy