1. Treatment and Prevention of Substance Use Disorders • Lecture Overview • Nature and treatment of alcoholism • Tobacco Treatments and Prevention • Relapse Prevention Substance Abuse

2. Prevalence of Substance Disorders Substance Abuse

3. Lifetime Prevalence of DSM-III-R Substance Abuse Disorders Source: Tsuang et al (1998). Archives of General Psychiatry, 55, 967-972. Data based on 3372 Male Twin Pairs Substance Abuse

4. Conditional Probabilities of Drug Use Co-occurrence SOURCE: Tsuang et al (1998). Archives of General Psychiatry, 55, 967-972.Data based on 3372 Male Twin Pairs Substance Abuse

5. Lifetime Prevalence of DSM-III-R Drug Use and Dependence Source: Warner et al (1995). Archives of General Psychiatry, 52, 219-228. Data from National Comorbidity Study Substance Abuse

6. Family history • Personality traits • Sensation seeking • Impulsivity • Antisocial • Being the victim of assault (Lown & Vega, 2001) • Reduced Auditory P300 Amplitude (Enoch et al, 2001) Substance Abuse

7. Pharmacological Treatment for Alcohol Dependence • Disulfiram • Lithium • Naltrexone • Acamprosate? Substance Abuse

8. Effects of Naltrexone in Reducing Relapse SOURCE: Volpicelli et al (1992). Archives of General Psychiatry, 49, 876-880. Substance Abuse

9. Effects of Naltrexone in Reducing Relapse SOURCE: O’Malley et al (1992). Archives of General Psychiatry, 49, 881-887. Substance Abuse

10. Effects of Naltrexone in Reducing Relapse SOURCE: O’Malley et al (1992). Archives of General Psychiatry, 49, 881-887. Substance Abuse

11. Behavioral Approaches to Alcoholism • Aversion Methods • Chemical • Electrical • Imaginal Substance Abuse

12. Controlled Trial of Covert Sensitization Substance Abuse

13. Behavioral Approaches to Alcoholism • Cue Exposure • Rationale Substance Abuse

14. Evidence Supporting the Role of Cue Reactivity in Alcoholism • CR is positively associated with pretreatment levels of physical dependency (Kaplan et al, 1985) • CR is associated with positive outcome expectancies (Cooney et al, 1984) • Urge strength during cue exposure predicts amount of drinking in laboratory (Walitzer & Sher, 1990) Substance Abuse

15. Cue Exposure:Treatment Components • Continuous exposure to an opened alcohol beverage • Focus on the sight and smell of the beverage • Focus on imaginal drinking cues (high risk situations) • Guided practice in specific coping skills to reduce urges to drink during in vivo and imaginal exposures Substance Abuse

16. Efficacy Studies: Cued Exposure Monti et al, 1993 Substance Abuse

17. Procedural Elements of Cue Exposure + Coping Skills • Continuous exposure to an opened alcohol beverage • Focus on the sight and smell of the beverage • Focus on imaginal drinking cues (high risk situations) • Guided practice in specific coping skills to reduce urges to drink during in vivo and imaginal exposures Substance Abuse

18. Cue Exposure With Coping Skills Training SOURCE: Monti et al (1993). JCCP, 61, 1011-1019. CET = Cue Exposure + Skills Training CC = Control Condition Substance Abuse

19. Efficacy Studies: Cue Exposure Sitharthan et al, 1993 Substance Abuse

20. Procedural Elements in the Sitharthan et al (1993) • Participants drank three priming drinks (males) two priming drinks (females) of their favorite beverage; • They were then instructed to expose themselves to another drink but not consume it. • looking at the drink for 3-min. • holding it in their hands for three min. • sniff the drink for three min. • During the exposure, subjects were instructed to report on their thoughts, their desire to continue drinking, and changes in this desire. Substance Abuse

21. Efficacy of Cue Exposure in Moderation Drinking SOURCE: Sitharthan et al, (1993). JCCP, 65, 878-882. Data presented are for the 6-mo follow-up. Frequency = Drinks per month Substance Abuse

22. Efficacy Studies: Cue Exposure Monti et al, 2001 Substance Abuse

23. Efficacy of Cue Exposure in SOURCE: Sitharthan et al, (1993). JCCP, 65, 878-882. Data presented are for the 6-mo follow-up. Frequency = Drinks per month Substance Abuse

24. Behavioral Approaches to Alcoholism • Relapse Prevention Training • Rationale Substance Abuse

25. Approaches for Preventing Relapse • Booster session method • Shot gun method • Self-control method • Analyses of relapse process Substance Abuse

26. Marlatt's Relapse Prevention Model • Major components of the model • High-risk situation Substance Abuse

27. Triggers for Relapse • Intrapersonal • Coping with negative emotional states • Coping with negative physical/physiological states • Enhancement of positive emotional state • Testing personal control • Giving in to urges Substance Abuse

28. Triggers for Relapse • Interpersonal triggers • Coping with interpersonal conflict • Social pressure • Enhancement of positive emotional state Substance Abuse

29. Most Common High-risk Situations • Coping with negative emotional states (37%) • Coping with social pressures (24%) • Coping with interpersonal conflict (15%) Substance Abuse

30. Marlatt's Relapse Prevention Model • Major components of the model • High-risk situation • Ability to engage in adaptive coping response Substance Abuse

31. Marlatt’s Relapse Prevention Model • Major components of the model • High-risk situation • Ability to engage in adaptive coping response • Positive outcome expectancies about the substance Substance Abuse

32. Marlatt’s Relapse Prevention Model • Major components of the model • High-risk situation • Ability to engage in adaptive coping response • Positive outcome expectancies about the substance • Abstinence violation effect (AVE) Substance Abuse

33. Major Treatment Components of Relapse Prevention Training • Learning to identify high risk situations via self-monitoring • Specific skill training to build effective coping responses • General lifestyle skill training to increase patients' general coping and sense of personal control • Development of leisure activities that do not involve alcohol • Information to counter positive outcome expectancies • Training in coping with slips and the AVE Substance Abuse

34. Controlled Efficacy Data on Relapse Prevention Training • Description of controlled outcome studies • Number of studies • Type of substance • Abstinence initiation vs. Maintenance of abstinence • Types of comparison groups Substance Abuse

35. Controlled Efficacy Data on Relapse Prevention Training • Major findings • Comparison to minimal or no treatment • Comparison to attention controls • Comparison to alternative active treatments Substance Abuse

36. Efficacy of Relapse Prevention:Meta-Analysis (Irvin et al, 99) • RP showed small but significant overall effect size when compared with no treatment (r = .11) • Effect sizes were greatest when outcome was assessed immediately after treatment • Effect sizes were significantly greater for alcohol and poly substance use than for smoking; • Effect sizes were significantly greater when RP was combined with medication Substance Abuse

37. Research on Treatment Matching Substance Abuse

38. Treatment Matching • Rationale • Efforts to evaluate the effectiveness of various treatment methods averaged across alcoholic subjects have been far from successful. Substance Abuse

39. Treatment Matching • Conditions for which matching is most appropriate • No single treatment has been shown to be superior • Evidence to suggest that significant subject heterogeneity exists • When evidence suggests that treatment outcome is a function of the interaction between subject characteristics and type of treatment delivered Substance Abuse

40. Treatment Matching • Practical obstacles to treatment matching • Lack of alternative treatments • Need to specify the treatments along a number of therapy-relevant dimensions • Need to specify the client characteristics at which the treatments are targeted • Practical impact of the increased workload associated with the necessary assessments and treatments • Need to determine the best methods for matching clients and treatments Substance Abuse

41. Treatment Matching • Observed moderator effects • Social skills (Kadden et al (1992) • Level of craving (Jaffe et al, 1996) • Religiosity (Craig et al, 1997) Substance Abuse

42. Project Match Substance Abuse

43. Project MATCH • Primary aim • To assess the benefits of matching alcohol dependent patients to three different treatments based on selected patient characteristics Substance Abuse

44. Project MATCH • Design • Two parallel but independent 3-arm multisite (10 sites) randomized clinical trials, one with outpatients (N = 952) and one with patients receiving aftercare treatment following intensive inpatient treatment (N = 774) • Treatment conditions (12 individual sessions) • Cognitive-behavior therapy (CBT) • Twelve-step facilitation therapy (12-step) • Motivational enhancement therapy (MET) Substance Abuse

45. Project MATCH • Apriori matching variables • Severity of alcohol involvement (Edwards & Lader, 1994) • Cognitive impairment (Cooney et al, 1991) • Client conceptual level (McLachlan, 1972) • Gender (Cronkite & moos, 1983) • Meaning seeking (brown et al, 1993) • Readiness to change (DiClemente and Hughes, 1990) • Psychiatric severity ((Kadden et al, 1989) • Social support for drinking (Longabaugh e al, 1993; 1995) • Sociopathy (Cooney et al, 1991) • Typology (Litt et al, 1992) Substance Abuse

46. Project MATCH • Primary treatment outcome measures • Percent days abstinent (PDA) • Measures drinking frequency • Drinks per drinking days (DDD) • Measures drinking severity Substance Abuse

47. Project MATCH – Study Findings • Treatment outcome • All three treatments led to significant reductions in PDA and DDD • The improvements on alcohol indices were largely maintained over a 15-month period • The majority of patients did not maintain complete abstinence over thee study period • In general, there were no significant differences between the three treatments for either the aftercare trial or the outpatient trial Substance Abuse

48. Project MATCH – Study Findings • Matching findings • None of the apriori matching hypotheses were significant for the aftercare sample for either PDA or DDD • One matching hypothesis (psychiatric severity) was significant in the outpatient sample Substance Abuse

49. Differential Effects of Psychiatric Severity Substance Abuse

50. Project MATCH – Study Findings • Other moderator effects • For the aftercare sample • Male gender was associated with poorer outcome on PDA • Male gender, higher alcohol involvement, higher social support for drinking was associated with poorer outcome on DDD • Outpatient sample • Higher pretreatment motivation and lower scores on social support for drinking were each associated with a more favorable outcome Substance Abuse