Behavioral therapies for drug dependence

1. Behavioral therapies for drug dependence Kathleen Carroll PhD Yale University School of Medicine

4. Effectiveness of drug treatment • The majority of individuals in treatment improve, but relapse is common • Cost effective: Estimates $1 in treatment associated with $12 saved in criminal, health, occupational costs • Most drug dependent individuals do not access treatment • Treatment need not be voluntary to be effective • Better outcomes are associated with: • Longer retention in treatment • Addressing multiple problems (psychiatric, family, legal, housing, employment) • Self-help and aftercare participation

5. Behavioral Therapies for Drug Dependence • Rigorous science has yielded more, and more effective, behavioral therapies • Effective behavioral therapies for substance use parallel those for alcohol, mental health • Effects of many behavioral therapies are durable • Behavioral therapies reliably enhance effects of medications • Evidence based approaches can be used by clinical community

6. “Technology Model” of Behavioral Therapies Research Specification of behavioral therapies analogous to specification of medication in pharmacotherapy research

7. Key elements of the technology model • What is the treatment? Clear definition/specification of treatment in manuals • Who delivers the treatment? Criterion-based training of clinicians • What was actually delivered and how well? Monitoring of treatment fidelity

8. Motivational interviewing Marijuana users: Stephens & Roffman Dual diagnosis: Swanson Methadone maintenance: Saunders HIV Risk Reduction: Carey Contingency management Community reinforcement + vouchers: Higgins Therapeutic workplace: Silverman Low cost CM: Petry Community reinforcement: Azrin Smokers: Stitzer & Bigelow Cognitive-behavioral therapy Cocaine users: Carroll Methamphetamine: Rawson Marijuana: Marijuana Treatment Research Group Combined CBT and nicotine replacement: Family and couples therapy Multisystemic therapy for adolescents: Henggeler Brief strategic family therapy: Szapocznik Multidimensional family therapy Behavioral couples therapy for adults” Fals-Stewart & O’Farrell Scientifically Validated Behavioral Therapies: Drug Dependence

10. MI for individuals referred to drug treatment by child welfare system: Effects of single session on retention

11. Contingency Management:Basic Principles • Drug use must be swiftly detected • Abstinence is reinforced • Drug use results in loss of reinforcement • Emphasis on development of competing reinforcers

12. Effectiveness of contingency management: Cocaine abuseHiggins et al., 1991

13. Lower cost “prize” contingency management: Petry et al. 2002

14. Effects of ‘lower cost’ contingency management on drug use Petry et al., 2000

15. Family, couples approaches • Inclusion of social network in treatment • Reinforce social networks that promote abstinence • Essential among adolescents

16. Behavioral Family Counseling in Naltrexone Maintenance: Retention in treatment Fals-Stewart & O’Farrell, JCCP, 2003

17. Behavioral therapies effective across types of drug use

18. Consistency in effective behavioral approaches

19. Behavioral Therapies for Drug Dependence • Rigorous science has yielded more, and more effective, behavioral therapies • Effective behavioral therapies for substance use parallel those for alcohol, mental health • Effects of many behavioral therapies are durable • Behavioral therapies reliably enhance effects of medications • Evidence based approaches can be used by clinical community

20. Cognitive-behavioral Therapy(CBT) • Emphasis on development of coping skills • Coping with urges to use • Coping with thoughts about using • Changing behavior patterns • Managing impulsivity, problem solving skills • Bolstering interpersonal skills • Planning for emergencies • Practicing new skills • Based on functional analysis of substance use

21. Continuing improvement after CBT Carroll et al., 1994, Arch Gen Psychiatry

23. Rawson et al., 2002: CM vs CBT in methadone maintenance

24. Behavioral Therapies for Drug Dependence • Rigorous science has yielded more, and more effective, behavioral therapies • Effective behavioral therapies for substance use parallel those for alcohol, mental health • Effects of many behavioral therapies are durable • Behavioral therapies reliably enhance effects of medications used to treat drug addiction • Evidence based approaches can be used by clinical community

25. Available pharmacotherapies for substance use disorders

26. Behavioral therapies effective across types of drug use

27. Limitations of purely pharmacologic approaches • Variable efficacy • Some not helped • Partial effects • Side effects may limit compliance • Effects often fall off with treatment cessation • Treatment efficacy often limited to single drug class • Multidimensionality of problems

28. Ball et al., 1991Rates of drug-positive urines across methadone programs

29. McLellan et al, 1993Effects of Psychosocial Services in Methadone Maintenance • 92 male methadone maintenance patients • Randomly assigned to 3 levels of services: • No services • Standard counseling • Enhanced services

31. CM to enhance medication compliance:Mean number of drug-free urines by group

32. Behavioral Therapies for Drug Dependence • Rigorous science has yielded more, and more effective, behavioral therapies • Effective behavioral therapies for substance use parallel those for alcohol, mental health • Effects of many behavioral therapies are durable • Behavioral therapies reliably enhance effects of medications • Evidence based approaches can be used by clinical community

33. Institute of Medicine, 1998 Bridging the Gap ResearchPractice

34. CTN’s Mission To Improve Drug Abuse Treatment Throughout the Nation… Using SCIENCE as the Vehicle

35. Washington Node U. Washington Northern NE Node McLean/Harvard Oregon Node OHSU New England Node Yale Great Lakes Node Wayne State U. New York Node NYU Long Island Node NY State Psych. Inst. California/Arizona Node UCSF/U. Arizona Ohio Valley Node U. Cincinnati Delaware Valley Node U. Pennsylvania Mid-Atlantic Node JHU/MCV Rocky Mountain Node U. Colorado Pacific Node UCLA North Carolina Node Duke Southwest Node U. New Mexico South Carolina Node MUSC Florida Node U. Miami CTN Centers* A research infrastructure of17 RRTCsand118 CTPs across27 States, the District of Columbia, and Puerto Rico

36. CTN Research to Date 26Research Studies • 23 multisite clinical trials • 12 completed 70Community Treatment Programs have enrolled over 4700 study participants Positive results for completed trials Coordinated dissemination, collaboration with CSAT ATTCs

37. Opiate dependence Buprenorphine detoxification Adolescent detoxification Prescription opioid dependence Ethnic minorities MI for Spanish speakers Adolescents Brief strategic family therapy HIV/HCV HIV Risk Reduction for men and women HIV/HCV interventions Women MI for pregnant women Trauma & substance use Stimulants Contingency management outpatient and methadone maintenance CTN Trials: Evidence based treatments, underserved populations

38. Empirically supported behavioral therapies ✔ Demonstrated efficacy across types of drug use and co-occurring problems ✔ Reliably improve retention ✔ Reliably promote meaningful, durable changes in drug use ✔ Reliably enhance compliance and outcome when used in combination with pharmacotherapy