1. What is drug addiction treatment?
There are many addictive drugs, and
treatments for specific drugs can differ.
Treatment also varies depending on the
characteristics of the patient.
Problems associated with an individual's
drug addiction can vary significantly.
People who are addicted to drugs come from
all walks of life. Many suffer from mental
health, occupational, health, or social
problems that make their addictive
disorders much more difficult to treat.
Even if there are few associated problems,
the severity of addiction itself ranges
widely among people.
A variety of scientifically based
approaches to drug addiction treatment
exists. Drug addiction treatment can
include behavioral therapy (such as
counseling, cognitive therapy, or
psychotherapy), medications, or their
combination. Behavioral therapies offer
people strategies for coping with their
drug cravings, teach them ways to avoid
drugs and prevent relapse, and help them
deal with relapse if it occurs. When a
person's drug-related behavior places him
or her at higher risk for AIDS or other
infectious diseases, behavioral therapies
can help to reduce the risk of disease
transmission. Case management and referral
to other medical, psychological, and
social services are crucial components of
treatment for many patients. (See
Treatment Section for more detail on types
of treatment and treatment components.)
The best programs provide a combination of
therapies and other services to meet the
needs of the individual patient, which are
shaped by such issues as age, race,
culture, sexual orientation, gender,
pregnancy, parenting, housing, and
employment, as well as physical and sexual
abuse.
Drug addiction treatment can include
behavioral therapy, medications, or their
combination.
Treatment medications, such as methadone,
LAAM, and naltrexone, are available for
individuals addicted to opiates. Nicotine
preparations (patches, gum, nasal spray)
and bupropion are available for
individuals addicted to nicotine.
Components of Comprehensive Drug Abuse
Treatment
[Click to Enlarge]
The best treatment programs provide a
combination of therapies and other
services to meet the needs of the
individual patient.
Medications, such as antidepressants, mood
stabilizers, or neuroleptics, may be
critical for treatment success when
patients have co-occurring mental
disorders, such as depression, anxiety
disorder, bipolar disorder, or psychosis.
Treatment can occur in a variety of
settings, in many different forms, and for
different lengths of time. Because drug
addiction is typically a chronic disorder
characterized by occasional relapses, a
short-term, one-time treatment often is
not sufficient. For many, treatment is a
long-term process that involves multiple
interventions and attempts at abstinence.
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2. Why can't drug addicts quit on their
own?
Nearly all addicted individuals believe in
the beginning that they can stop using
drugs on their own, and most try to stop
without treatment. However, most of these
attempts result in failure to achieve
long-term abstinence. Research has shown
that long-term drug use results in
significant changes in brain function that
persist long after the individual stops
using drugs. These drug-induced changes in
brain function may have many behavioral
consequences, including the compulsion to
use drugs despite adverse consequencesÑthe
defining characteristic of addiction.
Long-term drug use results in significant
changes in brain function that persist
long after the individual stops using
drugs.
Understanding that addiction has such an
important biological component may help
explain an individual's difficulty in
achieving and maintaining abstinence
without treatment. Psychological stress
from work or family problems, social cues
(such as meeting individuals from one's
drug-using past), or the environment (such
as encountering streets, objects, or even
smells associated with drug use) can
interact with biological factors to hinder
attainment of sustained abstinence and
make relapse more likely. Research studies
indicate that even the most severely
addicted individuals can participate
actively in treatment and that active
participation is essential to good
outcomes.
3. How effective is drug addiction
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 typically include levels of
criminal behavior, family functioning,
employability, and medical condition.
Overall, treatment of addiction is as
successful as treatment of other chronic
diseases, such as diabetes, hypertension,
and asthma.
Treatment of addiction is as successful as
treatment of other chronic diseases such
as diabetes, hypertension, and asthma.
According to several studies, drug
treatment reduces drug use by 40 to 60
percent and significantly decreases
criminal activity during and after
treatment. For example, a study of
therapeutic community treatment for drug
offenders (See Treatment Section)
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. Treatment
can improve the prospects for employment,
with gains of up to 40 percent after
treatment.
Although these effectiveness rates hold in
general, individual treatment outcomes
depend on the extent and nature of the
patient's presenting problems, the
appropriateness of the treatment
components and related services used to
address those problems, and the degree of
active engagement of the patient in the
treatment process.
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4. How long does drug addiction treatment
usually last?
Individuals progress through drug
addiction treatment at various speeds, so
there is no predetermined length of
treatment. However, research has shown
unequivocally that good outcomes are
contingent on adequate lengths of
treatment. Generally, for 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.
Good outcomes are contingent on adequate
lengths of treatment.
Many people who enter treatment drop out
before receiving all the benefits that
treatment can provide. Successful outcomes
may require more than one treatment
experience. Many addicted individuals have
multiple episodes of treatment, often with
a cumulative impact.
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5. What helps people stay in treatment?
Since successful outcomes often depend
upon retaining the person long enough to
gain the full benefits of treatment,
strategies for keeping an individual in
the program are critical. Whether a
patient stays in treatment depends on
factors associated with both the
individual and the program. Individual
factors related to engagement and
retention include motivation to change
drug-using behavior, degree of support
from family and friends, and whether there
is pressure to stay in treatment from the
criminal justice system, child protection
services, employers, or the family. Within
the program, successful counselors are
able to establish a positive, therapeutic
relationship with the patient. The
counselor should ensure that a treatment
plan is established and followed so that
the individual knows what to expect during
treatment. Medical, psychiatric, and
social services should be available.
Whether a patient stays in treatment
depends on factors associated with both
the individual and the program.
Since some individual problems (such as
serious mental illness, severe cocaine or
crack use, and criminal involvement)
increase the likelihood of a patient
dropping out, intensive treatment with a
range of components may be required to
retain patients who have these problems.
The provider then should ensure a
transition to continuing care or
"aftercare" following the patient's
completion of formal treatment.
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6. Is the use of medications like
methadone simply replacing one drug
addiction with another?
No. As used in maintenance treatment,
methadone and LAAM are not heroin
substitutes. They are safe and effective
medications for opiate addiction that are
administered by mouth in regular, fixed
doses. Their pharmacological effects are
markedly different from those of heroin.
As used in maintenance treatment,
methadone and LAAM are not heroin
substitutes.
Injected, snorted, or smoked heroin causes
an almost immediate "rush" or brief period
of euphoria that wears off very quickly,
terminating in a "crash." The individual
then experiences an intense craving to use
more heroin to stop the crash and
reinstate the euphoria. The cycle of
euphoria, crash, and craving - repeated
several times a day - leads to a cycle of
addiction and behavioral disruption. These
characteristics of heroin use result from
the drug's rapid onset of action and its
short duration of action in the brain. An
individual who uses heroin multiple times
per day subjects his or her brain and body
to marked, rapid fluctuations as the
opiate effects come and go. These
fluctuations can disrupt a number of
important bodily functions. Because heroin
is illegal, addicted persons often become
part of a volatile drug-using street
culture characterized by hustling and
crimes for profit.
Methadone and LAAM have far more gradual
onsets of action than heroin, and as a
result, patients stabilized on these
medications do not experience any rush. In
addition, both medications wear off much
more slowly than heroin, so there is no
sudden crash, and the brain and body are
not exposed to the marked fluctuations
seen with heroin use. Maintenance
treatment with methadone or LAAM markedly
reduces the desire for heroin. If an
individual maintained on adequate, regular
doses of methadone (once a day) or LAAM
(several times per week) tries to take
heroin, the euphoric effects of heroin
will be significantly blocked. According
to research, patients undergoing
maintenance treatment do not suffer the
medical abnormalities and behavioral
destabilization that rapid fluctuations in
drug levels cause in heroin addicts.
7. What Role Can The Criminal Justice
System Play In The Treatment Of Drug
Addiction?
Increasingly, research is demonstrating
that treatment for drug-addicted offenders
during and after incarceration can have a
significant beneficial effect upon future
drug use, criminal behavior, and social
functioning. The case for integrating drug
addiction treatment approaches with the
criminal justice system is compelling.
Combining prison- and community-based
treatment for drug-addicted offenders
reduces the risk of both recidivism to
drug-related criminal behavior and relapse
to drug use. For example, a recent study
found that prisoners who participated in a
therapeutic treatment program in the
Delaware State Prison and continued to
receive treatment in a work-release
program after prison were 70 percent less
likely than nonparticipants to return to
drug use and incur rearrest (See Treatment
Section).
Individuals Who Enter Treatment Under
Legal Pressure Have Outcomes As Favorable
As Those Who Enter Treatment Voluntarily.
The majority of offenders involved with
the criminal justice system are not in
prison but are under community
supervision. For those with known drug
problems, drug addiction treatment may be
recommended or mandated as a condition of
probation. Research has demonstrated that
individuals who enter treatment under
legal pressure have outcomes as favorable
as those who enter treatment voluntarily.
The criminal justice system refers drug
offenders into treatment through a variety
of mechanisms, such as diverting
nonviolent offenders to treatment,
stipulating treatment as a condition of
probation or pretrial release, and
convening specialized courts that handle
cases for offenses involving drugs. Drug
courts, another model, are dedicated to
drug offender cases. They mandate and
arrange for treatment as an alternative to
incarceration, actively monitor progress
in treatment, and arrange for other
services to drug-involved offenders.
The most effective models integrate
criminal justice and drug treatment
systems and services. Treatment and
criminal justice personnel work together
on plans and implementation of screening,
placement, testing, monitoring, and
supervision, as well as on the systematic
use of sanctions and rewards for drug
abusers in the criminal justice system.
Treatment for incarcerated drug abusers
must include continuing care, monitoring,
and supervision after release and during
parole.
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8. How does drug addiction treatment help
reduce the spread of HIV/AIDS and other
infectious diseases?
Many drug addicts, such as heroin or
cocaine addicts and particularly injection
drug users, are at increased risk for
HIV/AIDS as well as other infectious
diseases like hepatitis, tuberculosis, and
sexually transmitted infections. For these
individuals and the community at large,
drug addiction treatment is disease
prevention.
Drug Addiction Treatment Is Disease
Prevention.
Drug injectors who do not enter treatment
are up to six times more likely to become
infected with HIV than injectors who enter
and remain in treatment. Drug users who
enter and continue in treatment reduce
activities that can spread disease, such
as sharing injection equipment and
engaging in unprotected sexual activity.
Participation in treatment also presents
opportunities for screening, counseling,
and referral for additional services. The
best drug abuse treatment programs provide
HIV counseling and offer HIV testing to
their patients.
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9. Where Do 12-Step or Self-Help Programs
Fit Into Drug Addiction Treatment?
Self-help groups can complement and extend
the effects of professional treatment. The
most prominent self-help groups are those
affiliated with Alcoholics Anonymous (AA),
Narcotics Anonymous (NA), and Cocaine
Anonymous (CA), all of which are based on
the 12-step model, and Smart Recovery®.
Most drug addiction treatment programs
encourage patients to participate in a
self-help group during and after formal
treatment.
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10. How can families and friends make a
difference in the life of someone needing
treatment?
Family and friends can play critical roles
in motivating individuals with drug
problems to enter and stay in treatment.
Family therapy is important, especially
for adolescents (See Approaches to
Treatment Section). Involvement of a
family member in an individual's treatment
program can strengthen and extend the
benefits of the program.
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11. Is Drug Addiction Treatment Worth Its
Cost?
Drug addiction treatment is cost-effective
in reducing drug use and its associated
health and social costs. Treatment is less
expensive than alternatives, such as not
treating addicts or simply incarcerating
addicts. For example, the average cost for
1 full year of methadone maintenance
treatment is approximately $4,700 per
patient, whereas 1 full year of
imprisonment costs approximately $18,400
per person.
Drug Addiction Treatment Is cost-effective
in reducing drug use and its associated
health and social costs.
According to several conservative
estimates, 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. When savings related to health care
are included, total savings can exceed
costs by a ratio of 12 to 1. Major savings
to the individual and society also come
from significant drops in interpersonal
conflicts, improvements in workplace
productivity, and reductions in
drug-related accidents.
Drug Addiction Treatment in the United
States
Treatment for drug abuse and addiction is
delivered in many different settings,
using a variety of behavioral and
pharmacological approaches.
Drug addiction is a complex disorder that
can involve virtually every aspect of an
individual's functioningÑin the family, at
work, and in the community. Because of
addiction's complexity and pervasive
consequences, drug addiction treatment
typically must involve many components.
Some of those components focus directly on
the individual's drug use. Others, like
employment training, focus on restoring
the addicted individual to productive
membership in the family and society (see
Components of Comprehensive Drug Abuse
Treatment diagram).
Treatment for drug abuse and addiction is
delivered in many different settings,
using a variety of behavioral and
pharmacological approaches. In the United
States, more than 11,000 specialized drug
treatment facilities provide
rehabilitation, counseling, behavioral
therapy, medication, case management, and
other types of services to persons with
drug use disorders.
Because drug abuse and addiction are major
public health problems, a large portion of
drug treatment is funded by local, State,
and Federal governments. Private and
employer-subsidized health plans also may
provide coverage for treatment of drug
addiction and its medical consequences.
Drug abuse and addiction are treated in
specialized treatment facilities and
mental health clinics by a variety of
providers, including certified drug abuse
counselors, physicians, psychologists,
nurses, and social workers. Treatment is
delivered in outpatient, inpatient, and
residential settings. Although specific
treatment approaches often are associated
with particular treatment settings, a
variety of therapeutic interventions or
services can be included in any given
setting.
General Categories of Treatment Programs
Research studies on drug addiction
treatment have typically classified
treatment programs into several general
types or modalities, which are described
in the following text. Treatment
approaches and individual programs
continue to evolve, and many programs in
existence today do not fit neatly into
traditional drug addiction treatment
classifications. Examples of specific
research-based treatment components are
described in the Approaches to Treatment
Section.
General Categories of Treatment Programs
Agonist Maintenance Treatment for opiate
addicts usually is conducted in outpatient
settings, often called methadone treatment
programs. These programs use a long-acting
synthetic opiate medication, usually
methadone or LAAM, administered orally for
a sustained period at a dosage sufficient
to prevent opiate withdrawal, block the
effects of illicit opiate use, and
decrease opiate craving. Patients
stabilized on adequate, sustained dosages
of methadone or LAAM can function
normally. They can hold jobs, avoid the
crime and violence of the street culture,
and reduce their exposure to HIV by
stopping or decreasing injection drug use
and drug-related high-risk sexual
behavior.
Patients stabilized on opiate agonists can
engage more readily in counseling and
other behavioral interventions essential
to recovery and rehabilitation. The best,
most effective opiate agonist maintenance
programs include individual and/or group
counseling, as well as provision of, or
referral to, other needed medical,
psychological, and social services.
Patients stabilized on adequate sustained
dosages of methadone or LAAM can function
normally.
Further Reading:
Ball, J.C., and Ross, A. The Effectiveness
of Methadone Treatment. New York:
Springer-Verlag, 1991.
Cooper, J.R. Ineffective use of
psychoactive drugs; Methadone treatment is
no exception. JAMA Jan 8; 267(2): 281-282,
1992.
Dole, V.P.; Nyswander, M.; and Kreek, M.J.
Narcotic Blockade. Archives of Internal
Medicine 118: 304-309, 1996.
Lowinson, J.H.; Payte, J.T.; Joseph, H.;
Marion, I.J.; and Dole, V.P. Methadone
Maintenance. In: Lowinson, J.H.; Ruiz, P.;
Millman, R.B.; and Langrod, J.G., eds.
Substance Abuse: A Comprehensive Textbook.
Baltimore, MD, Lippincott, Williams &
Wilkins, 1996, pp. 405-414.
McLellan, A.T.; Arndt, I.O.; Metzger,
D.S.; Woody, G.E.; and O'Brien, C.P. The
effects of psychosocial services in
substance abuse treatment. JAMA Apr 21;
269(15): 1953-1959, 1993.
Novick, D.M.; Joseph, J.; Croxson, T.S.,
et al. Absence of antibody to human
immunodeficiency virus in long-term,
socially rehabilitated methadone
maintenance patients. Archives of Internal
Medicine Jan; 150(1): 97-99, 1990.
Simpson, D.D.; Joe, G.W.; and Bracy, S.A.
Six-year follow-up of opioid addicts after
admission to treatment. Archives of
General Psychiatry Nov; 39(11): 1318-1323,
1982.
Simpson, D.D. Treatment for drug abuse;
Follow-up outcomes and length of time
spent. Archives of General Psychiatry
38(
: 875-880, 1981.
Narcotic Antagonist Treatment Using
Naltrexone for opiate addicts usually is
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. The theory behind this
treatment is that the repeated lack of the
desired opiate effects, as well as the
perceived futility of using the opiate,
will gradually over time 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. Therefore, a favorable
treatment outcome requires that there also
be a positive therapeutic relationship,
effective counseling or therapy, and
careful monitoring of medication
compliance.
Patients stabilized on naltrexone can hold
jobs, avoid crime and violence, and reduce
their exposure to HIV.
Many experienced clinicians have found
naltrexone most useful for highly
motivated, recently detoxified patients
who desire total abstinence because of
external circumstances, including impaired
professionals, parolees, probationers, and
prisoners in work-release status. Patients
stabilized on naltrexone can function
normally. They can hold jobs, avoid the
crime and violence of the street culture,
and reduce their exposure to HIV by
stopping injection drug use and
drug-related high-risk sexual behavior.
Further Reading:
Cornish, J.W.; Metzger, D.; Woody, G.E.;
Wilson, D.; McLellan, A.T.; Vandergrift,
B.; and O'Brien, C.P. Naltrexone
pharmacotherapy for opioid dependent
federal probationers. Journal of Substance
Abuse Treatment 14(6): 529-534, 1997.
Greenstein, R.A.; Arndt, I.C.; McLellan,
A.T.; and O'Brien, C.P. Naltrexone: a
clinical perspective. Journal of Clinical
Psychiatry 45 (9 Part 2): 25-28, 1984.
Resnick, R.B.; Schuyten-Resnick, E.; and
Washton, A.M. Narcotic antagonists in the
treatment of opioid dependence: review and
commentary. Comprehensive Psychiatry
20(2): 116-125, 1979.
Resnick, R.B. and Washton, A.M. Clinical
outcome with naltrexone: predictor
variables and followup status in
detoxified heroin addicts. Annals of the
New York Academy of Sciences 311: 241-246,
1978.
Outpatient Drug-Free Treatment in the
types and intensity of services offered.
Such treatment costs less than residential
or inpatient treatment and often is more
suitable for individuals who are employed
or who have extensive social supports.
Low-intensity programs may offer little
more than drug education and admonition.
Other outpatient models, such as intensive
day treatment, can be comparable to
residential programs in services and
effectiveness, depending on the individual
patient's characteristics and needs. In
many outpatient programs, group counseling
is emphasized. Some outpatient programs
are designed to treat patients who have
medical or mental health problems in
addition to their drug disorder.
Further Reading:
Higgins, S.T.; Budney, A.J.; Bickel, W.K.;
Foerg, F.E.; Donham, R.; and Badger, G.J.
Incentives to improve outcome in
outpatient behavioral treatment of cocaine
dependence. Archives of General Psychiatry
51, 568-576, 1994.
Hubbard, R.L.; Craddock, S.G.; Flynn,
P.M.; Anderson, J.; and Etheridge, R.M.
Overview of 1-year follow-up outcomes in
the Drug Abuse Treatment Outcome Study
(DATOS). Psychology of Addictive Behaviors
11(4): 291-298, 1998.
Institute of Medicine. Treating Drug
Problems. Washington, D.C.: National
Academy Press, 1990.
McLellan, A.T.; Grisson, G.; Durell, J.;
Alterman, A.I.; Brill, P.; and O'Brien,
C.P. Substance abuse treatment in the
private setting: Are some programs more
effective than others? Journal of
Substance Abuse Treatment 10, 243-254,
1993.
Simpson, D.D. and Brown, B.S. Treatment
retention and follow-up outcomes in the
Drug Abuse Treatment Outcome Study
(DATOS). Psychology of Addictive Behaviors
11(4): 294-307, 1998.
Long-Term Residential Treatment 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.
TCs are residential programs with planned
lengths of stay of 6 to 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, and
treatment focuses on developing personal
accountability and responsibility and
socially productive lives. Treatment is
highly structured and can at times be
confrontational, with 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. Many TCs are quite comprehensive
and can include employment training and
other support services on site.
Therapeutic communities focus on the
"resocialization" of the individual and
use the program's entire "community" as
active components of treatment.
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 (see Treating
Criminal Justice-Involved Drug Abusers and
Addicts ).
Further Reading:
Leukefeld, C.; Pickens, R.; and Schuster,
C.R. Improving drug abuse treatment:
Recommendations for research and practice.
In: Pickens, R.W.; Luekefeld, C.G.; and
Schuster, C.R., eds. Improving Drug Abuse
Treatment, National Institute on Drug
Abuse Research Monograph Series, DHHS Pub
No. (ADM) 91-1754, U.S. Government
Printing Office, 1991.
Lewis, B.F.; McCusker, J.; Hindin, R.;
Frost, R.; and Garfield, F. Four
residential drug treatment programs:
Project IMPACT. In: Inciardi, J.A.; Tims,
F.M.; and Fletcher, B.W. eds. Innovative
Approaches in the Treatment of Drug Abuse.
Westport, CN: Greenwood Press, 1993, pp.
45-60.
Sacks, S.; Sacks, J.; DeLeon, G.;
Bernhardt, A.; and Staines, G. Modified
therapeutic community for mentally ill
chemical abusers: Background; influences;
program description; preliminary findings.
Substance Use and Misuse 32(9); 1217-1259,
1998.
Stevens, S.J., and Glider, P.J.
Therapeutic communities: Substance abuse
treatment for women. In: Tims, F.M.; De
Leon, G.; and Jainchill, N., eds.
Therapeutic Community: Advances in
Research and Application, National
Institute on Drug Abuse Research Monograph
144, NIH Pub. No. 94-3633, U.S. Government
Printing Office, 1994, pp. 162-180.
Stevens, S.; Arbiter, N.; and Glider, P.
Women residents: Expanding their role to
increase treatment effectiveness in
substance abuse programs. International
Journal of the Addictions 24(5): 425-434,
1989.
Short-Term Residential Programs provide
intensive but relatively brief residential
treatment based on a modified 12-step
approach. These programs were originally
designed to treat alcohol problems, but
during the cocaine epidemic of the
mid-1980's, many began to treat illicit
drug abuse and addiction. The original
residential treatment model consisted of a
3 to 6 week hospital-based inpatient
treatment phase followed by extended
outpatient therapy and participation in a
self-help group, such as Alcoholics
Anonymous. Reduced health care coverage
for substance abuse treatment has resulted
in a diminished number of these programs,
and the average length of stay under
managed care review is much shorter than
in early programs.
Further Reading:
Hubbard, R.L.; Craddock, S.G.; Flynn,
P.M.; Anderson, J.; and Etheridge, R.M.
Overview of 1-year follow-up outcomes in
the Drug Abuse Treatment Outcome Study
(DATOS). Psychology of Addictive Behaviors
11(4): 291-298, 1998.
Miller, M.M. Traditional approaches to the
treatment of addiction. In: Graham A.W.
and Schultz T.K., eds. Principles of
Addiction Medicine, 2nd ed. Washington,
D.C.: American Society of Addiction
Medicine, 1998.
Medical Detoxification is a process
whereby individuals are systematically
withdrawn from addicting drugs in an
inpatient or outpatient setting, typically
under the care of a physician.
Detoxification is sometimes called a
distinct treatment modality but is more
appropriately considered a precursor of
treatment, because it is designed to treat
the acute physiological effects of
stopping drug use. Medications are
available for detoxification from opiates,
nicotine, benzodiazepines, alcohol,
barbiturates, and other sedatives. In some
cases, particularly for the last three
types of drugs, detoxification may be a
medical necessity, and untreated
withdrawal may be medically dangerous or
even fatal.
Detoxification is a precursor of
treatment.
Detoxification is not designed to address
the psychological, social, and behavioral
problems associated with addiction and
therefore does not typically produce
lasting behavioral changes necessary for
recovery. Detoxification is most useful
when it incorporates formal processes of
assessment and referral to subsequent drug
addiction treatment.
Further Reading:
Kleber, H.D. Outpatient detoxification
from opiates. Primary Psychiatry 1: 42-52,
1996.
Treating Criminal Justice-Involved Drug
Abusers and Addicts
Research has shown that combining criminal
justice sanctions with drug treatment can
be effective in decreasing drug use and
related crime. Individuals under legal
coercion tend to stay in treatment for a
longer period of time and do as well as or
better than others not under legal
pressure. Often, drug abusers come into
contact with the criminal justice system
earlier than other health or social
systems, and intervention by the criminal
justice system to engage the individual in
treatment may help interrupt and shorten a
career of drug use. Treatment for the
criminal justice-involved drug abuser or
drug addict may be delivered prior to,
during, after, or in lieu of
incarceration.
Combining criminal justice sanctions with
drug treatment can be effective in
decreasing drug use and related crime.
Prison-Based Treatment Programs
Offenders with drug disorders may
encounter a number of treatment options
while incarcerated, including didactic
drug education classes, self-help
programs, and treatment based on
therapeutic community or residential
milieu therapy models. The TC model has
been studied extensively and can be quite
effective in reducing drug use and
recidivism to criminal behavior. Those in
treatment should be segregated from the
general prison population, so that the
"prison culture" does not overwhelm
progress toward recovery. As might be
expected, treatment gains can be lost if
inmates are returned to the general prison
population after treatment. Research shows
that relapse to drug use and recidivism to
crime are significantly lower if the drug
offender continues treatment after
returning to the community.
Community-Based Treatment for Criminal
Justice Populations
A number of criminal justice alternatives
to incarceration have been tried with
offenders who have drug disorders,
including limited diversion programs,
pretrial release conditional on entry into
treatment, and conditional probation with
sanctions. The drug court is a promising
approach. Drug courts mandate and arrange
for drug addiction treatment, actively
monitor progress in treatment, and arrange
for other services to drug-involved
offenders. Federal support for planning,
implementation, and enhancement of drug
courts is provided under the U.S.
Department of Justice Drug Courts Program
Office.
As a well-studied example, the Treatment
Accountability and Safer Communities
(TASC) program provides an alternative to
incarceration by addressing the multiple
needs of drug-addicted offenders in a
community-based setting. TASC programs
typically include counseling, medical
care, parenting instruction, family
counseling, school and job training, and
legal and employment services. The key
features of TASC include (1) coordination
of criminal justice and drug treatment;
(2) early identification, assessment, and
referral of drug-involved offenders; (3)
monitoring offenders through drug testing;
and (4) use of legal sanctions as
inducements to remain in treatment.
Further Reading:
Anglin, M.D. and Hser, Y. Treatment of
drug abuse. In: Tonry M. and Wilson J.Q.,
eds. Drugs and crime. Chicago: University
of Chicago Press, 1990, pp. 393-460.
Hiller, M.L.; Knight, K.; Broome, K.M.;
and Simpson, D.D. Compulsory
community-based substance abuse treatment
and the mentally ill criminal offender.
The Prison Journal 76(2), 180-191, 1996.
Hubbard, R.L.; Collins, J.J.; Rachal,
J.V.; and Cavanaugh, E.R. The criminal
justice client in drug abuse treatment. In
Leukefeld C.G. and Tims F.M., eds.
Compulsory treatment of drug abuse:
Research and clinical practice [NIDA
Research Monograph 86]. Washington, DC:
U.S. Government Printing Office, 1998.
Inciardi, J.A.; Martin, S.S.; Butzin,
C.A.; Hooper, R.M.; and Harrison, L.D. An
effective model of prison-based treatment
for drug-involved offenders. Journal of
Drug Issues 27 (2): 261-278, 1997.
Wexler, H.K. The success of therapeutic
communities for substance abusers in
American prisons. Journal of Psychoactive
Drugs 27(1): 57-66, 1997.
Wexler, H.K. Therapeutic communities in
American prisons. In Cullen, E.; Jones,
L.; and Woodward R., eds. Therapeutic
Communities in American Prisons. New York:
Wiley and Sons, 1997.
Wexler, H.K.; Falkin, G.P.; and Lipton,
D.S. (1990). Outcome evaluation of a
prison therapeutic community for substance
abuse treatment. Criminal Justice and
Behavior 17(1): 71-92, 1990.
Scientifically Based Approches to Drug
Addiction Treatment
This section presents several examples of
treatment approaches and components that
have been developed and tested for
efficacy through research supported by the
National Institute on Drug Abuse (NIDA).
Each approach is designed to address
certain aspects of drug addiction and its
consequences for the individual, family,
and society. The approaches are to be used
to supplement or enhanceÑnot
replaceÑexisting treatment programs.
This section is not a complete list of
efficacious, scientifically based
treatment approaches. Additional
approaches are under development as part
of NIDA's continuing support of treatment
research.
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Relapse Prevention, a cognitive-behavioral
therapy, was developed for the treatment
of problem drinking and adapted later for
cocaine addicts. Cognitive-behavioral
strategies are 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. Relapse
prevention encompasses several
cognitive-behavioral strategies that
facilitate abstinence as well as provide
help for people who experience relapse.
The relapse prevention approach to the
treatment of cocaine addiction consists of
a collection of strategies intended to
enhance self-control. Specific techniques
include exploring the positive and
negative consequences of continued use,
self-monitoring to recognize drug cravings
early on and to identify high-risk
situations for use, and developing
strategies for coping with and avoiding
high-risk situations and the desire to
use. A central element of this treatment
is anticipating the problems patients are
likely to meet and helping them develop
effective coping strategies.
Research indicates that the skills
individuals learn through relapse
prevention therapy remain after the
completion of treatment. In one study,
most people receiving this
cognitive-behavioral approach maintained
the gains they made in treatment
throughout the year following treatment.
References:
Carroll, K.; Rounsaville, B.; and Keller,
D. Relapse prevention strategies for the
treatment of cocaine abuse. American
Journal of Drug and Alcohol Abuse 17(3):
249-265, 1991.
Carroll, K.; Rounsaville, B.; Nich, C.;
Gordon, L.; Wirtz, P.; and Gawin, F.
One-year follow-up of psychotherapy and
pharmacotherapy for cocaine dependence:
delayed emergence of psychotherapy
effects. Archives of General Psychiatry
51: 989-997, 1994.
Marlatt, G. and Gordon, J.R., eds. Relapse
Prevention: Maintenance Strategies in the
Treatment of Addictive Behaviors. New
York: Guilford Press, 1985.
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The Matrix Model provides a framework for
engaging stimulant abusers in treatment
and helping them achieve abstinence.
Patients learn about issues critical to
addiction and relapse, receive direction
and support from a trained therapist,
become familiar with self-help programs,
and are monitored for drug use by urine
testing. The program includes education
for family members affected by the
addiction.
The therapist functions simultaneously as
teacher and coach, fostering a positive,
encouraging relationship with the patient
and using that relationship to reinforce
positive behavior change. The interaction
between the therapist and the patient is
realistic and direct but not
confrontational or parental. Therapists
are trained to conduct treatment sessions
in a way that promotes the patient's
self-esteem, dignity, and self-worth. A
positive relationship between patient and
therapist is a critical element for
patient retention.
Treatment materials draw heavily on other
tested treatment approaches. Thus, this
approach includes elements pertaining to
the areas of relapse prevention, family
and group therapies, drug education, and
self-help participation. Detailed
treatment manuals contain work sheets for
individual sessions; other components
include family educational groups, early
recovery skills groups, relapse prevention
groups, conjoint sessions, urine tests,
12-step programs, relapse analysis, and
social support groups.
A number of projects have demonstrated
that participants treated with the Matrix
model demonstrate statistically
significant reductions in drug and alcohol
use, improvements in psychological
indicators, and reduced risky sexual
behaviors associated with HIV
transmission. These reports, along with
evidence suggesting comparable treatment
response for methamphetamine users and
cocaine users and demonstrated efficacy in
enhancing naltrexone treatment of opiate
addicts, provide a body of empirical
support for the use of the model.
References:
Huber, A.; Ling, W.; Shoptaw, S.; Gulati,
V.; Brethen, P.; and Rawson, R.
Integrating treatments for methamphetamine
abuse: A psychosocial perspective. Journal
of Addictive Diseases 16: 41-50, 1997.
Rawson, R.; Shoptaw, S.; Obert, J.L.;
McCann, M.; Hasson, A.; Marinelli-Casey,
P.; Brethen, P.; and Ling, W. An intensive
outpatient approach for cocaine abuse: The
Matrix model. Journal of Substance Abuse
Treatment 12(2): 117-127, 1995.
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Supportive-Expressive Psychotherapy is a
time-limited, focused psychotherapy that
has been adapted for heroin- and
cocaine-addicted individuals. The therapy
has two main components:
Supportive techniques to help patients
feel comfortable in discussing their
personal experiences.
Expressive techniques to help patients
identify and work through interpersonal
relationship issues.
Special attention is paid to the role of
drugs in relation to problem feelings and
behaviors, and how problems may be solved
without recourse to drugs.
The efficacy of individual
supportive-expressive psychotherapy has
been tested with patients in methadone
maintenance treatment who had psychiatric
problems. In a comparison with patients
receiving only drug counseling, both
groups fared similarly with regard to
opiate use, but the supportive-expressive
psychotherapy group had lower cocaine use
and required less methadone. Also, the
patients who received
supportive-expressive psychotherapy
main-tained many of the gains they had
made. In an earlier study,
supportive-expressive psychotherapy, when
added to drug counseling, improved
outcomes for opiate addicts in metha-done
treatment with moderately severe
psychiatric problems.
References:
Luborsky, L. Principles of Psychoanalytic
Psychotherapy: A Manual for
Supportive-Expressive (SE) Treatment. New
York: Basic Books, 1984.
Woody, G.E.; McLellan, A.T.; Luborsky, L.;
and O'Brien, C.P. Psychotherapy in
community methadone programs: a validation
study. American Journal of Psychiatry
152(9): 1302-1308, 1995.
Woody, G.E.; McLellan, A.T.; Luborsky, L.;
and O'Brien, C.P. Twelve month follow-up
of psychotherapy for opiate dependence.
American Journal of Psychiatry 144:
590-596, 1987.
Individualized Drug Counseling focuses
directly on reducing or stopping the
addict's illicit drug use. It also
addresses related areas of impaired
functioningÑsuch as employment status,
illegal activity, family/social
relationsÑas well as the content and
structure of the patient's recovery
program. Through its emphasis on
short-term behavioral goals,
individualized drug counseling helps the
patient develop coping strategies and
tools for abstaining from drug use and
then maintaining abstinence. The addiction
counselor encourages 12-step participation
and makes referrals for needed
supplemental medical, psychiatric,
employment, and other services.
Individuals are encouraged to attend
sessions one or two times per week.
In a study that compared opiate addicts
receiving only methadone to those
receiving methadone coupled with
counseling, individuals who received only
methadone showed minimal improvement in
reducing opiate use. The addition of
counseling produced significantly more
improvement. The addition of onsite
medical/psychiatric, employment, and
family services further improved
outcomes.
In another study with cocaine addicts,
individualized drug counseling, together
with group drug counseling, was quite
effective in reducing cocaine use. Thus,
it appears that this approach has great
utility with both heroin and cocaine
addicts in outpatient treatment.
References:
McLellan, A.T.; Arndt, I.; Metzger, D.S.;
Woody, G.E.; and O'Brien, C.P. The effects
of psychosocial services in substance
abuse treatment. Journal of the American
Medical Association 269(15): 1953-1959,
1993.
McLellan, A.T.; Woody, G.E.; Luborsky, L.;
and O'Brien, C.P. Is the counselor an
'active ingredient' in substance abuse
treatment? Journal of Nervous and Mental
Disease 176: 423-430, 1988.
Woody, G.E.; Luborsky, L.; McLellan, A.T.;
O'Brien, C.P.; Beck, A.T.; Blaine, J.;
Herman, I.; and Hole, A. Psychotherapy for
opiate addicts: Does it help? Archives of
General Psychiatry 40: 639-645, 1983.
Crits-Cristoph, P.; Siqueland, L.; Blaine,
J.; Frank, A.; Luborsky, L.; Onken, L.S.;
Muenz, L.; Thase, M.E.; Weiss, R.D.;
Gastfriend, D.R.; Woody, G.; Barber, J.P.;
Butler, S.F.; Daley, D.; Bishop, S.;
Najavits, L.M.; Lis, J.; Mercer, D.;
Griffin, M.L.; Moras, K.; and Beck, A.
Psychosocial treatments for cocaine
dependence: Results of the NIDA Cocaine
Collaborative Study. Archives of General
Psychiatry (in press).
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Motivational Enhancement Therapy is a
client-centered counseling approach for
initiating behavior change by helping
clients to resolve ambivalence about
engaging in treatment and stopping drug
use. This approach employs strategies to
evoke rapid and internally motivated
change in the client, rather than guiding
the client stepwise through the recovery
process. This therapy consists of an
initial assessment battery session,
followed by two to four individual
treatment sessions with a therapist. The
first treatment session focuses on
providing feedback generated from the
initial 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. In subsequent sessions, the
therapist monitors change, reviews
cessation strategies being used, and
continues to encourage commitment to
change or sustained abstinence. Clients
are sometimes encouraged to bring a
significant other to sessions. This
approach has been used successfully with
alcoholics and with marijuana-dependent
individuals.
References:
Budney, A.J.; Kandel, D.B.; Cherek, D.R.;
Martin, B.R.; Stephens, R.S.; and Roffman,
R. College on problems of drug dependence
meeting, Puerto Rico (June 1996).
Marijuana use and dependence. Drug and
Alcohol Dependence 45: 1-11, 1997.
Miller, W.R. Motivational interviewing:
research, practice and puzzles. Addictive
Behaviors 61(6): 835-842, 1996.
Stephens, R.S.; Roffman, R.A.; and
Simpson, E.E. Treating adult marijuana
dependence: a test of the relapse
prevention model. Journal of Consulting
& Clinical Psychology, 62: 92-99,
1994.
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Behavioral Therapy for Adolescents
incorporates the principle that unwanted
behavior can be changed by clear
demonstration of the desired behavior and
consistent reward of incremental steps
toward achieving it. Therapeutic
activities include fulfilling specific
assignments, rehearsing desired behaviors,
and recording and reviewing progress, with
praise and privileges given for meeting
assigned goals. Urine samples are
collected regularly to monitor drug use.
The therapy aims to equip the patient to
gain three types of control:
Stimulus Control helps patients avoid
situations associated with drug use and
learn to spend more time in activities
incompatible with drug use.
Urge Control helps patients recognize and
change thoughts, feelings, and plans that
lead to drug use.
Social Control involves family members and
other people important in helping patients
avoid drugs. A parent or significant other
attends treatment sessions when possible
and assists with therapy assignments and
reinforcing desired behavior.
According to research studies, this
therapy helps adolescents become drug free
and increases their ability to remain drug
free after treatment ends. Adolescents
also show improvement in several other
areasÑemployment/school attendance, family
relationships, depression,
institutionalization, and alcohol use.
Such favorable results are attributed
largely to including family members in
therapy and rewarding drug abstinence as
verified by urinalysis.
References:
Azrin, N.H.; Acierno, R.; Kogan, E.;
Donahue, B.; Besalel, V.; and McMahon,
P.T. Follow-up results of supportive
versus behavioral therapy for illicit drug
abuse. Behavioral Research & Therapy
34(1): 41-46, 1996.
Azrin, N.H.; McMahon, P.T.; Donahue, B.;
Besalel, V.; Lapinski, K.J.; Kogan, E.;
Acierno, R.; and Galloway, E. Behavioral
therapy for drug abuse: a controlled
treatment outcome study. Behavioral
Research & Therapy 32(
: 857-866, 1994.
Azrin, N.H.; Donohue, B.; Besalel, V.A.;
Kogan, E.S.; and Acierno, R. Youth drug
abuse treatment: A controlled outcome
study. Journal of Child & Adolescent
Substance Abuse 3(3): 1-16, 1994.
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Multidimensional Family Therapy (MDFT) for
Adolescents is an outpatient family-based
drug abuse treatment for teenagers. MDFT
views adolescent drug use in terms of a
network of influences (that is,
individual, family, peer, community) and
suggests that reducing unwanted behavior
and increasing desirable behavior occur in
multiple ways in different settings.
Treatment includes individual and family
sessions held in the clinic, in the home,
or with family members at the family
court, school, or other community
locations.
During individual sessions, the therapist
and adolescent work on important
developmental tasks, such as developing
decisionmaking, negotiation, and
problem-solving skills. Teenagers acquire
skills in communicating their thoughts and
feelings to deal better with life
stressors, and vocational skills. Parallel
sessions are held with family members.
Parents examine their particular parenting
style, learning to distinguish influence
from control and to have a positive and
developmentally appropriate influence on
their child.
References:
Diamond, G.S., and Liddle, H.A. Resolving
a therapeutic impasse between parents and
adolescents in Multi-dimensional Family
Therapy. Journal of Consulting and
Clinical Psychology 64(3): 481-488, 1996.
Schmidt, S.E.; Liddle, H.A.; and Dakof,
G.A. Effects of multidimensional family
therapy: Relationship of changes in
parenting practices to symptom reduction
in adolescent substance abuse. Journal of
Family Psychology 10(1): 1-16, 1996.
Multisystemic Therapy (MST) addresses the
factors associated with serious antisocial
behavior in children and adolescents who
abuse drugs. These factors include
characteristics of the adolescent (for
example, favorable attitudes toward drug
use), the family (poor discipline, family
conflict, parental drug abuse), peers
(positive attitudes toward drug use),
school (dropout, poor performance), and
neighborhood (criminal subculture). By
participating in intense treatment in
natural environments (homes, schools, and
neighborhood settings) most youths and
families complete a full course of
treatment. MST significantly reduces
adolescent drug use during treatment and
for at least 6 months after treatment.
Reduced numbers of incarcerations and
out-of-home placements of juveniles offset
the cost of providing this intensive
service and maintaining the clinicians'
low caseloads.
References:
Henggeler, S.W.; Pickrel, S.G.; Brondino,
M.J.; and Crouch, J.L. Eliminating
(almost) treatment dropout of substance
abusing or dependent delinquents through
home-based multisystemic therapy. American
Journal of Psychiatry 153: 427-428, 1996.
Henggeler, S.W.; Schoenwald, S.K.;
Borduin, C.M.; Rowland, M.D.; and
Cunningham, P. B. Multisystemic treatment
of antisocial behavior in children and
adolescents. New York: Guilford Press,
1998.
Schoenwald, S.K.; Ward, D.M.; Henggeler,
S.W.; Pickrel, S.G.; and Patel, H. MST
treatment of substance abusing or
dependent adolescent offenders: Costs of
reducing incarceration, inpatient, and
residential placement. Journal of Child
and Family Studies 5: 431-444, 1996.
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Combined Behavioral and Nicotine
Replacement Therapy for Nicotine Addiction
consists of two main components:
The transdermal nicotine patch or nicotine
gum reduces symptoms of withdrawal,
producing better initial abstinence.
The behavioral component concurrently
provides support and reinforcement of
coping skills, yielding better long-term
outcomes.
Through behavioral skills training,
patients learn to avoid high-risk
situations for smoking relapse early on
and later to plan strategies to cope with
such situations. Patients practice skills
in treatment, social, and work settings.
They learn other coping techniques, such
as cigarette refusal skills,
assertiveness, and time management. The
combined treatment is based on the
rationale that behavioral and
pharmacological treatments operate by
different yet complementary mechanisms
that produce potentially additive
effects.
References:
Fiore, M.C.; Kenford, S.L.; Jorenby, D.E.;
Wetter, D.W.; Smith, S.S.; and Baker, T.B.
Two studies of the clinical effectiveness
of the nicotine patch with different
counseling treatments. Chest 105: 524-533,
1994.
Hughes, J.R. Combined psychological and
nicotine gum treatment for smoking: a
critical review. Journal of Substance
Abuse 3: 337-350, 1991.
American Psychiatric Association: Practice
Guideline for the Treatment of Patients
with Nicotine Dependence. American
Psychiatric Association, 1996.
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Community Reinforcement Approach (CRA)
Plus Vouchers is an intensive 24-week
outpatient therapy for treatment of
cocaine addiction. The treatment goals are
twofold:
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. Those who also abuse
alcohol receive clinic-monitored
disulfiram (Antabuse) therapy. Patients
submit urine samples two or three times
each week and receive vouchers for
cocaine-negative samples. The value of the
vouchers increases with consecutive clean
samples. Patients may exchange vouchers
for retail goods that are consistent with
a cocaine-free lifestyle.
This approach facilitates patients'
engagement in treatment and systematically
aids them in gaining substantial periods
of cocaine abstinence. The approach has
been 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.
References:
Higgins, S.T.; Budney, A.J.; Bickel, H.K.;
Badger, G.; Foerg, F.; and Ogden, D.
Outpatient behavioral treatment for
cocaine dependence: one-year outcome.
Experimental & Clinical
Psychopharmacology 3(2): 205-212, 1995.
Higgins, S.T.; Budney, A.J.; Bickel, W.K.;
Foerg, F.; Donham, R.; and Badger, G.
Incentives improve outcome in outpatient
behavioral treatment of cocaine
dependence. Archives of General Psychiatry
51: 568-576, 1994.
Silverman, K.; Higgins, S.T.; Brooner,
R.K.; Montoya, I.D.; Cone, E.J.; Schuster,
C.R.; and Preston, K.L. Sustained cocaine
abstinence in methadone maintenance
patients through voucher-based
reinforcement therapy. Archives of General
Psychiatry 53: 409-415, 1996.
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Voucher-Based Reinforcement Therapy in
Methadone Maintenance Treatment helps
patients achieve and maintain abstinence
from illegal drugs by providing them with
a voucher each time they provide a
drug-free urine sample. The voucher has
monetary value and can be exchanged for
goods and services consistent with the
goals of treat-ment. Initially, the
voucher values are low, but their value
increases with the number of consecutive
drug-free urine specimens the individual
provides. Cocaine- or heroin-positive
urine specimens reset the value of the
vouchers to the initial low value. The
contingency of escalating incentives is
designed specifically to reinforce periods
of sustained drug abstinence.
Studies show that patients receiving
vouchers for drug-free urine samples
achieved significantly more weeks of
abstinence and significantly more weeks of
sustained abstinence than patients who
were given vouchers independent of
urinalysis results. In another study,
urinalyses positive for heroin decreased
significantly when the voucher program was
started and increased significantly when
the program was stopped.
References:
Silverman, K.; Higgins, S.; Brooner, R.;
Montoya, I.; Cone, E.; Schuster, C.; and
Preston, K. Sustained cocaine abstinence
in methadone maintenance patients through
voucher-based reinforcement therapy.
Archives of General Psychiatry 53:
409-415, 1996.
Silverman, K.; Wong, C.; Higgins, S.;
Brooner, R.; Montoya, I.; Contoreggi, C.;
Umbricht-Schneiter, A.; Schuster, C.; and
Preston, K. Increasing opiate abstinence
through voucher-based reinforcement
therapy. Drug and Alcohol Dependence 41:
157-165, 1996.
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Day Treatment With Abstinence
Contingencies and Vouchers was developed
to treat homeless crack addicts. For the
first 2 months, participants must spend
5.5 hours daily in the program, which
provides lunch and transportation to and
from shelters. Interventions include
individual assessment and goal setting,
individual and group counseling, multiple
psychoeducational groups (for example,
didactic groups on community resources,
housing, cocaine, and HIV/AIDS prevention;
establishing and reviewing personal
rehabilitation goals; relapse prevention;
weekend planning), and patient-governed
community meetings during which patients
review contract goals and provide support
and encouragement to each other.
Individual counseling occurs once a week,
and group therapy sessions are held three
times a week. After 2 months of day
treatment and at least 2 weeks of
abstinence, participants graduate to a
4-month work component that pays wages
that can be used to rent inexpensive,
drug-free housing. A voucher system also
rewards drug-free related social and
recreational activities.
This innovative day treatment was compared
with treatment consisting of twice-weekly
individual counseling and 12-step groups,
medical examinations and treatment, and
referral to community resources for
housing and vocational services.
Innovative day treatment followed by work
and housing dependent upon drug abstinence
had a more positive effect on alcohol use,
cocaine use, and days homeless.
References:
Milby, J.B.; Schumacher, J.E.; Raczynski,
J.M.; Caldwell, E.; Engle, M.; Michael,
M.; and Carr, J. Sufficient conditions for
effective treatment of substance abusing
homeless. Drug & Alcohol Dependence
43: 39-47, 1996.
Milby, J.B.; Schumacher, J.E.; McNamara,
C.; Wallace, D.; McGill, T.; Stange, D.;
and Michael, M. Abstinence contingent
housing enhances day treatment for
homeless cocaine abusers. National
Institute on Drug Abuse Research Monograph
Series 174, Problems of Drug Dependence:
Proceedings of the 58th Annual Scientific
Meeting. The College on Problems of Drug
Dependence, Inc., 1996.
