Recommended Treatment Policies

Since many Americans are still in need of treatment for drug abuse problems, rational treatment policies need to be established on the basis of our current knowledge regarding the extent of the problem and what interventions work. Such policies should address the following issues (Kleber,

1. Available treatment needs to be expanded. Although there are approximately 6 million individuals in need of drug treatment, the current system can treat less than 2 million a year.

2. Patients need to have access to a wide variety of treatment modalities. Since no one treatment is suitable for all patients, a community with a diversity of treatment services can more likely offer appropriate interventions to its population.

3. For treatment improvement to occur, there must be more funds dedicated to research along with efficient dissemination of new technologies. Without new research, progress will not be achieved. Without training and education of staff regarding new research findings, treatment will not improve.

4. Pressure must be exerted to encourage drug-addicted individuals to enter treatment. As noted earlier, those who enter under pressure from the criminal justice system do as well as those entering voluntarily. The family, employer, or criminal justice system can all be instrumental in getting individuals to enter and remain in treatment. This pressure must be sustained since when it remits, the individual often drops out of treatment.

5. The treatment needs of special populations (e.g., prisoners, pregnant women, HIV-infected individuals) require greater attention. There are few programs designed to treat drug-addicted prisoners while they are incarcerated or newly released. For pregnant drug abusers to engage in treatment, programs need to be accessible, be affordable, include child care (for optimal results), and reflect a nonjudgmental view. For HIV-infected individuals, comprehensive medical care should be linked with the substance-abuse treatment, especially considering the rising incidence of tuberculosis in this group.

6. Rehabilitation and habilitation need to be integrated into substance-abuse treatment programs. Some drug-dependent individuals have the educational background or skills that allow them to gain employment once their drug problem has been treated. Others may require jobseeking skills, job training, or additional schooling prior to seeking employment. A goal of treatment needs to be integration into society, not simply cessation of drug use.

When examining the different modalities of treatment the question is not, ''Does treatment work?'' but rather, ''What works best for a particular individual?'' and ''What can be done to engage drug abusers in appropriate, well-organized treatment systems?'' If these issues are successfully addressed, treatment strategies can be designed for each patient and yet remain affordable. Millions spent on effective treatment will save billions spent elsewhere.

(See also: Abuse Liability of Drugs; Coerced Treatment for Substance Offenders; Comorbidity and Vulnerability; Research; Substance Abuse and AIDS; Treatment; Treatment in the Federal Prison System)


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Frances R. Levin Herbert D. Kleber Revised by Anne Davidson

Acupuncture The art of acupuncture is an ancient and integral part of the armamentarium used in China for the treatment of medical problems. Acupuncture consists of the insertion of very fine needles into the skin at specific points intended, according to traditional Chinese medicine, to influence specific body functions or body parts. In the traditional Chinese view of the body, life energy, (chi), circulates through pathways; blockage of the pathways leads to deficiency of chi, or disease. The goal of the traditional acupuncturist is to open up the pathways and stimulate the movement of chi. The specific points for needle insertion are based on traditional anatomy maps that depict which pathways affect which body functions.

Following President Richard M. Nixon's historic trip to China in 1972, considerable public interest in acupuncture was generated when the media observed that acupuncture was not only effective in relieving pain, but could also be a substitute for general anesthesia. The following year, Dr. H. L. Wen, a neurosurgeon in Hong Kong, reported a serendipitous observation that acupuncture with electrical stimulation (AES) eliminated withdrawal symptoms in a narcotics addict on whom he had intended to perform brain surgery to treat drug addiction. The discovery occurred the day before the scheduled surgery while Dr. Wen was demonstrating to the patient that AES could relieve pain. Fifteen minutes after the AES had begun, the patient reported a significant reduction of his drug withdrawal symptoms, which disappeared altogether thirty minutes after AES was started. Dr. Wen followed this patient, noting that AES had to be administered every eight hours for the first three days, and gradually the intervals could be increased. Within a week there were no further signs or symptoms of withdrawal. This led Dr. Wen to conduct a study of AES in 40 narcotics addicts experiencing withdrawal. All but one (who re-

The use of acupuncture in addiction treatment is popular, despite the absence of clear evidence that it is an effective treatment for opiate or cocaine dependence. (© Roger Ressmeyer/CORBIS)

quired medication for severe pain and was dropped from the study) were successfully detoxified. It is noteworthy that Dr. Wen's initial observations occurred prior to the discovery, in 1975, of endogenous opioid substances in the brain (also called endorphins).

In a later study, in 1977, Dr. Wen noted that AES increased endorphin levels and relieved abstinence syndromes while simultaneously inhibiting the autonomic nervous system, primarily the para-sympathetic nervous system. The findings by Dr. Wen and several other scientific groups that peripheral stimulation could release endogenous opi-oid substances in the central nervous system (CNS) gave scientific credibility to the possibility that this traditional Chinese therapy could help to deal with a contemporary problem. Chronic or repeated exposure to opioids leads to adaptive changes in the

CNS; withdrawal symptoms occur when these drugs are abruptly discontinued. Since the administration of opioid drugs alleviates withdrawal, it was reasonable to believe that one's own endogenous opioids might do the same.

During the mid-1970s, the use of acupuncture became popular in the United States, despite the absence of the kind of rigorous clinical investigation typically required for new pharmacological treatments. There were probably a number of factors that contributed to its popularity. Because it involved no pharmacological agents, it was seen as being more compatible with the approach espoused by Self-Help groups, ranging from Alcoholics

Anonymous (AA) to Therapeutic Communities.

Also, acupuncture did not initially require medical personnel, so it was relatively inexpensive compared to either psychotherapy or pharmacotherapy. In addition, its popularity increased at a time when some people objected to using Methadone for drug detoxification or for maintenance, on the grounds that such use made drug-dependent minority-group members dependent upon the medical establishment. A technique from a non-Western tradition seemed, therefore, to have special appeal for treatment programs that dealt predominantly with minorities.

One such program was the Division of Substance Abuse at Lincoln Hospital in the south Bronx, New York, under the leadership of Dr. Michael O. Smith. Smith was interested in alternatives to methadone for detoxification. Based on Wen's work, Smith first used electrical stimulation along with acupuncture, but he later discarded the use of electrical stimulation. Eventually, a standard protocol was developed which used four or five acupuncture points on each ear. By 1975, the use of acupuncture as a treatment for drug abuse was extended to alcohol patients, then later to cocaine and crack-cocaine patients.

In 1985 Smith founded the National Acupuncture Detoxification Association (NADA) at 3115 Broadway, #51, New York, New York 10027. By 1993, when the second international conference of NADA was held in Budapest, Hungary, there were participants from all over the world.

In the early 1990s, the use of acupuncture in addiction treatment had become popular with many people working in the criminal-justice system. Most of the funding for treatment programs using acupuncture at that time came initially from the criminal-justice system, rather than from the federal and state agencies that usually fund drug treatment programs. Although the scientific community had been unable to show the efficacy of acupuncture in properly controlled clinical studies, this relatively inexpensive and easily expanded procedure became the mainstay of a number of ''drug courts,'' where judges involved themselves directly in managing the treatment of drug offenders.

At many clinics in the United States, acupuncture treatment is now offered as part of a broad psychosocial program that has elements of self-help and Twelve-Step programs, plus traditional medicine and alternative medicine (some clinics, for example, use a ''sleep mix'' tea brewed from a variety of herbs).

As practiced in the United States, several technical procedures broadly described as acupuncture have been used. Standard bilateral acupuncture is the application of five needles to the concha and cartilage ridge of each ear at defined points (shen men, lung, sympathetic, kidney, and liver) determined from traditional Chinese anatomy maps. With unilateral acupuncture, the needles are applied to one ear. Acupressure involves applying pressure by hand or by an object to the same areas. Electroacupuncture applies low level electric current to needles placed at the traditional points. With moxibustion, herbs are burned near the needles to add heat; and with neuroelectric stimulation, low dose electrical current is passed through surface electrodes. Some practitioners advocate the use of surface electrodes and special currents, designating this approach neuroelectrical therapy (NET). There is no more evidence for the efficacy of added electrical current in the acupuncture treatment of drug and alcohol problems than there is for acupuncture itself.

Many acupuncture practitioners in the United States belong to and are accredited by the American Association of Acupuncture and Oriental Medicine (AAAOM), founded in 1981. Others may be accredited by the National Acupuncture and Oriental Medicine Alliance (NAOMA), founded in 1992, which accepts a broader range of training for purposes of certification than AAAOM.

In 1991, the National Institute on Drug Abuse (NIDA) sponsored a technical review of the current state of knowledge about the use of acupuncture in the treatment of alcoholism and other drug-dependence problems. One of the partici pants, Dr. George Ulett, noted that although there is some evidence that electrical stimulation through needles or electrodes placed at certain points on the body can release endogenous opioids and other neuropeptides in the central nervous system, there is little evidence that such release is caused by needles alone. He also asserted that the critical factor is the frequency characteristic of the current, not the specific placement site of needles or electrodes. This group of researchers concluded that part of the difficulty in deciding whether acupuncture is effective was the lack of standard terminology and standard methods. A number of procedures, all called acupuncture, were being applied to a variety of drug and alcohol problems, but in different ways, over varying periods of time, with results measured in differing ways. For example, different numbers of acupuncture needles could be used, at different sites, with or without electrical current. One study of acupuncture for alcohol detoxification, by Bullock and coworkers, which came closest to being scientifically valid, used appropriate controls (placement of needles in non-sites) and staff who were ''blinded'' as to which group was control and which was receiving acupuncture at specific body sites. This study found a far better outcome for patients in the specific body-site group than for controls—and that the difference persisted even when measured six months later. However, another research group using similar methodology could not replicate the findings and reported no difference between point-specific acupuncture, sham transdermal stimulation, or standard care (no acupuncture control).

Many practitioners who have used acupuncture, even those who are convinced of its efficacy, report that only a small proportion of people who start treatment actually complete the typical series of ten to twenty treatments. Those who have used the technique believe that the minimal amount of treatment required for benefit is at least one twenty-minute session per day of bilateral acupuncture for at least ten days. In general, among both opioid-dependent and cocaine-dependent patients, those with lighter habits seemed to fare best.

The NIDA technical review panel concluded that, at the time of the review (1991), there was no compelling evidence that acupuncture is an effective treatment for opiate or cocaine dependence. Nevertheless, they found no evidence that acupuncture is harmful.


Brumbaugh, A. G. (1993). Acupuncture: New perspectives in chemical dependency treatment. Journal of Substance Abuse Treatment, 10, 35-43.

McLellan, A. T., ETAL. (1993). Acupuncture treatment for drug abuse: A technical review. Journal of Substance Abuse Treatment, 10, 569-576.

Joyce H. Lowinson Jerome H. Jaffe

Approaches Based on Behavior Principles Behavioral treatments are based on a model of drug dependence wherein drug use is considered a learned behavior that is directly influenced by antecedent and consequent events associated with drug use. Within this framework, drug use is deemed the primary target of assessment and treatment. The treatments are generally directed toward a goal of complete abstinence from drug use when dealing with dependent individuals, but moderation is an acceptable goal when dealing with non-dependent individuals who engage in problematic use (e.g., drinking and driving). Many of the treatments also focus on the promotion of prosocial behaviors that are incompatible with continuing the lifestyle of a drug abuser.

Three well-known behavioral treatments are covered in this section (for more comprehensive reviews regarding behavioral treatments for alcohol dependence, illicit drug dependence, and nicotine dependence, see Hester & Miller, 1995; Stitzer & Higgins, 1995; U.S. Department of Health and Human Services, 1996, respectively). Each of these treatments has been demonstrated to be efficacious in controlled studies. Contingency management is another prominent behavioral treatment for drug dependence, but is covered in a separate section of this volume. Other important learning-based treatments, such as brief interventions, motivational interviewing, and relapse prevention therapy are covered in the Cognitive Behavioral Treatments section of this volume.

Behavioral Counseling/Skills Training. Behavioral counseling/skills training emphasizes environmental restructuring and the acquisition of specific skills deemed important to eliminating harmful drug use and avoiding relapse. Whether the treatment goal is abstinence or moderation of harmful use, patients learn how to identify environ mental, social and interpersonal antecedents and consequences of their drug use. For example, if drug use or problematic use is more likely when patients are in aparticular setting (e.g., bars) or the company of certain individuals (e.g., former high-school buddies), they are counseled to restructure their environment to avoid or minimize contact with those settings or people. Sometimes the goal might be to alter the setting in which the patient socializes with a particular individual (e.g., get together with a particular friend at a sporting event rather than a bar). Regarding consequences, the individual is counseled to make explicit the negative consequences of drug use and to identify healthy alternatives to the positive consequences derived from drug use and intoxication.

Patients often receive coping skills training in areas deemed important to discontinuing drug use and avoiding relapse. To combat the common problem of social pressure to use drugs, for example, patients are systematically instructed in drug-refusal skills through role-playing and other exercises. Other aspects of social skills training and problem solving are also commonly included in behavioral treatments for drug dependence (Monti et al., 1995). When moderation is the goal with problem drinkers, individuals are taught to monitor their drinking, set ingestion limits, and to use specific strategies to limit the amount consumed (e.g., do not drink alcoholic beverages to quench thirst, take small sips, alternate between alcoholic and nonalcoholic drinks) (Hester, 1995).

A relatively extensive scientific literature supports the efficacy of behavioral treatments for various forms of drug dependence and problematic use. For example, a series of clinical trials have demonstrated that social skills training is an efficacious adjunct treatment for alcohol dependence (Miller at al., 1995; Monti et al., 1995). Most of these studies have examined the effectiveness of social skills training as an adjunct to other treatments, and focused on assertiveness and related social skills. In a seminal study on this topic, for example, forty adults hospitalized for alcohol dependence were randomly assigned to either (1) an eight-session skills-training group focused on drinking-related problem-solving or (2) a control group in which similar topics were discussed but no specific training was provided. During a one-year follow-up period, the skills group compared to the control group reported an average of fourfold fewer drinks con sumed, sixfold fewer days drunk (eleven versus sixty-four days during the twelve-month follow-up), and a ninefold reduction in duration of drinking episodes (average of five days versus forty-four days).

Although the bulk of the evidence supporting the efficacy of social skills training and other coping skills training has been obtained with alco-holies and problem drinkers, evidence is also available supporting the efficacy of this approach with individuals who abuse or are dependent on illicit drugs like cocaine (Monti et al., 1997).

With regard to teaching non-dependent, problem drinkers to moderate their intake, a series of experimental studies reported over a ten-year period indicated that 20 to 70 percent of clinical samples can learn to drink moderately and that those effects can be sustained for up to two years (Hester, 1995).

Numerous reviews and meta-analyses support the efficacy of behavioral treatments for cessation of cigarette smoking (U.S. Department of Health and Human Services, 1996). The proportion of patients who successfully quit smoking at six- or twelve-month follow-ups generally increases as the intensity of the intervention increases, with 20 percent abstinence rates being common and 40 percent being reported in some early studies with intensive behavioral treatments. Combining behavioral therapy with pharmacological treatments (e.g., nicotine gum or patch) generally increases quit rates above either intervention alone (Hughes, 1995).

Behavioral Marital Therapy. Evidence from studies with alcohol-dependent individuals (O'Farrell, 1995) and with individuals dependent on illicit drugs (Fals-Stewart et al., 1996) indicates that involving spouses who are not themselves drug abusers in treatment and providing them with behavioral marital therapy can improve the quality of the relationship and drug-use outcomes. The evidence is more robust regarding improvements in marital satisfaction than reductions in drug use, but both have been documented in controlled studies. The rationales for involving spouses in treatment is that they may engage in behavior that initiates or reinforces drug use; they can acquire skills that promote abstinence or moderation; and spouses are an important potential source of alternative reinforcement when drug use ceases. Two aspects of behavioral marital therapy particularly merit mention. First, couples receive training in positive communication skills (how to constructively negotiate for changes in each other's behavior that will improve the quality of the relationship. Second, when treatment involves disulfiram therapy for alcohol dependence, spouses are taught how to effectively monitor compliance with the medication regimen (Azrin et al., 1982).

Multimodal Treatments. Treatment packages are sometimes implemented that utilize most of the adjunct behavioral treatments noted above as components in a more comprehensive treatment effort, usually for severely dependent individuals. The Community Reinforcement Approach (CRA) is perhaps the best example of a multimodal-behav-ioral treatment. CRA includes various forms of social skills and problem-solving training, vocational counseling, marital therapy, social/recreational counseling, and socially monitored disulfiram therapy (see Meyers & Smith, 1995).

In the seminal study examining the efficacy of the CRA treatment for alcohol dependence, sixteen males who had been admitted to a state hospital for alcoholism were divided into matched pairs and randomly assigned to receive CRA plus standard hospital care or standard care alone (Hunt & Azrin, 1973). Following discharge from the hospital, CRA patients received a tapered schedule of counseling sessions across several months. During a six-month follow-up period, patients who received CRA reported approximately six- to fourteen-fold less time drinking, unemployed, away from their families, or institutionalized compared to control patients. Several of the CRA elements noted above were added in subsequent studies conducted by this same group of investigators as the treatment moved from being an adjunct to inpatient treatment to a standalone, comprehensive treatment that could be delivered in outpatient settings. Findings from these later studies were at least as impressive as in the seminal study (see Meyers & Smith, 1995). Other groups have effectively extended CRA to the treatment of opiate (Abbott et al., 1998; Bickel et al.,

1997) and cocaine dependence (Higgins et al., 1993, 2000). A contingency management element was added in the extension of CRA to the treatment of cocaine dependence (see Budney & Higgins,

1998) as well as one of the studies on opiate dependence (Bickel et al, 1997), and is discussed in the section of this volume on contingency management.


Abbott, P. J., Weller, S. B., Delaney, et al. (1998). Community reinforcement approach in the treatment of opiate addicts. American Journal of Drug and Alcohol Abuse, 24, 17-30.

Azrin, N. H., Sisson, R. W., Meyers, R., et al. (1982). Alcoholism treatment by disulfiram and community reinforcement therapy. Journal of Behavior Therapy & Experimental Psychiatry, 13, 105-112.

Bickel, W. K., Amass, L., Higgins, S. T., et al. (1997). Effects of adding behavioral treatment to opioid detoxification with buprenorphine. Journal of Consulting and Clinical Psychology, 65, 803-810.

Budney, A. J., & Higgins, S. T. (1998). The community reinforcement plus vouchers approach: Manual 2: National Institute on Drug Abuse therapy manuals for drug addiction. NIH publication # 98-4308. Rock-ville, MD: National Institute on Drug Abuse.

Fals-Stewart, W., Birchler, G. R., & O'Farrell (1996). Behavioral couples therapy for male substance abusing patients: Effects on relationship adjustment and drug-using behavior. Journal of Consulting and Clinical Psychology, 64, 959-972.

Hester, R. K., & Miller, W. R. (1995). Handbook of alcoholism treatment approaches: Effective alternatives, 2nd edition. Boston: Allyn and Bacon.

Hester, R. K. (1995). Behavioral self-control training. In R. K. Hester & W. R. Miller (Eds.) Handbook of alcoholism treatment approaches: Effective alternatives, 2nd edition, pp 148-159. Boston: Allyn and Bacon.

Higgins, S. T., Budney, A. J., Bickel, et al. (1993). Achieving cocaine abstinence with a behavioral approach. American Journal of Psychiatry, 150, 763769.

Higgins, S. T., Wong, C. J., Badger, et al. (2000). Contingent reinforcement increases cocaine abstinence during outpatient treatment and one year of follow-up. Journal of Consulting and Clinical Psychology, 68, 64-72.

HUGHES, J. R. (1995). Combining behavioral therapy and pharmacotherapy for smoking cessation: An update. In L.S. Onken, J.D. Blaine, & J.J. Boren (Eds.), Integrating behavioral therapies with medications in the treatment of drug dependence: NIDA Research Monograph 150, pp. 92-109. Rockville, MD: National institute on Drug Abuse. NIH Publication No. 95-3899.

Hunt, G. M., & Azrin, N. H. (1973). A community-reinforcement approach to alcoholism. Behavior Research and Therapy, 11, 91-104.

Meyers, R. J., & Smith, J. E. (1995). Clinical guide to alcohol treatment: the community reinforcement approach. New York: Guilford Press.

Miller, W. R., Brown, J. M., Simpson, et al. (1995). Coping and social skills training. In R.K. Hester & W.R. Miller (Eds.) Handbook of alcoholism treatment approaches: Effective alternatives, 2nd edition, pp 12-44. Boston: Allyn and Bacon.

Monti, P.M., Rohsenow, D. J., Colby, S. M., et al. (1995). Coping and social skills training. In R.K. Hester & W.R. Miller (Eds.) Handbook of alcoholism treatment approaches: Effective alternatives, 2nd edition, pp. 221-241. Boston: Allyn and Bacon.

Monti, P.M., Rohsenow, D. J., Michalec, E., et al. (1997). Brief coping skills treatment for cocaine abuse: substance use outcomes at three months. Addiction, 92, 1717-1728.

O'FARRELL, T. J. (1995). Marital and family therapy. In R. K. Hester & W. R. Miller (Eds.) Handbook ofalco-holism treatment approaches: Effective alternatives, 2nd edition, pp 195-220. Boston: Allyn and Bacon.

Stitzer, M. L. & Higgins, S. T. (1995). Behavioral treatment of drug and alcohol abuse. In F.E. Bloom & D.J. Kupfer (Eds.), Psychopharmacology: The fourth generation of progress (pp. 1807-1819). New York: Raven Press.

U. S. Department of Health and Human Services. Smoking cessation: Clinical practice guidelines. Washington, DC: US Department of Health and Human Services, 1996; Agency for Health Care Policy and Research, Research Publication No. 96-0692.

Stephen T. Higgins Alan J. Budney Sarah Heil

Aversion Therapy For many years, attempts have been made to condition alcoholics to dislike alcohol. For example, alcoholics are asked to taste or smell alcohol just before a preadministered drug makes them nauseated. Repeated pairing of alcohol and nausea results in a conditioned response—after a while, alcohol alone makes them nauseated. Thereafter, it is hoped, the smell or taste of alcohol will cause nausea and discourage drinking.

Instead of pairing alcohol with nausea, other therapists have associated it with pain, shocking patients just after they drink, or they have associated it with panic from not being able to breathe by giving them a drug that causes very brief respiratory paralysis. Others have trained patients to imagine unpleasant effects from drinking, hoping to set up a conditioned response without causing so much physical distress.

Does it work? Some degree of conditioning is usually established, but it is uncertain how long the conditioning lasts. The largest study that involved conditioning alcoholics was conducted many years ago in Seattle, Washington (Lemere & Voegtlin, 1940). More than 34,000 patients conditioned to feel nauseated when exposed to alcohol were studied ten to fifteen years after treatment. Sixty-six percent were abstinent, an impressive recovery rate compared to other treatments. The patients who did best had had booster sessions—that is, they had come back to the clinic after the initial treatment to repeat the conditioning procedure. Of those who attended booster sessions, 90 percent were abstinent. Based on this study, the nausea treatment for alcoholism would seem an outstanding success. Why hasn't it been universally accepted?

One reason is that the results can be attributed to factors other than the conditioning. The patients in the study were a special group. Generally, they were well educated, had jobs, and were well off financially. They may not have received the treatment otherwise, since the clinic where they were treated was private and expensive. Studies of alcoholics have often shown that certain subject characteristics are more predictive of successful treatment outcome than the type of treatment administered. These factors include job stability, living with a relative, absence of a criminal record, and living in a rural community. In the Seattle study there was no control group that did not receive conditioning therapy. It is possible that this select group of patients, many having characteristics that favor a good outcome, would have done as well without conditioning.

Furthermore, in conditioning treatments, motivation is important. Treatment is voluntary and involves acute physical discomfort; presumably few would consent to undergo the therapy if they were not strongly motivated to stop drinking. The Seattle study makes this point graphically clear. Those who came back for booster sessions did better than those who didn't, but another group did better still: those who wanted to come back but couldn't because they lived too far from the hospital. All of these people remained abstinent.

For many years, chemically induced aversive conditioning of alcoholics was virtually ignored in the literature. Then, in 1990, Smith and Frawley published an outcome study of patients who received aversion therapy as part of their inpatient treatment. From a randomly selected sample of 200 patients, 80 percent were located and interviewed by telephone. Between thirteen and twenty-five months had passed since their discharges from the hospital. The overall abstinence rate for the first twelve months was 71 percent; it was 65 percent for the total period.

Follow-up studies of alcoholism treatment rarely report abstinence rates this high. How should these be interpreted?

As in the original Seattle study, in the Smith and Frawley study, the patients, by and large, had good prognostic features. At the time of admission, more than 50 percent were married and had some college education. Nearly 80 percent were employed. They could afford a private hospital. In short, with characteristics that favor a good outcome, they might have done as well without conditioning. Moreover, the inpatient program involved more than aversive conditioning. It included many ingredients found in other treatment programs, including counseling, a family program and aftercare plan, and Alcoholics Anonymous.

One finding in this report was similar to that of the original study—booster sessions are important. One month and three months after discharge, the patients were asked to return for reinforcement treatments. Just as in the original studies, those who returned for the booster sessions had a particularly good outcome. In fact, the most powerful predictor of abstinence was the number of reinforcement treatments utilized by each patient. Those taking two reinforcement treatments had a twelve-month abstinence rate of 70 percent; those who took only one had a 44 percent rate; and those who had no reinforcement had only a 27 percent rate. Seven percent took more than two reinforcement treatments and had a phenomenal twelvemonth abstinence rate of 92 percent.

The importance of reinforcement sessions may reflect motivation on the part of the patient, actual Pavlovian conditioning, or both. The paper does not tell whether the patients developed a true conditioned response to alcohol at any time. Information about this would help separate nonspecific motivational factors from actual conditioning.

The study lacked a control group. This was remedied in a report (Smith, Frawley, & Polissar, 1991) that compared 249 alcoholic inpatients who received aversion therapy with patients from a national treatment registry who did not receive aversion therapy. The patients treated with aversion therapy had significantly higher abstinence rates at six and twelve months, suggesting that motivation and good prognostic features may not completely explain the success of this still rather unpopular treatment.

Frawley and Smith (1992) have also reported remarkably high abstinence rates from cocaine (current abstinence of at least six months, 68 percent) among a similar group of patients, with good prognostic features, treated with aversion therapy and follow-up at an average of fifteen months after treatment. Again there was no control group.

Aversion treatment for cigarette smoking has been studied by using appropriate controls. The technique involves encouraging the smoker to keep inhaling at rapid intervals over a period of five to ten minutes until he or she becomes sick, presumably because the nicotine levels exceed the smoker's tolerance levels. This approach has consistently produced higher levels of abstinence from smoking than have control groups.

(See also: Calcium Carbimide; Disulfiram)


Frawley, P. J., & Smith, J. W. (1992). One-year follow-up after multimodal inpatient treatment for cocaine and methamphetamine dependencies. Journal of Substance Abuse Treatment, 9, 271-286. LEMERE, F., & VOEGTLIN, W. L. (1940). Conditioned reflex therapy of alcoholic addiction: Specificity of conditioning against chronic alcoholism. California and Western Medicine, 53 (6), 1-4. Smith, J. W., & Frawley, P. J. (1990). Long-term abstinence from alcohol in patients receiving aversion therapy as part of a multimodal inpatient program. Journal of Substance Abuse Treatment, 7, 77-82. Smith, J. W., Frawley, P. J., & Polisser (1991). Six-and twelve-month abstinence rates in inpatient alcoholics treated with aversion therapy compared with matched inpatients from a treatment registry. Alcohol: Clinical and Experimental Research .5, 862-870.

Donald W. Goodwin

Cognitive Therapy Cognitive treatment is based on the assumption that the way one thinks is a primary determinant of feelings and behavior. Developed from Beck's research (Beck et al., 1979, 1993), cognitive treatment is approached as a collaborative effort between the client and therapist to examine the client's errors and distortions in thinking that contribute to problematic behavior. This examination is fostered through a combination of verbal techniques and behavioral experiments to test the underlying assumptions the client holds about the problematic behavior.

Cognitive treatment in the substance-abuse field was a direct extension of Beck's work. Beck's catalog of distorted thoughts examined in depression were found to be applicable to cognitive distortions and errors that accompany addictive disorders. Various cognitive treatments for substance abuse focus on these distortions and vary primarily in the techniques used to change these thought processes.

In Relapse Prevention (Marlatt & Gordon, 1985), cognitive distortions are viewed as instrumental in the process that leads to relapse. By helping the client thoroughly examine the thoughts that accompany substance use, therapy can reduce the likelihood of a lapse (single use), as well as help prevent a lapse from becoming a relapse (return to uncontrolled use). This is accomplished by examining the following cognitive errors:

1. Overgeneralizing—this is one of the most frequently occurring cognitive errors that helps a single lapse become a full-blown relapse. By viewing the single use as a sign of total relapse, the client overgeneralizes the single use of a substance as a symptom of total failure, thereby allowing for increasing use over time and in a variety of situations. This is sometimes referred to as the Abstinence Violation Effect (AVE).

2. Selective abstraction—by excessively focusing on the immediate lapse, with an accompanying neglect of all past accomplishments and learning, the client interprets a single slip as equivalent to total failure. The individual measures progress almost exclusively in terms of errors and weaknesses.

3. Excessive responsibility—by attributing the cause of a lapse to personal, internal weaknesses or lack of willpower, the client assumes total responsibility for the slip, which in turn makes reassuming control more difficult than when environmental factors are considered partially responsible for the slip.

4. Assuming temporal causality—here, the client views a slip as the first of many to come, thereby dooming all future attempts at self-control.

5. Self-reference—when the client thinks that a lapse becomes the focus of everyone else's attention, believing that others will attribute blame for the event to the client, this adds to feelings of guilt and shame that may already be present within the person.

6. Catastrophizing—the client believes the worst possible outcome will occur from a single use of the substance instead of thinking about how to cope successfully with the initial lapse.

7. Dichotomous thinking—by viewing events in ''black and white,'' clients view their addictive behavior exclusively in terms of abstinence or relapse and leave no logical room for ''gray'' areas, where they can get back on track once a slip has occurred.

8. Absolute willpower breakdown—here, the client assumes that once willpower has failed, loss of control is inevitable, never to be regained.

9. Body over mind—the cognitive error here is assuming that once a single lapse has occurred, the physiological process of addiction has exclusive control over subsequent behavior, making continued use inevitable.

These errors in thinking are targeted for change in relapse prevention by helping the client learn how to reattribute the cause of a lapse from internal, stable, personal causes to mistakes or errors in the learning process. To facilitate the client's sense of personal control, lapses are viewed as opportunities for corrective learning, instead of indications of total failure. Congruent with the research in the area (Shiffman, 1991), the therapist presents a lapse as a frequently occurring event in the journey toward recovery. The therapist therefore encourages the client to examine the thoughts and expectancies that surround the lapse closely, with the aim of learning alternative coping skills for similar situations that may arise in the future. By re-framing a lapse as a learning opportunity, the client is encouraged to view the event as a chance to hone the skills required for abstinence, thereby countering the cognitive errors of selective abstraction.

To intervene with the errors of overgeneraliza-tion and temporal causality, the client is taught to view a lapse as a specific, unique event in time and space, instead of as a symptom with greater significance attached to it (e.g., the beginning of the inevitable end). The errors of self-reference and willpower breakdown can be countered by teaching the client to reattribute a lapse to external, specific, and controllable factors. By examining the difficulty of the high-risk situation, the appropriateness of the coping response employed, and any motivational deficits (fatigue or excessive stress), the client can maintain a sense of control over the event and the process of recovery.

Each of these techniques is aimed at conveying the idea that abstinence is the result of a learning process, requiring an acquisition of skills similar to many other skills one learns. This general metaphor can help the client reverse catastrophizing, by reframing a relapse as a ''prolapse,'' as a fall forward rather than backward. This view, combined with viewing a lapse as a unique event in time, helps the client maintain a sense of personal control, since abstinence or control is framed as just a moment away if use is discontinued.

Several skills are taught to the client in relapse prevention to facilitate these cognitive changes and prevent future lapses. Identifying specific sources of stress that contribute to urges, cravings, or lapses helps isolate the event in time as well as identify other distortions that may be present. For example, clients may identify discussing money with one's spouse as the high-risk situation that preceded a lapse. While discussing the lapse with a therapist, clients can learn to anticipate that discussing money in the marriage may trigger an urge or craving to drink. Teaching clients to use visual imagery, such as viewing the urge as a wave that they can surf, can help manage the feeling that urges will continue to build until they must inevitably be given in to. Self-talk is encouraged if a client believes this will help gain a sense of personal control (such as reciting a phrase to oneself about the goal of abstinence or remembering who can be telephoned when an urge is experienced). In addition, clients are taught to be alert for ''apparently irrelevant decisions,'' which can inadvertently lead to relapse. For example, an abstinent gambler may decide to take a scenic drive through Reno, only to find a situation that would be extremely difficult for many to ignore, thus in this case causing a relapse.

Other theorists have developed treatments based exclusively on changing irrational thinking. Ellis and colleagues (1988) founded a self-help group network called Rational Recovery (RR), based on the principles of rational emotive therapy. Developed as an alternative to the Alcoholics Anonymous network, RR focuses on ''addictive thinking'' and views abstinence as possible— purely as a result of changing these thought processes. This differs from the relapse prevention model described above, which in its entirety combines cognitive and behavioral techniques. Ellis's RR movement teaches addicts how to identify, their own faulty thinking through a self-help manual (Trimpey, 1989) and the attendance at support groups.

(See also: Alcoholism; Causes of Substance Abuse; Disease Concept of Alcoholism and Drug Abuse)


BECK, Aaron T. (1993). Cognitive therapy of substance abuse. New York: Guilford Press. Carroll, Kathleen M. (1998). A cognitive behavioral approach: Treating cocaine addiction. Therapy Manuals for Drug Addiction. U.S. Department of Health and Human Services: National Institute on Drug Abuse.

Liese, Bruce S. & BECK, Aaron T. (1997). Back to basics: Fundamental cognitive therapy skills for keeping drug-dependent individuals in treatment. In Lisa S. Onken, JackD. Blaine, & John J. Boren (Eds), Beyond the therapeutic alliance: Keeping the drug-dependent individual in treatment. NIDA Research Monograph 165, 207-232. U.S. Department of Health and Human Services: National Institute on Drug Abuse.

Molly Carney Revised by Rebecca Horn

Contingency Management Contingency management (CM) is an intervention that promotes behavior change by providing positive reinforcement when treatment goals are achieved and withholding reinforcement or providing punitive consequences when undesirable behavior occurs. CM has been used effectively in the treatment of a wide variety of forms of drug dependence, including amphetamine (Boudin, 1972), alcohol (Miller, 1975; Petry et al., 2000), cocaine (Higgins et al., 1993, 2000), marijuana (Budney at al., in press), nicotine (Donatelle et al., 2000), and opiates (Hall, et al., 1979; Bickel et al., 1997).

Contingency management involves an agreement or contract that carefully stipulates the desired behavior change, the schedule and methods for monitoring progress, the consequences that will follow success or failure in making the behavior change, and the duration of the contract. Practical details on the development and implementation of CM interventions can be found in several sources (Budney & Higgins, 1998; Higgins & Silverman, 1999; Petry, 2000)

The most common use of CM with drug-dependent individuals is to reinforce abstinence from drug use. Numerous studies have demonstrated that providing incentives contingent on objective evidence of abstinence from recent drug use (e.g., negative urinalysis results) increases future abstinence (see Higgins & Silverman, 1999; Stitzer & Higgins, 1995). Although compelling evidence regarding the efficacy of CM has been available since the 1970s, interest in this treatment approach was bolstered substantially by successes achieved with CM in the treatment of cocaine dependence. In a seminal study on that topic, thirty-eight cocaine-dependent adults were randomly assigned to twenty-four weeks of behavior therapy including CM or to drug abuse counseling (Higgins et al., 1993). In the CM condition, vouchers redeemable for retail items were earned by submitting specimens that tested negative for cocaine use in urine toxicology testing. More than 50 percent of patients in the CM condition remained in treatment for the recommended twenty-four weeks and achieved several months of continuous cocaine abstinence while only 11 percent of patients in the comparison condition did so. Subsequent studies of CM in the treatment of cocaine dependence replicated those findings and also demonstrated benefits during the year after treatment ended (Higgins et al., 2000; Silverman et al., 1996). These positive results with CM were particularly encouraging because so few other treatment approaches have been shown to be efficacious with cocaine dependence.

Most typically, but not always, CM is used as part of a more comprehensive treatment plan. In deed, CM can be used to improve compliance with other treatment regimens. Early studies with alcoholics, for example, demonstrated that CM could be used to improve medication compliance among individuals receiving disulfiram (Antabuse) therapy (Liebson et al., 1978). More recent studies have demonstrated CM's efficacy in improving medication compliance among tuberculosis-exposed and HIV-infected drug abusers (Elk, 1999; Rosen et al., 2000). CM can also improve compliance with participation in therapy-related activities among opiate-dependent patients (Bickel et al., 1997; Iguchi et al., 1997). In these applications, patients earned vouchers by completing some minimum number of therapy-related activities weekly. The activities might include attending a job interview if the goal was gaining employment, or attending a self-help meeting if the goal was to increase contact with a social network to support sobriety. Vouchers were provided when patients submitted documentation verifying that they had completed a designated therapeutic activity. Completion of therapeutic activities was associated with greater drug abstinence.

CM is also proving to be capable of improving outcomes with important special populations of drug abusers. Improving adherence to medication regimens among those with infectious diseases was noted above. Another special population is the seriously mentally ill who are also drug-dependent. Results from several preliminary studies indicate that CM may be effective in reducing cigarette smoking (Roll et al., 1998), cocaine use (Shaner et al., 1997), and marijuana use (Sigmon et al., in press) among individuals with schizophrenia. CM is an integral component of a multielement treatment that is efficacious in the treatment of homeless crack and other drug abusers (Milby et al., 2000). Another special group for whom effective treatments are sorely needed is drug-dependent pregnant women. A voucher-based CM intervention has been demonstrated to significantly increase abstinence from cocaine and heroin use while simultaneously increasing vocational skills among pregnant women who were both drug dependent and chronically unemployed (Silverman et al., in press). In another effective CM intervention with pregnant women, vouchers delivered contingent on abstinence from cigarette smoking increased cessation rates during pregnancy and postpartum (Do-natelle et al., 2000).

As illustrated in the preceding material, CM is effective in increasing drug abstinence and in improving compliance with treatment regimens for various types of drug dependence and populations. Positive outcomes have been achieved even with some of the most challenging and recalcitrant subgroups of drug abusers. A notable shortcoming associated with CM is a loss of treatment gains when the intervention is terminated. As noted above, beneficial carryover effects have been demonstrated through a year or more posttreatment, and the rates of relapse appear to be comparable to those observed among individuals treated with other interventions. Nevertheless, relapse is an important problem needing improvement. Systematic use of multimodel interventions designed to address the many changes likely to be necessary for longer-term success is one reasonable approach, as is the development of longer-term CM interventions that can be kept in place until the patient gains the requisite skills to sustain abstinence without CM support.


Bickel, W. K., et al. (1997). Effects of adding behavioral treatment to opioid detoxification with buprenorphine. Journal of Consulting and Clinical Psychology, 65, 803-810. BOUDIN, H. M. (1972). Contingency contracting as a therapeutic tool in the reduction of amphetamine use. Behavior Therapy, 14, 378-381. Budney, A. J., & Higgins, S. T. (1998). The community reinforcement plus vouchers approach: Manual 2: National Institute on Drug Abuse therapy manuals for drug addiction. NIH publication # 98-4308. Rock-ville, MD: National Institute on Drug Abuse. Budney, A. J., ET AL. (in press). Adding voucher-based incentives to coping skills and motivational enhancement improves outcomes during treatment for marijuana dependence. Journal of Consulting and Clinical Psychology.

DONATELLE, R. J., ETAL. (2000). Randomized controlled trial using social support and financial incentives for high-risk pregnant smokers: The Significant-Other Supporter (SOS) Program. Tobacco Control, 9, iii67-iii69.

Elk, R. (1999). Pregnant women and tuberculosis-exposed drug abusers: Reducing drug use and increasing treatment compliance. In S.T. Higgins & K. Silverman (Eds.), Motivating behavior change among illicit-drug abusers: Research on contingency management interventions 123-144. Washington, DC: American Psychological Association.

HALL, S. M., ETAL. (1979). Contingency management and information feedback in outpatient heroin detoxification. Behavior Therapy, 10, 443-451.

Higgins, S. T., ET AL. (1993). Achieving cocaine abstinence with a behavioral approach. American Journal of Psychiatry, 150, 763-769.

Higgins, S. T., & Silverman, K. (1999). Motivating behavior change among illicit-drug abusers: Research on contingency management interventions. Washington, DC: American Psychological Association.

Higgins, S. T., ETAL. (2000). Contingent reinforcement increases cocaine abstinence during outpatient treatment and one year of follow-up. Journal of Consulting and Clinical Psychology, 68, 64-72.

iGUCHi, M. Y., ET AL. (1997). Reinforcing operants other than abstinence in drug abuse treatment: An effective alternative for reducing drug use. Journal ofConsult-ing and Clinical Psychology, 65, 421-428.

Liebson, i. A., Tommasello, A., & Bigelow, G. E. (1978). A behavioral treatment of alcoholic methadone patients. Annals of Internal Medicine, 89, 342344.

Milby, J. B., ET AL. (2000). initiating abstinence in cocaine-abusing dually diagnosed homeless persons. Drug and Alcohol Dependence, 60, 55-67.

MiLLER, P. M. (1975). A behavioral intervention program for chronic drunkenness offenders. Archives of General Psychiatry, 32, 915-918.

Petry, N. M. (2000). A comprehensive guide to the application of contingency management procedures in clinical settings. Drug and Alcohol Dependence, 58, 9-25.

Petry, N. M., ET AL. (2000). Give them prizes and they will come: Contingency management treatment of alcohol dependence. Journal of Consulting and Clinical Psychology, 68, 250-257.

Roll, J. M., ET AL. (1998). Use of monetary reinforcement to reduce the cigarette smoking of persons with schizophrenia: A feasibility study. Experimental and Clinical Psychopharmacology, 6, 157-161.

Rosen, M. i., ET AL. (2000). Monetary reinforcement combined with structured training increases compliance to antiretroviral therapy. in L.S. Harris (Ed.), Problems of drug dependence, 1999: proceedings of the 61st annual scientific meeting, The College on Problems of Drug Dependence, Inc. NIDA Research Monograph 180. NiH publication # 00-4737. Bethesda, MD: National institute on Drug Abuse.

Shaner, A., ET AL. (1997). Monetary reinforcement of abstinence from cocaine among mentally ill patients with cocaine dependence. Psychiatric Services, 48, 807-810.

SIGMON, S. C., ET AL. (in press). Contingent reinforcement of marijuana abstinence among individuals with serious mental illness: A feasibility study. Experimental and Clinical Psychopharmacology.

Silverman, K., ET AL. (1996). Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy. Archives of General Psychiatry, 53, 409-415.

Silverman, K., ET AL. (in press). A reinforcement-based therapeutic workplace for the treatment of drug abuse: 6-month abstinence outcomes. Experimental and Clinical Psychopharmacology.

STITZER, M. L. & HIGGINS, S. T. (1995). Behavioral treatment of drug and alcohol abuse. In F.E. Bloom & D.J. Kupfer (Eds.), Psychopharmacology: The fourth generation of progress 1807-1819. New York: Raven Press.

Stephen T. Higgins Alan J. Budrey Sarah Heil

Group and Family Therapy The illnesses of drug addiction and alcoholism are so severe that they pervade every aspect of an individual's existence. It is rare that so extensive an illness can be reversed by individual therapy alone. Thus therapists are espousing an integration of individual, Twelve -step, group, and family treatment, with specific combinations of treatments tailored to each individual's needs.

Dealing with the family is one more involvement with the patient's ecosystem, which includes working with the treatment team, twelve-step groups, sponsors, employers, EAPs (Employee Assistance Program counselors), managed-care workers, parole officers, and other members of the legal system. However, family work is most critical to the success of treatment.

Group therapy has frequently been designated as the treatment of choice for addicted patients. This article views group therapy as an essential component of the integrated, individualized approach to addicts and alcoholics.


The family treatment of substance abuse begins with developing a system to achieve and maintain abstinence. This system, together with specific family therapeutic techniques and knowledge of patterns commonly seen in families with a substance-abusing member, provides a workable, therapeutic approach to substance abuse.

Family treatment of substance abuse must begin with an assessment of the extent of substance dependence as well as the difficulties it presents for the individual and the family. The quantification of substance-abuse history can take place with the entire family present; substance abusers often will be honest in this setting, and ''confession'' is a helpful way to begin communication. Moreover, other family members can often provide more accurate information than the substance abusers (also known as the identified patient, IP). However, some IPs will give an accurate history only when interviewed alone.

In taking a drug-abuse history, it is important to know current and past use of every type of abusable drug as well as of Alcohol: quantity, quality, duration, expense, how intake was supported and prevented, physical effects, tolerance, withdrawal, and medical complications. At times, other past and present substance abusers within the family are identified; their own use and its consequences should be quantified without putting the family on the defensive. It is also essential to document the family's patterns of reactivity to drug use and abuse. Previous attempts at abstinence and treatment are reviewed to determine components of success and failure. The specific method necessary to achieve abstinence can be decided only after the extent and nature of substance abuse are quantified.

Establishing a System to Achieve a Substance-Free State. It is critical first to establish a system for enabling the substance abuser to become drug-free, so that family therapy can be effective. The specific methods employed to achieve abstinence vary according to the extent of use, abuse, and dependence. Mild-to-moderate abuse in adolescents can often be controlled if both parents agree on clear limits and expectations, and how to enforce them. Older abusers may stop if they are aware of the medical or psychological consequences to themselves or the effects on their family.

If substance abuse is moderately severe or intermittent and without physical dependence, such as intermittent use of Hallucinogens or weekend Cocaine abuse, the family is offered a variety of measures, such as regular attendance at Alcoholics Anonymous (AA), Narcotics Anonymous (NA), or Cocaine Anonymous (CA) for the IP and Al-Anon or Naranon for family members.

If these methods fail, short-term hospitalization or treatment in an intensive outpatient program (20 hours or more per week) may be necessary to establish a substance-free state and to begin effective treatment even with nondependent patients. In more severe cases of drug abuse and dependence, more aggressive methods are necessary to establish a substance-free state.

Family Education. A substantial amount of family education is generally very helpful in the early stages of the family's involvement in therapy. In many inpatient addiction treatment programs, the family spends several days or more receiving appropriate education. If this is not available, the therapist should include this education process in early sessions.

Some of the issues covered by this educational emphasis are: (1) the physiological and psychological effects of drugs and alcohol; (2) the disease concept; (3) cross addiction (which helps families learn that a recovering cocaine addict should not drink or vice versa); (4) common family systems— emphasizing the family's roles in addiction and recovery, including enabling, scapegoating, and Codependency; (5) the phases of treatment, with an emphasis on the deceptiveness of the ''honeymoon'' period in early recovery; and (6) the importance of twelve-step family support groups (Al-anon, Alateen).

Working with Families with Continued Drug Abuse. The family therapist is in a unique position with regard to continued substance abuse and other manifestations of the IP's resistance to treatment, including total nonparticipation. The family therapist still has a workable and highly motivated patient(s): the family. One technique that can be used with an absent or highly resistant patient is the intervention, which was developed for use with alcoholics but can be readily adapted to work with drug abusers, particularly those who are middle class, involved with their nuclear families, and employed.

In this technique, the family (excluding the abuser) and significant network members (e.g., employer

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