Evidence-based cognitive-behavioral and behavioral treatments for drug dependence

Psychological therapies and opioid dependence

By: Tara M. Neavins, Caroline J. Easton, Janet Brotchie and Kathleen M. Carroll

Overview

The purpose of empirical validation of psychological therapies is to identify effective treatments that assist clinicians in delivering appropriate therapies (Chambless et al., 1996; Chambless et al., 1998). In general, this review focuses on interventions classified as ‘empirically validated’ or ‘likely to be efficacious’. To be considered empirically validated, it is necessary that a given treatment demonstrate efficacy in at least two randomized controlled trials (RCTs (McGovern & Carroll, 2003)). Included studies should be methodologically sound and incorporate features such as treatment manuals, random assignment to targeted and appropriate control and treatment conditions, and use validated measures. Moreover, a treatment’s efficacy should be confirmed by at least two independent investigation teams. In contrast, to be considered ‘probably efficacious’, a treatment’s efficacy must be confirmed by at least two positive randomized clinical trials with a waiting list control group, a small series of single case experiments, or one or more experiments meeting criteria for empirical validation but not by independent teams. Although this framework has generated considerable controversy, this model afforded a standard by which to compare treatments (McGovern & Carroll, 2003).

Behavioral therapies in the context of methadone maintenance

The development of methadone maintenance treatment revolutionized the treatment of opioid addiction by producing outcomes far surpassing those produced by the use of non-pharmacologic treatments (Carroll, 2000; Rounsaville & Carroll, 1997). Specifically, methadone maintenance treatment allowed addicts to remain in treatment and to reduce their illicit opioid use (Brill, 1977; Nyswander et al., 1958; O’Malley et al., 1972). In addition, methadone maintenance is associated with less risk of HIV infection and other medical complications by decreasing intravenous drug use (Ball et al., 1988; Metzger et al., 1993; Sorenson & Copeland, 2000).

Methadone maintenance, particularly when given at therapeutic doses and combined with drug counseling, substantially reduces illicit opioid use, injection drug use, criminal activity, and morbidity as well as mortality risk (Institute of Medicine, 1998). Another advantage to methadone maintenance is that by stabilizing patients and retaining them in treatment it creates an opportunity to address concurrent disorders, including medical problems, family issues, and psychiatric conditions (Lowinson et al., 1992).

Despite the enormous success of methadone maintenance treatments, several problems with this approach are evident. First, different methadone maintenance programs vary widely in their success rates, which may in part be attributed to variability in delivery of therapeutic dosing of methadone as well as variability in provision and quality of psychosocial services (Ball & Ross, 1991). Second, it is not uncommon for methadone maintenance clients to sell their take-home methadone doses or to use other substances, especially alcohol, benzodiazepines, and cocaine, while on methadone (Kosten & McCance, 1996).

Before describing specific behavioral therapies useful in enhancing the effectiveness of methadone maintenance treatment, a landmark study will first be summarized to clarify the importance of psychosocial treatments even within the framework of a pharmacotherapy as potent as methadone. In their 24-week trial, McLellan et al. (1993) randomly assigned 92 opiate-dependent individuals to one of three conditions:

(1) Methadone maintenance alone, without psychosocial services,

(2) Methadone maintenance with standard services, which included regular meetings with a counselor, and

(3) Enhanced methadone maintenance, which included regular counseling plus on-site medical, employment and family therapy services.

Although some patients did reasonably well in the methadone alone condition, 69% of this group had to be removed from this condition within the first 3 months of the study protocol as their substance use did not improve or had worsened, or they experienced significant medical or psychiatric difficulties which necessitated a higher level of care. With regard to substance use and psychosocial functioning, success rates were highest in the enhanced methadone maintenance condition followed by the standard methadone maintenance condition. Comparatively, individuals in the methadone alone condition fared most poorly. Thus, although basic methadone maintenance treatment aids in treatment retention and reduces continued illicit opioid abuse as well as associated illegal and dangerous behavior, a purely pharmacologic approach may not be sufficient for the vast majority of opioid addicts. Outcomes can be improved with higher levels of behavioral treatment (McLellan et al., 1993).

Contingency management approaches and opioid dependence

The effectiveness of decreasing opioid use via contingency management as an adjunct to methadone maintenance treatment has received wide empirical attention (Carroll, 2000; Rounsaville & Carroll, 1997). In these studies, patients who meet delineated target behaviors, such as providing drug-free urine specimens, attaining certain treatment goals, or attending treatment session, receive a reinforcer (reward). An example of an inexpensive, readily-available reinforcer is having methadone take-home privileges be conditional upon a demonstration of a decrease in drug use. Stitzer and her colleagues (1992, 1993) have devoted considerable attention to evaluating methadone take-home privileges as a reward for reduced illicit drug use. In a series of well-controlled trials, these investigators have documented several findings:

(1) The relative benefits of positive contingencies (e.g. rewarding desired behaviors such as abstinence) compared with negative contingencies (e.g. punishing undesired behaviors such as continued drug use through discharges or dose reductions; (Stitzer et al., 1986)),

(2) The desirability of take-home privileges over other incentives available within methadone maintenance clinics (Stitzer & Bigelow, 1978), and

(3) The relative effectiveness of rewarding drug-free urines compared with other target behaviors (Iguchi et al., 1996).

Drawing upon the compelling work of Higgins and colleagues (2000) (outlined in later discussion), Silverman and his colleagues (1996a) evaluated a voucher-based contingency management system to reduce concurrent illicit drug use (generally cocaine) among methadone maintained opioid addicts. This approach requires urine specimens thrice weekly in order to reliably detect drug use. Abstinence, verified through drug-free urine screens, is reinforced through a voucher system through which patients receive points redeemable for items consistent with an abstinence-based (drug-free) lifestyle. In other words, these vouchers are intended to help patients create alternate reinforcers to drug use (e.g. movie tickets, sporting events). Using this voucher system, Silverman and colleagues (Robles et al., 2002; Silverman et al., 1996a, 1996b, 1998, 2001) demonstrated less opioid and cocaine use amongst individuals participating in methadone maintenance treatment.

In a very elegant series of studies, Silverman and his colleagues (1996a, 1996b, 1998) built upon the voucher method. These investigators (Silverman et al., 2001) created the ‘therapeutic workplace’ in which methadone maintained study participants are paid to work in a job but only are allowed to work and get financial compensation on the days on which they provide drug-free urines. These jobs follow an initial employment training program during which time individuals’ participation in this orientation program is considered their job. Similar to their findings with their previous voucher system, their ‘therapeutic workplace’ treatment models resulted in less opioid and cocaine use as well as produced additional treatment benefits among methadone-maintained opioid addicts (Silverman et al., 2001; Wong et al., 2003, 2004).

Other psychological approaches and opioid dependence

Relatively few studies have evaluated the efficacy of formal psychotherapy in enhancing outcomes achieved by methadone maintenance treatment. Woody and colleagues (1983) randomly assigned 110 opiate addicts who were starting a methadone maintenance program to one of three conditions:

(1) Drug counseling alone,

(2) Drug counseling plus supportive-expressive psychotherapy (SE), or

(3) Drug counseling plus cognitive psychotherapy (CT).

After 6 months of treatment, there was little difference between the SE and CT groups on the majority of outcome measures. However, opiate addicts who received either of the two types of professional psychotherapy demonstrated greater strides in more outcome domains than opiate addicts who simply received drug counseling (Woody et al., 1983). In addition, treatment gains made by the subjects in the professional psychotherapy conditions were sustained over a 1-year follow-up. In contrast, treatment advances made by subjects in the drug counseling condition tended to dissipate over time (Woody et al., 1995). Furthermore, this study showed that methadone maintained opiate addicts with higher levels of psychopathology, as contrasted with those having lower levels of psychopathology, tended to improve only if they received professional psychotherapy. This finding indicates a differential response to psychotherapy based on patient characteristics, which may suggest the best use of psychotherapy (relative to drug counseling) when resources are scarce.

Behavioral couples therapy and opioid dependence

One form of psychotherapy that has received increasing empirical validation for individuals with opioid dependence is behavioral couples therapy (O’Farrell & FalsStewart, 2000). Behavioral couples therapy has several critical components. First, the patient develops a ‘sobriety contract’ such that the patient promises to their partner that the patient will not use drugs that day. The partner then reciprocates by indicating that they know the patient can succeed. Second, there is effort to ‘catch your partner doing something nice’ and offering compliments. Third, partners set up a ‘caring day’ for each other so that partners can take turns making the other one feel special. Fourth, ‘shared rewarding activities’ provide an opportunity for partners to engage in mutually satisfying endeavors, which are substance-free. Finally, time is devoted to ‘communication skills’ and relapse-prevention skills in order to best cope with daily stressors without returning to drug use.

The first randomized clinical trial to examine behavioral couples therapy was conducted with married (or co-habitating), male, substance treatment, outpatients who were struggling primarily with opioid or cocaine dependence (Fals-Stewart et al., 1996). These investigators randomly assigned 80 participants to:

(1) Behavioral couples therapy (BCT; one weekly couples session with their female partner and one weekly individual session) or
(2) Individual treatment (IT; two weekly individual sessions).

Although both groups similarly had few urine samples positive for substances during the 12-week comparison, men in the BCT condition self-reported significantly fewer days of using drugs, fewer drug-related consequences and greater lengths of abstinence than did men in the IT condition. These self-reported findings were noted through the 12-month follow-up assessment. In addition, men (and their female partners) had better couple functioning and were less apt to abuse each other than was true for men (and their female partners) assigned to the IT condition. These results have been replicated with female, substance-abusing, patients who have participated in BCT with their male, non-drug-abusing, male, partners (Winters et al., 2002). Furthermore, Fals-Stewart et al.
(1997) showed that BCT was a better value treatment economically than individual behavioral therapy. Fals-Stewart et al. (2001) randomly assigned 36 married (or co-habitating) men, who were beginning methadone maintenance (MM) treatment, to:

(1) Individual-based MM treatment (IBMM; two individual, weekly, counseling sessions in addition to methadone maintenance) or
(2) Behavioral couples therapy (BCT; a weekly couples session with female partner, a weekly individual session, and MM).

During treatment, men in the BCT condition produced fewer opioid- and cocaine-positive urine specimens than did men in the IBMM condition. In addition, the BCT condition was associated with greater relationship satisfaction during the study and better dyadic functioning at the end of the study. Finally, BCT participants noted fewer family and social problems post-treatment than did IBMM participants.

References

Peter Tyrer and Kenneth R. Silk, Cambridge Textbook of Effective Treatments in Psychiatry, Cambridge University Press 2008.

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