Introduction to Empirically validated psychological therapies for drug dependence

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

About empirically validated psychological therapies for adults with substance use problems. There is not a corresponding topic in this part for psychopharmacologic treatment for substance dependence because psychopharmacology in these disorders is much more limited and may be substance class specific.

Psychopharmacologic approaches are covered with the specific disorders, while the psychological therapies, almost all of which fall into the broader psychological therapy categories, can extend across the classes of substances that are frequently misused. CBT, especially when accompanied by contingency management, is effective in cocaine and opioid dependence, while CBT alone is effective in cocaine and cannabis abuse. Contingency management with vouchers may also, by itself, be effective in cocaine and opioid abuse as well. Behavioral couples therapy appears to be effective in reducing opioid and cocaine use. Motivational interviewing appears effective in alcohol or cannabis misuse in adults. Other forms of psychological/psychosocial therapy may be effective for other types of substance misuse, but the empirical evidence is not as strong. Often these interventions are combined with some psychopharmacologic intervention that has been shown to reduce, in some instances, craving for the particular substance.

During the past 10–15 years, tremendous gains have been made in the development of effective psychological therapies for drug abuse and dependence for adults. An increasing number of well-conducted randomized controlled trials have shown the effectiveness of many psychological therapies in treating drug dependence. Whereas there are highly effective pharmacotherapies for some classes of drug dependence (e.g. opioids), treatment outcomes often dramatically improve with the addition of psychological therapies in areas such as patient motivation, medication compliance, self-efficacy, and overall reduced treatment cost. For other classes of drugs (e.g. cocaine) where pharmacological interventions do not yet exist, psychological approaches are the state-of-the-art treatments.

Today, many psychological approaches have been evaluated in rigorous controlled clinical trials. Treatment manuals and training materials are available, which facilitate the use of these psychological approaches by a wider variety of clinicians and within and across a multidisciplinary approach. Thus, the medical treatment of patients who are dependent on illicit drugs likely will be improved with a basic understanding of these therapies and their underlying principles.

Three issues deserve emphasis.

First, ‘‘talk’’ therapies remain the most common form of drug dependence treatment in the United States excluding treatment facilities that focus on detoxification or methadone maintenance services (Simpson et al., 1997).

Second, there tends to be limited interaction between clinical researchers and clinicians (Institute of Medicine, 1998). so that, on the one hand, psychological treatments found to be effective in clinical trials often are not incorporated into mainstream clinical practice, and, on the other hand, many widely utilized clinical treatments have not been subjected to randomized trials.

Third, for the majority of illicit drugs, no generally effective pharmacotherapies have been developed. Classes of drug use for which no effective pharmacotherapies yet exist include cocaine, amphetamines, methamphetamines, sedative/hypnotic/ anxiolytics, cannabis, phencyclidine (PCP), hallucinogens, club drugs (e.g. MDMA), and inhalants. Although strides have been made in discovering the physiological mechanisms of action for many of these illicit substances, behavioral approaches remain the only available treatment for most types of drug dependence (O’Brien, 1996).

Within the UK treatment context there has been a focus on two approaches to the treatment of problematic drug use that have resulted in different developments in relation to the use of psychological approaches within the drug treatment system.

First, UK statutory treatment providers have focused largely on the provision of pharmacological interventions to primary heroin-using clients. This pharmacological orientation has led to the position that treatment often equates to the provision of methadone for heroin-dependent clients, while clients who use other substances receive minimal interventions. It is rare in the UK for non-opioid using clients to be the focus of treatment provision, or indeed for non-opioid use in opioid using clients to be targeted. As poly-drug use grows and the numbers of clients who use other illicit drugs increases, the UK is addressing the need to implement more evidence based psychological interventions. However, at this time there is a paucity of provision of evidence-based psychological interventions within the drug treatment system as a whole.

The second approach to treatment that has influenced the provision of psychological interventions has been the focus on harm reduction as a primary intervention for opioid and non-opioid-using clients. Here harm reduction has often meant that clients receive psychoeducational interventions, with the focus being on changing risk-related behaviors rather than changing drug use per se.

References

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

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