Behavioral treatments

Although their results were encouraging, these studies demonstrated how difficult it is to treat cannabis dependence. Experience with treating tobacco dependence has revealed that a combination of various psychotherapeutic techniques and pharmacotherapies is more effective than either approach alone in producing and maintaining cessation. Thus, the use of medication during the cessation period may significantly improve quit rates and maintenance of abstinence. 

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The development of effective pharmacotherapy has lagged behind progress in understanding the reward mechanisms and chronic impairments underlying stimulant abuse. Pharmacological and behavioral treatment approaches that have been used for cocaine abuse have not been as widely tested for the treatment of amphetamine abuse, limiting what can be offered for treatment of this disorder. No treatment agents are approved by the FDA for treatment of cocaine or amphetamine dependence. 

With all of these pharmacotherapies, concurrent behavioral treatment is critical to retain the patient in treatment and maintain adherence to medication treatment. Contingency management programs in which patients receive vouchers that can be used to purchase pro-social goods and services are the most common reinforcer approaches used to initiate and maintain stimulant-free urine test results (Anker and Crowley 1982 Boudin 1972 Higgins et al. 1991, 1993, 1994). The major problem with these approaches has been maintaining abstinence after the reinforcers are withdrawn completely and devel-... 

Higgins ST, Budney AJ, Bickel WK, er al Incentives improve outcome in outpatient behavioral treatment of cocaine dependence. Arch Gen Psychiarry 51 568-576, 1994... 

A number of psychosocial treatments for alcohol and other substance use disorders exist and are widely used. In this chapter, we discuss six of these psychotherapies as they are applied to alcohol, cocaine, and opioid dependence brief interventions, motivational enhancement therapy, cognitive-behavioral therapy, behavioral treatments (including contingency management and community reinforcement approaches), behavioral marital therapy, and 12-step facilitation. We also describe studies that examined the efficacy of a medication in combination with one or more of the six psychotherapies. In the second section of the chapter, we highlight research that directly studied the interaction between psychosocial and pharmacological treatments. 

These studies suggest that behavioral treatment strategies, such as CRA and CM, can be effective alone and as adjuncts to pharmacotherapy. Whether the emphasis is on abstinence, treatment retention, or medication compliance, the results of studies on behavioral approaches are promising. 

Azrin NH, Sisson RW, Meyers R, et al Alcoholism treatment by disulfiram and community reinforcement therapy. J Behav Ther Exp Psy 13 105-112, 1982 Bickel WK, Amass L, Higgins ST, et al Effects of adding behavioral treatment to opioid detoxification with buprenorphine. J Consult Clin Psychol 65 803—810, 1997 Bien TH, Miller WR, Tonigan JS Brief interventions for alcohol prohlems a review. Addiction 88 315-335, 1993... 

Behavioral treatment delivered by a variety of clinicians (e.g., physician, psychologist, nurse, pharmacist, and dentist) increases abstinence rates. The five As should be applied by all... 

Rose, J.E., Behm, F.M. Extinguishing the rewarding value of smoke cues pharmacological and behavioral treatments. Nicotine Tob. Res. 6 523, 2004. 

Several other clinically available pharmacological agents have been tested for their potential to facilitate smoking cessation, although they are not approved by the FDA for this purpose. For example, tricyclic antidepressants, which inhibit reuptake of noradrenaline and 5-HT, promote smoking cessation in conjunction with behavioral treatment in some individuals.107 However, these medications are limited because of their significant side effects. 5-HT-selective reuptake inhibitors (SSRIs) are believed to be a safer class of antidepressants but have not demonstrated effectiveness in smoking cessation.108... 

Linehan, M. M. (1993). Cognitive-behavioral treatment of Borderline Personality Disorder. New York Guilford Press. 

Hall SM, Tunstall CD, Ginsberg D, Benowitz NL, Jones RT (1987) Nicotine gum and behavioral treatment a placebo controlled trial. J Consult Clin Psychol 55 603-605 Harris LS (1988) Problems of drug dependence 1987. Proceedings of the 49th annual scientific meeting of the Committee on Problems of Drug Dependence, Philadelphia, June 1987. NIDA Research Monograph no. 81. US Department of Health and Human Services, Rockville, MD... 

Despite the overwhelming evidence for short-term effectiveness, only recently have studies begun to address long-term benefits of stimulant treatments. Prospective randomized controlled trials with durations of 12 to 24 months and doses up to 60 mg/day of MPH have been conducted to address this issue. The largest of these studies, the National Institute of Mental Health (NIMH)-sponsored Multimodal Treatment Study of Attention-Deficit Hyperactivity Disorder (MTA Study), showed that stimulants (either by themselves or in combination with behavioral treatments) lead to stable, long-term improvements in ADHD symptoms as long as the medication is taken (MTA Cooperative Group, 1999). 

Franklin, M.E., Kozak, M.J., Cashman, L.A., Coles, M.E., Rhein-gold, A.A., and Foa, E.B. (1998) Cognitive-behavioral treatment of pediatric obsessive-compulsive disorder an open clinical trial. / Am Acad Child Adolesc Psychiatry 37 412—419. 

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