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Integrating Behavioral Therapies with Medications in the Treatment of Drug Dependence

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Integrating Behavioral Therapies with Medications in the Treatment of Drug Dependence National Institute on Drug Abuse RESEARCH MONOGRAPH SERIES Integrating Behavioral Therapies With Medications in the Treatment of Drug Dependence U.S. Department of Health and Human 1Services • 5Public Health Service0 • National Institutes of Health Integrating Behavioral Therapies With Medications in the Treatment of Drug Dependence Editors: Lisa Simon Onken, Ph.D. Jack D. Blaine, M.D. John J. Boren, Ph.D. NIDA Research Monograph 150 1995 U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Public Health Service National Institutes of Health National Institute on Drug Abuse 5600 Fishers Lane Rockville, MD 20857 ACKNOWLEDGMENT This monograph is based on the papers from a technical review on “Integrating Behavioral Therapies With Medications in the Treatment of Drug Dependence” held on June 11- 11, 1993. The review meeting was sponsored by the National Institute on Drug Abuse. COPYRIGHT STATUS The National Institute on Drug Abuse has obtained permission from the copyright holders to reproduce certain previously published material as noted in the text. Further reproduction of this copyrighted material is permitted only as part of a reprinting of the entire publication or chapter. For any other use, the copyright holder’s permission is required. All other material in this volume except quoted passages from copyrighted sources is in the public domain and may be used or reproduced without permission from the Institute or the authors. Citation of the source is appreciated. Opinions expressed in this volume are those of the authors and do not necessarily reflect the opinions or official policy of the National Institute on Drug Abuse or any other part of the U.S. Department of Health and Human Services. The U.S. Government does not endorse or favor any specific commercial product or company. Trade, proprietary, or company names appearing in this publication are used only because they are considered essential in the context of the studies reported herein. National Institute on Drug Abuse NIH Publication No. 95-3899 Printed 1995 NIDA Research Monographs are indexed in the Index Medicus. They are selectively included in the coverage of American Statistics Index, BioSciences Information Service, Chemical Abstracts, Current Contents, Psychological Abstracts, and Psychopharmacology Abstracts. Contents Medications and Behavioral Therapies: The Whole May Be Greater Than the Sum of the Parts . 1 Lisa Simon Onken, Jack D. Blaine, and John J. Boren Enhancing the Effectiveness of Methadone Using Psychotherapeutic Interventions.............................................. 5 Charles P. O’Brien, George E. Woody, and A. Thomas McLellan Integrating Psychotherapy and Pharmacotherapy for Cocaine Dependence: Results From a Randomized Clinical Trial . 19 Kathleen M. Carroll, Bruce J. Rounsaville, Charla Nich, Lynn Gordon, and Frank Gawin Can Psychotherapy Rescue Naltrexone Treatment of Opioid Addiction? . 37 Bruce J. Rounsaville Strategies To Maximize the Efficacy of Naltrexone for Alcohol Dependence . 53 Stephanie S. O‘Malley Disulfiram (Antabuse) Contracts in Treatment of Alcoholism . 65 Timothy J. O’Farrell, John P. Allen, and Raye Z. Litten Combining Behavioral Therapy and Pharmacotherapy for Smoking Cessation: An Update . 92 John R. Hughes Integrating Psychological and Pharmacological Treatment of Dually Diagnosed Patients . 110 Roger D. Weiss, Shelly F. Greenfield, and Lisa M. Najavits Combining Pharmacotherapy With Psychotherapy for Substance Abusers With Borderline Personality Disorder: Strategies for Enhancing Compliance. 129 Marsha M. Linehan iii Integration of Behavioral and Pharmacological Treatments for Panic Disorder: Implications for the Treatment of Substance Dependence . 143 Michael W. Otto, Murk H. Pollack, Susan G. Ball, and Jerrold F. Rosenbaum Some Methodological Comments . 167 Kenneth I. Howard Comments . 170 Stephen T. Higgins iv Medications and Behavioral Therapies: The Whole May Be Greater Than the Sum of the Parts Lisa Simon Onken, Jack D. Blaine, and John J. Boren It is no revelation that drug dependence is a complex problem with behavioral, cognitive, psychosocial, and biological dimensions and may be treated with behavioral therapy (including behavior therapy, psychotherapy, and counseling), and, where available, pharmacotherapy. Drug use can be reduced behaviorally with appropriate manipulation of reinforcements within the environment (Higgins et al. 1993). Continued improvements over time in drug use can be initiated by cognitive- behavioral psychotherapies to modify cognitions that perpetuate drug use (Carroll et al., submitted for publication), and a reduced likelihood of relapse has been engendered by specialized training approaches (Rohsenow et al., in press). Methadone, of course, has long been recognized as an effective pharmacotherapy to reduce opiate use, and its biological mechanism of action is well understood. Even though a complete understanding of drug dependence must address behavioral, psychosocial, cognitive, and biological issues, an effective treatment for an individual need not, in all cases, do so. Sometimes no treatment is necessary, as is evidenced by the veterans of Vietnam who tested positive for heroin while in Vietnam but showed no sign of addiction after returning home (Robins 1993). Many a baby boomer who experienced the drug culture of the late sixties and early seventies can attest to knowing more than a few seemingly addicted individuals who, without treatment, are now drug-free, upstanding members of the community. Where treatment is required, integrated behavioral and pharmacological treatment is not always possible, practical, or necessary. For example, except for opiate, alcohol, and nicotine dependence, no medications exist. When behavioral treatments are the only treatments available, of course, there is no integration to be done. Even where medications exist, many individuals will not take them, and some individuals may be able to conquer their drug dependence with behavioral interventions alone. Finally, there may be compelling reasons to administer medication in the 1 absence of any behavioral or psychosocial services. Although controversial, some have argued that in this era of AIDS, methadone alone may be preferable to no treatment at all for a subgroup of opiate- addicted individuals awaiting more comprehensive treatment or as an initial step in a harm reduction approach. So why a monograph on “Integrating Behavioral Therapies With Medications in the Treatment of Drug Dependence”? Two concepts drove this monograph and the technical review that led to this monograph. First, appropriate behavioral interventions can potentially interact effectively with medications, enhancing their effects. From the earliest days of methadone maintenance, Dole and Nyswander (1965) stressed the importance of combining psychosocial services with methadone, and there has been ample literature since then to support this point of view (Grabowski et al. 1993; McLellan et al. 1993; Stitzer et al. 1993). Similarly, behavioral interventions alone are sometimes insufficient to treat many drug abusers effectively, and it is believed that medications, whether for concomitant mental or physical disorders or for drug abuse per se, have a potential for improving the effect of behavioral treatments. One function of this monograph is to review the literature to date on combined behavioral and pharmacological treatments for drug dependence. The ultimate goal of this monograph is to shed light on the questions of when and how behavioral and pharmacological therapies for drug dependence can be integrated for optimal treatment outcome. The participants in the technical review who spawned this monograph included the scientific editors of this monograph and Drs. Kathleen Carroll, John Docherty, Stephen Higgins, Kenneth Howard, John Hughes, Marsha Linehan, Charles P. O’Brien, Timothy O’Farrell, Stephanie O’Malley, Michael Otto, Bruce Rounsaville, and Roger Weiss. The technical review was held on June 10 and 11, 1993, preceding the annual College on Problems of Drug Dependence meeting in Toronto. The thoughts expressed at this meeting follow. It is hoped the contributions to this monograph will stimulate innovative research on the integration of pharmacological and behavioral therapies. REFERENCES Carroll, K.M.; Rounsaville, B.J.; and Nich, C. “One Year Follow-Up of Psychotherapy and Pharmacotherapy for Cocaine Abuse: Evidence for Continued Improvement After Psychotherapy.” Manuscript submitted for publication. Dole, V.P., and Nyswander, M.E. A medical treatment for diacetylmorphine (heroin) addiction. JAMA 193:646-650, 1965. Grabowski, J.; Rhoades, H.; Elk, R.; Schmitz, J.; and Creson, D. Clinicwide and individualized behavioral interventions in drug dependence treatment. In: Onken, L.S.; Blaine, J.D.; and Boren, J.J., eds. Behavioral Treatments for Drug Abuse and Dependence. National Institute on Drug Abuse Research Monograph 137. DHHS Pub. No. (ADM)93-3684. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1993. Higgins, S.T.; Budney, A.J.; Bickel, W.K.; Hughes, J.R.; Foerg, F.; and Badger, G. Achieving cocaine abstinence with a behavioral approach. Am J Psychiatry 150:5, 1993. McLellan, A.T.; Amdt, I.O.; Metzger, D.S.; Woody, G.E.; and O’Brien, C.P. The effects of psychosocial services in substance abuse treatment. JAMA 269:1953-1959, 1993. Robins, L. Vietnam veterans’ rapid recovery from heroin addiction: A fluke or normal expectation. Addiction 88:1041-1054, 1993. Rohsenow, D.J.; Monti, P.M.; and Abrams, D.B. Psychosocial
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