A novel cognitive-behavioral approach for treatment-resistant drug dependence

Evaluating comparative effectiveness of psychosocial interventions adjunctive to opioid agonist therapy for opioid use disorder: A systematic review with network meta-analyses

BACKGROUND

Guidelines recommend that individuals with opioid use disorder (OUD) receive pharmacological and psychosocial interventions; however, the most appropriate psychosocial intervention is not known. In collaboration with people with lived experience, clinicians, and policy makers, we sought to assess the relative benefits of psychosocial interventions as an adjunct to opioid agonist therapy (OAT) among persons with OUD.

METHODS

A review protocol was registered a priori (CRD42018090761), and a comprehensive search for randomized controlled trials (RCT) was conducted from database inception to June 2020 in MEDLINE, Embase, PsycINFO and the Cochrane Central Register of Controlled Trials. Established methods for study selection and data extraction were used. Primary outcomes were treatment retention and opioid use (measured by urinalysis for opioid use and opioid abstinence outcomes). Odds ratios were estimated using network meta-analyses (NMA) as appropriate based on available evidence, and in remaining cases alternative approaches to synthesis were used.

RESULTS

Seventy-two RCTs met the inclusion criteria. Risk of bias evaluations commonly identified study limitations and poor reporting with regard to methods used for allocation concealment and selective outcome reporting. Due to inconsistency in reporting of outcome measures, only 48 RCTs (20 unique interventions, 5,404 participants) were included for NMA of treatment retention, where statistically significant differences were found when psychosocial interventions were used as an adjunct to OAT as compared to OAT-only. The addition of rewards-based interventions such as contingency management (alone or with community reinforcement approach) to OAT was superior to OAT-only. Few statistically significant differences between psychosocial interventions were identified among any other pairwise comparisons. Heterogeneity in reporting formats precluded an NMA for opioid use. A structured synthesis was undertaken for the remaining outcomes which included opioid use (n = 18 studies) and opioid abstinence (n = 35 studies), where the majority of studies found no significant difference between OAT plus psychosocial interventions as compared to OAT-only.

CONCLUSIONS

This systematic review offers a comprehensive synthesis of the available evidence and the limitations of current trials of psychosocial interventions applied as an adjunct to OAT for OUD. Clinicians and health services may wish to consider integrating contingency management in addition to OAT for OUD in their settings to improve treatment retention. Aside from treatment retention, few differences were consistently found between psychosocial interventions adjunctive to OAT and OAT-only. There is a need for high-quality RCTs to establish more definitive conclusions.

TRIAL REGISTRATION

PROSPERO registration CRD42018090761.

Randomized Pilot of an Anxiety Sensitivity-Based Intervention for Individuals in a Substance Use Day Program

Anxiety sensitivity (AS), or the tendency to appraise physical symptoms as intolerable or dangerous, may maintain the cycle between co-occurring anxiety and substance use disorders. This study examined preliminary efficacy of a brief intervention targeting AS for individuals with heterogeneous substance use disorders. Forty-one patients with high AS entering an addictions day program were randomized to treatment as usual (TAU) or to TAU plus a nine-hour AS-focused intervention that consisted of interoceptive exposures, psychoeducation about the cycle of problematic substance use and anxiety, and a single session of cognitive challenging (e.g., reviewing common cognitive distortions and decatastrophizing anxiety symptoms). Mixed-effects intent-to-treat models suggested that participants in the AS condition showed greater decreases in AS at post-treatment, but this effect was lost at follow-up three months later. Intervention conditions did not differ in change in percent days abstinent or self-reported anxiety, with both conditions showing significant improvement at post-treatment. Results suggest that the nine-hour AS-focused intervention led to a short-term benefit over TAU alone, but this benefit was not sustained at three months' follow-up. Future AS interventions may need to target specific subconstructs of AS for selected populations, or target emotional distress tolerance more broadly.

Anxiety sensitivity and working memory capacity: Risk factors and targets for health behavior promotion

Understanding the nature and influence of specific risk profiles is increasingly important for health behavior promotion. The purpose of this article is to document the value of two factors-anxiety sensitivity (AS) and working memory capacity (WMC)-for enhancing risk for the initiation and/or maintenance of a range of negative health behaviors. AS is a distress-related risk factor that potentiates avoidance/coping motivations for negative health behaviors. Stress provides the conditions for negative somatic and affective states, and AS amplifies the aversiveness of these experiences and correspondingly hinders adaptive functioning. In contrast, low WMC is hypothesized to exert its effect by decreasing the capacity to filter out current temptations, attenuating a focus on longer-term goals and impairing the application of relevant coping skills at times of stress. In this review, we provide conceptual models for the separate roles of high AS and low WMC in negative health behaviors, review the influence of these factors on specific health behavior exemplars (eating behaviors/obesity, physical activity, smoking, alcohol use, and sleep promotion), provide preliminary evidence for their value as independent treatment targets for health-behavior promotion, and encourage specific research directions in relation to these variables.

A Cognitive Behavioral Therapy-Based Text Messaging Intervention Versus Medical Management for HIV-Infected Substance Users: Study Protocol for a Pilot Randomized Trial

Background

Evidence-based psychosocial interventions for addictions and related conditions such as cognitive behavioral therapy (CBT) are underutilized. Obstacles to implementation of CBT in clinical settings include limited availability of quality training, supervision, and certification in CBT for clinicians; high rates of clinician turnover and high caseloads; and limited qualifications of the workforce to facilitate CBT expertise.

Objective

Mobile phone–based delivery of CBT, if demonstrated to be feasible and effective, could be transformative in broadening its application and improving the quality of addiction treatment. No experimental interventions that deliver CBT targeting both drug use and medication adherence using text messaging have been previously reported; as such, the objective of this study is to develop and test an SMS-based treatment program for HIV-positive adults with comorbid substance use disorders.

Methods

With user input, we developed a 12-week CBT-based text messaging intervention (TXT-CBT) targeting antiretroviral (ART) adherence, risk behaviors, and drug use in a population of HIV-infected substance users.

Results

The intervention has been developed and is presently being tested in a pilot randomized clinical trial. Results will be reported later this year.

Conclusions

This investigation will yield valuable knowledge about the utility of a cost-effective, readily deployable text messaging behavioral intervention for HIV-infected drug users.

Distress Intolerance and Prescription Opioid Misuse Among Patients With Chronic Pain

The risk for misuse of opioid medications is a significant challenge in the management of chronic pain. The identification of those who may be at greater risk for misusing opioids is needed to facilitate closer monitoring of high-risk subgroups, and may help to identify therapeutic targets for mitigating this risk. The aim of this study was to examine whether distress intolerance-the perceived or actual inability to manage negative emotional and somatic states-was associated with opioid misuse in those with chronic pain. A sample of 51 participants prescribed opioid analgesics for chronic back or neck pain were recruited for a 1-time laboratory study. Participants completed measures of distress intolerance and opioid misuse, and a quantitative sensory testing battery. Results suggested that distress intolerance was associated with opioid misuse, even controlling for pain severity and negative affect. Distress intolerance was not associated with pain severity, threshold, or tolerance, but was associated with self-reported anxiety and stress after noxious stimuli. This study found robust differences in distress intolerance between adults with chronic pain with and without opioid medication misuse. Distress intolerance may be a relevant marker of risk for opioid misuse among those with chronic pain.

PERSPECTIVE

This study demonstrated that distress intolerance was associated with opioid misuse in adults with chronic pain who were prescribed opioids. Distress intolerance can be modified with treatment, and thus may be relevant not only for identification of risk for opioid misuse, but also for mitigation of this risk.

A randomized clinical trial of a tailored behavioral smoking cessation preparation program

Despite considerable progress in reducing cigarette smoking prevalence and enhancing smoking cessation treatments, most smokers who attempt to quit relapse. The current randomized clinical trial evaluated the efficacy of an adjunctive behavioral smoking cessation treatment based on learning theory. Adult daily smokers were randomly assigned to standard treatment (N = 47) with nicotine patch and individual counseling or to standard treatment plus a "practice quitting" program involving seven sessions of escalating prescribed abstinence periods (N = 46) prior to a target stop smoking date. Practice quitting was designed to extinguish smoking in response to withdrawal symptoms. Retention in treatment was excellent and the treatment manipulation increased the interval between cigarettes across practice quitting sessions on average by 400%. The primary endpoint, seven-day point-prevalence abstinence four weeks post-quit, was not significantly affected by practice quitting (31.9% in the standard treatment condition, 37.0% in the practice quitting condition). Practice quitting increased latency to a first lapse among those who quit smoking for at least one day and prevented progression from a first lapse to relapse (smoking daily for a week) relative to standard treatment, however. Practice quitting is a promising adjunctive treatment in need of refinement to enhance adherence and efficacy.

Efficacy of Cognitive Behavioral Therapy on Opiate Use and Retention in Methadone Maintenance Treatment in China: A Randomised Trial

Aims

Methadone maintenance treatment (MMT) is widely available in China; but, high rates of illicit opiate use and dropout are problematic. The aim of this study was to test whether cognitive behavioral therapy (CBT) in conjunction with MMT can improve treatment retention and reduce opiate use.

Method

A total of 240 opiate-dependent patients in community-based MMT clinics were randomly assigned to either weekly CBT plus standard MMT (CBT group, n=120) or standard MMT (control group, n=120) for 26 weeks. The primary outcomes were treatment retention and opiate-negative urine test results at 12 weeks and 26 weeks. The secondary outcomes were composite scores on the Addiction Severity Index (ASI) and total scores on the Perceived Stress Scale (PSS) at 12 weeks and 26 weeks.

Results

Compared to the control group in standard MMT, the CBT group had higher proportion of opiate-negative urine tests at both 12 weeks (59% vs. 69%, p<0.05) and 26 weeks (63% vs. 73%, p<0.05); however, the retention rates at 12 weeks (73.3% vs. 74.2%, p=0.88) and 26 weeks were not different (55.8% vs. 64.2%, p=0.19) between the two groups. At both 12 and 26 weeks, all of the ASI component scores and PSS total scores in the CBT group and control group decreased from baseline; but the CBT group exhibited more decreases in ASI employment scores at week 26 and more decrease in the PSS total score at week 12 and week 26.

Conclusions

CBT counselling is effective in reducing opiate use and improving employment function and in decreasing stress level for opiate-dependent patients in MMT in China.

Trial Registration

ClinicalTrials.gov NCT01144390

Development of a brief substance use sensation seeking scale: validation and prediction of injection-related behaviors

Sensation seeking, a personality trait, has been shown to predict engagement in high-risk behaviors. However, little is known regarding the impact of sensation seeking on substance use among street youth. We therefore sought to modify a sensation seeking scale (SSS) for use among this population. Street youth from the Vancouver-based At-Risk Youth Study (n = 226) completed the modified SSS. Exploratory and confirmatory factor analysis (EFA/CFA) were undertaken to establish the scale's dimensionality and internal validity. The association between SSS score and injection-related behaviors was tested using generalized estimating equation analysis. EFA results indicated scale unidimensionality. The comparative fit index (CFI) suggested acceptable fit (CFI = 0.914). In multivariate analysis, sensation seeking was independently associated with injection drug use, crystal methamphetamine use, polysubstance use, and binge drug use (all p < 0.05). Our findings provide preliminary support for the use of the modified SSS among street youth.

A randomized, controlled trial of the efficacy of an interoceptive exposure-based CBT for treatment-refractory outpatients with opioid dependence

Many patients diagnosed with opioid dependence do not adequately respond to pharmacologic, psychosocial, or combination treatment, highlighting the importance of novel treatment strategies for this population. The current study examined the efficacy of a novel behavioral treatment focusing on internal cues for drug use (Cognitive Behavioral Therapy for Interoceptive Cues; CBT-IC) relative to an active comparison condition, Individual Drug Counseling (IDC), when added to methadone maintenance treatment (MMT) among those who had not responded to MMT. Participants (N=78) were randomly assigned to receive 15 sessions of CBT-IC or IDC as an adjunct to ongoing MMT and counseling. Oral toxicology screens were the primary outcome. Results indicated no treatment differences between CBT-IC and IDC and a small, significant reduction of self-reported drug use, but no change on toxicology screens. Tests of potential moderators, including sex, anxiety sensitivity, and coping motives for drug use, did not yield significant interactions. Among opioid-dependent outpatients who have not responded to MMT and counseling, the addition of IDC or CBT-IC did not result in additive outcome benefits. These results highlight the need for more potent treatment strategies for opioid dependence, particularly among those who do not fully respond to frontline treatment.

Psychosocial interventions for benzodiazepine harmful use, abuse or dependence

BACKGROUND

Benzodiazepines (BZDs) have a sedative and hypnotic effect upon people. Short term use can be beneficial but long term BZD use is common, with several risks in addition to the potential for dependence in both opiate and non-opiate dependent patients.

OBJECTIVES

To evaluate the effectiveness of psychosocial interventions for treating BZD harmful use, abuse or dependence compared to pharmacological interventions, no intervention, placebo or a different psychosocial intervention on reducing the use of BZDs in opiate dependent and non-opiate dependent groups.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL- the Cochrane Library issue 12, 2014) which includes the Cochrane Drugs and Alcohol Group Specialized Register; PubMed (from 1966 to December 2014); EMBASE (from 1988 to December 2014); CINAHL Cumulative Index to Nursing and AlliedHealth Literature (1982 to September 2013); PsychINFO (1872 to December 2014); ERIC (Education Resources Information Centre, (January 1966 to September 2013); All EBM Reviews (1991 to September 2013, Ovid Interface); AMED (Allied & Alternative Medicine) 1985 to September 2013); ASSIA (Applied Social Sciences Index & Abstracts (1960 to September 2013); LILACS (January 1982 to September 2013);Web of Science (1900 to December 2014);Electronic Grey Literature Databases: Dissertation Abstract; Index to Theses.

SELECTION CRITERIA

Randomised controlled trials examining the use of a psychosocial intervention to treat BZDs versus pharmacological interventions,no intervention, placebo or a different psychosocial intervention on reducing the use of BZDs in opiate dependent and non-opiate dependent groups.

DATA COLLECTION AND ANALYSIS

We used the standard methodological procedures outlined in Cochrane Guidelines.

MAIN RESULTS

Twenty-five studies including 1666 people met the inclusion criteria. The studies tested many different psychosocial interventions including cognitive behavioural therapy (CBT) (some studies with taper, other studies with no taper), motivational interviewing (MI),letters to patients advising them to reduce or quit BZD use, relaxation studies, counselling delivered electronically and advice provided by a general practitioner (GP). Based on the data obtained, we performed two meta-analyses in this Cochrane review: one assessing the effectiveness of CBT plus taper versus taper only (575 participants), and one assessing MI versus treatment as usual (TAU) (80 participants).There was moderate quality of evidence that CBT plus taper was more likely to result in successful discontinuation of BZDs within four weeks post treatment compared to taper only (Risk ratio (RR) 1.40, 95% confidence interval (CI) 1.05 to 1.86; nine trials, 423 participants) and moderate quality of evidence at three month follow-up (RR 1.51, 95% CI 1.15 to 1.98) in favour of CBT (taper)for 575 participants. The effects were less certain at 6, 11, 12, 15 and 24 months follow-up. The effect of CBT on reducing BZDs by> 50% was uncertain for all time points examined due to the low quality evidence. There was very low quality evidence for the effect on drop-outs at any of the time intervals; post-treatment (RR 1.05, 95% CI 0.66 to 1.66), three month follow-up (RR 1.71, 95% CI0.16 to 17.98) and six month follow-up (RR 0.70, 95% CI 0.17 to 2.88).Based on the very low quality of evidence available, the effect of MI versus TAU for all the time intervals is unclear; post treatment(RR 4.43, 95% CI 0.16 to 125.35; two trials, 34 participants), at three month follow-up (RR 3.46, 95% CI 0.53 to 22.45; four trials,80 participants), six month follow-up (RR 0.14, 95% CI 0.01 to 1.89) and 12 month follow-up (RR 1.25, 95% CI 0.63 to 2.47).There was very low quality of evidence to determine the effect of MI on reducing BZDs by > 50% at three month follow-up (RR 1.52,95% CI 0.60 to 3.83) and 12 month follow-up (RR 0.87, 95% CI 0.52 to 1.47). The effects on drop-outs from treatment at any of e time intervals between the two groups were uncertain due to the wide CIs; post-treatment (RR 0.50, 95% CI 0.04 to 7.10), three month follow-up (RR 0.46, 95% CI 0.06 to 3.28), six month follow-up (RR 8.75, 95% CI 0.61 to 124.53) and 12 month follow-up(RR 0.42, 95% CI 0.02 to 7.71).The following interventions reduced BZD use - tailored GP letter versus generic GP letter at 12 month follow-up (RR 1.70, 95%CI 1.07 to 2.70; one trial, 322 participants), standardised interview versus TAU at six month follow-up (RR 13.11, 95% CI 3.25 to 52.83; one trial, 139 participants) and 12 month follow-up (RR 4.97, 95% CI 2.23 to 11.11), and relaxation versus TAU at three month follow-up (RR 2.20, 95% CI 1.23 to 3.94).There was insufficient supporting evidence for the remaining interventions.We performed a 'Risk of bias' assessment on all included studies. We assessed the quality of the evidence as high quality for random sequence generation, attrition bias and reporting bias; moderate quality for allocation concealment, performance bias for objective outcomes, and detection bias for objective outcomes; and low quality for performance bias for subjective outcomes and detection bias for subjective outcomes. Few studies had manualised sessions or independent tests of treatment fidelity; most follow-up periods were less than 12 months.Based on decisions made during the implementation of protocol methods to present a manageable summary of the evidence we did not collect data on quality of life, self-harm or adverse events.

AUTHORS' CONCLUSIONS

CBT plus taper is effective in the short term (three month time period) in reducing BZD use. However, this is not sustained at six months and subsequently. Currently there is insufficient evidence to support the use of MI to reduce BZD use. There is emerging evidence to suggest that a tailored GP letter versus a generic GP letter, a standardised interview versus TAU, and relaxation versus TAU could be effective for BZD reduction. There is currently insufficient evidence for other approaches to reduce BZD use.

WITHDRAWN: Psychosocial treatment for opiate abuse and dependence

The review has been withdrawn from publication because it is out of date and the authors are currently not available for updating it

The editorial group responsible for this previously published document have withdrawn it from publication.

Deepened extinction following compound stimulus presentation: noradrenergic modulation

Behavioral extinction is an active form of new learning involving the prediction of nonreward where reward has previously been present. The expression of extinction learning can be disrupted by the presentation of reward itself or reward-predictive stimuli (reinstatement) as well as the passage of time (spontaneous recovery) or contextual changes (renewal). The following experiments replicated the demonstration that presenting multiple previously rewarded stimuli in compound during extinction enhances extinction learning. To explore the pharmacological basis for this we next examined the effects of pharmacological treatments that either facilitated or blocked noradrenergic activity to test the hypothesis that increased noradrenergic activity at the time of extinction training would improve, whereas blockade of noradrenergic activity would impair the extinction of appetitive stimulus-reward memories. Different groups of rats were trained in a discriminative stimulus paradigm to lever-press for food reward. Once stable responding was achieved, responding was extinguished for 2 d. Prior to a third extinction session, rats received systemic administration of either saline, yohimbine (α2 antagonist), atomoxetine (norepinephrine reuptake inhibitor), or propranolol (β-receptor antagonist). Spontaneous recovery of responding to the stimuli was tested 4 wk later. Our results indicate that increasing noradrenergic activity during extinction augments extinction learning resulting in less recovery of responding at test. These results have important implications for models of relapse to drug seeking and the development of extinction-based therapies.

Anxiety sensitivity and illicit sedative use among opiate-dependent women and men

OBJECTIVES

Research has suggested that individuals with elevated anxiety sensitivity (AS) (the fear of benign bodily sensations associated with anxiety) are more likely to use substances to cope with distress, particularly substances with arousal-dampening effects such as benzodiazepines and other sedatives. Such coping motives may also vary as a function of gender, with women more likely to use substances for coping (self-medicating) purposes. Given these findings, we hypothesized that AS would be associated with illicit sedative use in an opioid-dependent sample and that gender would moderate this relationship, with a greater association among women.

METHOD

Participants were 68 opioid-dependent patients recruited from a methadone maintenance clinic. A logistic regression was used to determine whether AS was associated with presence or absence of a history of illicit sedative use.

RESULTS

AS was significantly associated with sedative use and this relationship was moderated by gender; elevated AS was associated with greater sedative use only in women.

CONCLUSION

The presence of elevated AS is related to greater illicit use of sedatives in women but not in men. Women may be more susceptible to seek sedatives as a means of coping with unpleasant, anxious sensations.

Cognitive behavioral therapy for substance use disorders

Cognitive behavioral therapy (CBT) for substance use disorders has shown efficacy as a monotherapy and as part of combination treatment strategies. This article provides a review of the evidence supporting the use of CBT, clinical elements of its application, novel treatment strategies for improving treatment response, and dissemination efforts. Although CBT for substance abuse is characterized by heterogeneous treatment elements such as operant learning strategies, cognitive and motivational elements, and skills-building interventions, across protocols several core elements emerge that focus on overcoming the powerfully reinforcing effects of psychoactive substances. These elements, and support for their efficacy, are discussed.

Cognitive-behavioral treatment with adult alcohol and illicit drug users: a meta-analysis of randomized controlled trials

OBJECTIVE

This meta-analysis examined 53 controlled trials of cognitive-behavioral treatment (CBT) for adults diagnosed with alcohol- or illicit-drug-use disorders. The aims were to provide an overall picture of CBT treatment efficacy and to identify client or treatment factors predictive of CBT effect magnitude.

METHOD

The inverse variance weighted effect size (Hedges' g) was calculated for each study and pooled using fixed and random effects methods. Potential study-level moderators were assessed in subgroup analyses by primary drug, type of CBT, and type of comparison condition. In addition, seven client and treatment variables were examined in meta-regression analyses.

RESULTS

Across studies, CBT produced a small but statistically significant treatment effect (g = 0.154, p < .005). The pooled effect was somewhat lower at 6-9 months (g = 0.1 15, p < .005) and continued to diminish at 12-month follow-up (g = 0.096, p < .05). The effect of CBT was largest in marijuana studies (g = 0.513, p < .005) and in studies with a no-treatment control as the comparison condition (g = 0.796, p < .005). Meta-regression analyses indicated that the percentage of female participants was positively associated and the number of treatment sessions was negatively associated with effect size.

CONCLUSIONS

The findings demonstrate the utility of CBT across a large and diverse sample of studies and under rigorous conditions for establishing efficacy. CBT effects were strongest with marijuana users, when CBT was compared with no treatment, and may be larger with women than with men and when delivered in a brief format.

The relationship of stress, impulsivity, and beliefs to drug use severity in a sample of women prison inmates

There is a paucity of research examining substance abuse issues among women prisoners. This study explored relationships between perceived stress, impulsivity, and beliefs in the efficacy of drugs as these variables pertain to self-reported drug use severity. Women prisoners (N = 100) participated in structured face-to-face interviews based on established research instruments. Although there was no significant correlation between demographic characteristics and substance use severity, positive relationships were found between substance use severity, perceived stress, impulsivity, and beliefs. A multiple linear model was estimated regressing drug use severity on beliefs, impulsivity, and perceived stress. Only the measures of beliefs and impulsivity were significant correlates of drug use severity. Implications are discussed for prison substance abuse programming and future research.

Assessment of an abstinence-oriented, outpatient drug addiction service in Greece

The 'Athena' service is an abstinence-oriented, outpatient substance addiction unit in Greece. To appraise the operation of the service, 459 clients who contacted the unit during a 3-yr. period were assessed in terms of treatment retention and situation upon discharge from the program; 182 of them had four or more appointments with the service and were thoroughly assessed using a battery of measures pertaining to their situation at discharge and their patterns of abuse and related problems. Most help-seekers were single, unemployed, young men who regularly used heroin (89%) intravenously (35%). From those who got involved in the therapeutic process (40%), 72% had positively modified their drug abuse by the time of discharge from the program (mean duration of treatment: approx. three months); the largest improvement (42%) was recorded in their psychological condition. Treatment retention was significantly higher for cannabis abusers than heroin addicts; longer treatment duration was significantly associated with a positive situation at discharge, while higher education was associated with a less favorable outcome regarding the abuse of the principal substance. These findings suggest that such outpatient programs may help a significant number of individuals who get involved in the therapeutic process and should be considered effective for treatment of substance abuse among the diversity of treatment modalities.

Attending to emotional cues for drug abuse: bridging the gap between clinic and home behaviors

Classical conditioning models of addiction provide keys to understanding the vexing discrepancy between substance abuse patients' desire to abstain when they are in therapy sessions and their tendency to relapse. Experiments using these models demonstrate the power of environmental relapse cues and support clinical approaches, including active exposure, aimed at helping patients recognize and withstand them. Internal cues, including emotions and somatic states such as withdrawal, can trigger urges as powerfully as external cues such as people, places, and things associated with prior abuse. The authors describe a cognitive-behavioral therapy approach that focuses on identifying and actively inducing each patient's high-risk emotions, then helping him or her develop and practice healthy responses. Clinical trials support the approach for patients with panic disorder who have trouble discontinuing benzodiazepines, and early trials suggest it may be useful for patients addicted to other drugs as well.

Opioid maintenance: a comparative review of pharmacological strategies

The use of opioids outside of medical practice is a significant health problem with important social and political implications. Although treatment of opioid dependence is traditionally focused on heroin users, there is increasing recognition that a large number of people become dependent through the use of prescription opioids. The necessity for long-term treatment has also been increasingly recognised. At present, there are several pharmacotherapies available for maintenance treatment, including drugs that are full agonists at the opioid receptor (e.g., methadone, slow-release oral morphine), a partial agonist (buprenorphine) and an opioid antagonist (naltrexone). This review examines the existing strategies, highlights problems associated with their use and discusses the opportunities for new treatment approaches, particularly the use of long-acting formulations.

Emotional exposure in the treatment of substance use disorders: conceptual model, evidence, and future directions

In this article, we review research on the nature and treatment of panic disorder, and apply these findings to a discussion of the role of internal cue exposure in the treatment of substance use disorders (SUDs). Two features of panic treatment were used as a model for interventions for SUDs: exposure to internal (interoceptive) cues rather than reliance on external (environmental) exposure alone, and use of cue exposure to try to inoculate individuals against future maladaptive patterns. Specifically, we emphasized the role of exposure to internal, largely emotional cues, as a way to enhance resilience to cues for relapse in individuals with SUDs. Hypothesized moderators and mediators of this treatment approach were discussed, as were similarities between this research agenda and an increasing focus on the role of emotional acceptance/tolerance in cognitive-behavioral treatments.

Spending on substance abuse treatment: how much is enough?

AIM

To describe a framework that can be used to determine optimal spending on substance abuse treatment in the United States.

METHODS

Selective review of the literature on spending for substance abuse treatment combined with an economic analysis of how to determine when spending is optimal, defining optimal spending as that which minimizes the social costs of substance use disorders.

RESULTS

In 1997, only $11.9 billion of the $294 billion estimated social costs of substance abuse was spent on treatment. The discrepancy between the high indirect costs of illness relative to the level of spending on treatment of addictive disorders leads many to believe that the United States spends too little on treatment. In this paper, we argue that information on the social costs of substance abuse disorders and the level of spending on treatment is insufficient to determine whether current spending is optimal. We develop a framework that could be used to determine optimal spending on substance abuse treatment in the United States. We develop this framework in four steps. First, we provide background on the unique financial and delivery features of substance abuse treatment. Secondly, we outline the points raised by advocates of expanded substance abuse treatment: substance abuse has high social costs, yet few people receive the many effective treatments available partly because of financial barriers to treatment. Thirdly, we provide a framework that can be used to judge the additional benefits of alternative levels and types of spending on substance abuse treatment. Finally, we discuss the distinction between the potential impact of spending on substance abuse treatment and its actual impact, using productivity as an example of one significant portion of the costs of substance abuse.

CONCLUSION

To determine optimal spending on substance abuse treatment, research should describe who receives treatment, the quality of treatment received, and how treatments relate to outcomes that comprise a large share of the economic burden of substance abuse.

Psychosocial treatment for opiate abuse and dependence

BACKGROUND

Substance dependence is a major social and public health problem; therefore it is a priority to develop effective treatments. The treatment of opioid dependence is complex. Previous Cochrane reviews have explored the efficacy of pharmacotherapy for opiate dependence. This current review focuses on the role of psychosocial interventions alone for the treatment of opiate dependence. There are many different psychosocial interventions offered to opiate addicts, which are widely spread. There is some evidence for the effectiveness of psychosocial interventions, but no systematic review has even been carried out.

OBJECTIVES

To assess the efficacy and acceptability of psychosocial interventions alone for treating opiate use disorders.

SEARCH STRATEGY

Electronic searches of Cochrane Library, EMBASE, MEDLINE, and LILACS; reference searching; personal communication; conference abstracts; unpublished trials; book chapters on treatment of opioid abuse/ dependence.

SELECTION CRITERIA

The inclusion criteria for all randomised-controlled trials were that they should focus on psychosocial interventions alone for treating opioid use disorders.

DATA COLLECTION AND ANALYSIS

Reviewers extracted the data independently using relative risks, weighted mean difference and number needed to treat estimated, when possible. The reviewers assumed that people who died or dropped out had no improvement (intention to treat analysis) and tested the sensitivity of the final results to this assumption.

MAIN RESULTS

Five studies fit the study criteria. These analysed Contingency Management, Brief Reinforcement Based Intensive Outpatient Therapy coupled with Contingency Management, Cue Exposure therapy, Alternative Program for Methadone Maintenance Treatment Program Drop-outs (MMTP) and Enhanced Outreach-Counselling Program. All the treatments were studied against the control (standard) treatment; therefore it was not possible to identify which type of psychosocial therapy was most effective. The main findings were that both Enhanced Outreach Counselling and Brief Reinforcement Based Intensive Outpatient Therapy coupled with Contingency Management had significantly better outcomes than standard therapy within treatment. This was regarding relapse to opioid use, re-enrollment in treatment and retention in treatment. At 1-month and 3- month follow up the effects of Reinforcement Based Intensive Outpatient Therapy were not sustained. There was no further follow up of the Enhanced Outreach Counselling group. The Alternative Program for MMTP Drop-outs and the behavioural therapies of Cue Exposure and Contingency Management alone were no better than the control (standard) therapy. As the studies were heterogeneous, it was not possible to pool the results and perform a meta-analysis.

AUTHORS' CONCLUSIONS

The available evidence has low numbers and is heterogeneous. At present psychosocial treatments alone are not adequately proved treatment modalities or superior to any other type of treatment. It is important to develop a better evidence base for psychosocial interventions to assist in future rationale planning of opioid use drug treatment services. Large-scale randomised trials are required with longer follow up stating methods of randomisation, allocation concealment and blinding. Where possible this should include intention to treat analysis, with power calculations performed prior to the trial. These studies can be designed and delivered to provide usable data for better understanding of this important component of intervention in the field of dependence.

A bio-behavioral model of addiction treatment: applying dual representation theory to craving management and relapse prevention

A bio-behavioral approach to drug addiction treatment is outlined. The presented treatment model uses dual representation theory as a guiding framework for understanding the bio-behavioral processes activated during the application of expressive therapeutic methods. Specifically, the treatment model explains how visual processing techniques can supplement traditional relapse prevention therapy protocols, to help clients better manage cravings and control triggers in hard-to-treat populations such as chronic substance-dependent persons.

Internal cue exposure and the treatment of substance use disorders: lessons from the treatment of panic disorder

Despite early recognition of the importance of internal cues (craving sensations and emotional states) for relapse in substance use disorders, relatively little attention has been devoted to exposure-based treatments targeting these cues. Drawing upon research on the conceptualization and treatment of panic disorder, we discuss the application of internal (largely emotional) cue exposure for substance use disorders. Our model for this discussion was based on the role of exposure to feared sensations of anxiety in the treatment of panic disorder and benzodiazepine (BZ) discontinuation. Shared research strategies between panic disorder and substance use--studies of biological provocation and anxiety sensitivity--were discussed, as were gender differences in drug-use motives. In accordance with research on anxiety sensitivity, provocation effects, and the treatment of benzodiazepine withdrawal, we discussed the potential value of internal cue-exposure strategies for individuals who use substances as a way to cope with negative affect.