MODULE 7EVIDENCE-BASED

PRACTICES FOR TREATMENT

INTERVENTION
Treatment for Substance Use
DisordersThe Continuum of Care
for Addiction Professionals
The Colombo Plan Asian Centre for Certification and Education of Addiction Professionals Training Series
Curriculum 2
7.2
Module 7 Learning Objectives
Define evidence-based practice (EBP)
Describe why it is important to know about
EBPs
Identify key components of six specific EBPs
Discuss the applicability of these EBPs to your
work

7.3
Creating Small Groups
A range of experience is needed in each group
Line up left to right, based on length of time
worked as an SUD counselor
Part-time and full-time work, internships, and
volunteer work counts
Count off from one to four, starting on the left
Move to new group tables and introduce
yourselves

7.4
Prior Module Topics
Recovery, recovery management, recovery
capital
Factors that may affect treatment outcomes
Process and stages of change
Basic principles of treatment
Components of treatment
7.5
What is an evidence-based
practice?
7.6
Evidence-based Practices (EBP): Definition
Practices for which the evidence is strongest
and most acceptedand that are most likely
to have significant impact on improving care

Source: U.S. National Quality Forum. (2007). National voluntary consensus standards for the
treatment of substance use conditions: Evidence-based treatment practices (abridged version).
Washington, DC: Author.

7.7
EBP Definition: Improving Care
Substandard SUD treatment was common
Substandard was defined as treatment that
was not:
Safe
Effective
Patient-centered
Timely
Efficient
Equitable (fair)


Source: McGlynn, E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A. et al.
(2003). The quality of health care delivered to adults in the United States. New England Journal of
Medicine 348.
7.8
EBP Definition: Improved Care
Only 10 percent of people with alcohol use
disorders received recommended care,
resulting in increased mortality and morbidity

Source: McGlynn, E. A., Asch, S. M., Adams, J., Keesey, J., Hicks, J., DeCristofaro, A. et al.
(2003). The quality of health care delivered to adults in the United States. New England Journal of
Medicine 348.
7.9
EBP Definition: Practices
Practices are sets of techniques and
approaches that may include elements from
more than one counseling theory
7.10

Evidence-Based Practice
EBP
Clinical
expertise
Science
Clinical &
financial
feasibility
7.11
Evidence-based: Science
Empirically validated evidence, meaning
evidence that is based on information gained
through:
Direct observation
Experience
Experiments

7.12
Evidence-based: Clinical and Financial
Feasibility
In a real-life treatment setting, not just in a
research setting, implementing the practice is:
Reasonable
Achievable
Economically possible

7.13
Evidence-based: Clinical Expertise
Counselors implementing a practice have
basic counseling skills, can connect with
clients, and have been trained in the use of the
specific practice

Photo credit: Family Health International, Hanoi,
Vietnam
7.14
Why Evidence-Based Practices?
Question:
Why do we need to know and care about EBPs?

7.15
EBPs Improve Outcomes
EBPs have been shown to improve treatment
outcomes
Source: World Health Organization (WHO) and UNODC. (2008). Principles of drug
dependence treatment: Discussion paper.
(http://www.unodc.org/documents/eastasiaandpacific//china/UNODC-WHO-Principles-of-Drug-
Dependence-Treatment.pdf)
7.16
WHO and United Nations Office on
Drugs and Crime
Evidence-based good practice and
accumulated scientific knowledge on the
nature of drug dependence should guide
interventions and investments in drug
dependency treatment. The high quality of
standards required for approval of
pharmacological or psychosocial interventions
in all the other medical disciplines should be
applied to the field of drug dependence.


Source: World Health Organization and UNODC (2008). Principles of drug dependence treatment: Discussion paper.
(http://www.unodc.org/documents/eastasiaandpacific//china/UNODC-WHO-Principles-of-Drug-Dependence-Treatment.pdf)
7.17
Recommended EBPs
Pharmacotherapy (use of medications to treat
SUDs)
Cognitive-behavioral therapies
Motivational enhancement therapy
Contingency management
12-step facilitation therapy
Marital and family therapies




Source: U.S. National Quality Forum. (2007). National voluntary consensus
standards for the treatment of substance use conditions: Evidence-based treatment
practices: A consensus report. Washington, DC: Author.

7.18
Practices Not Recommended
Acupuncture, relaxation therapy, education,
drug testing, detoxification as stand-alone
treatments
Individual psychodynamic therapy
Unstructured group therapy
Confrontation as the main approach to
treatment
Discharge from treatment in response to relapse



Source: U.S. National Quality Forum. (2004). Evidence-based treatment practices for substance use
disorders: Workshop proceedings. Washington, DC: Author.
7.19
Important to Know
An empathic, supportive approach may be just
as important as the specific practices used
A counselors ability to engage and develop a
helping relationship with a client is critical


7.20
EBPs Well Cover
Cognitive-behavioral therapy
Motivational approaches
Certain family approaches
Therapeutic community
Contingency management
Pharmacotherapy for opioid dependence
7.21
Cognitive-Behavioral Therapy
A combination of:
Cognitive therapy, which was originally
developed by Aaron Beck to treat depression
Behavioral therapy, which was originally
developed and conceptualized by Ivan Pavlov
and modified by B. F. Skinner and Albert
Bandura
7.22
Cognitive Therapy
Thoughts and interpretations cause feelings
and behaviors
Feelings and behaviors are not caused by
external things
People can change the way they think (and
feel and act), even if the situation does not
change

7.23
Instead of This
Event
Feelings
and
behavior
7.24
This
Event
Thoughts
and
Interpretations
Feelings
and
behavior
7.25
Behavioral Therapy Focus
Emotional and behavioral disorders are
learned responses that can be replaced by
healthy ones with appropriate training

7.26
Focus on identifying factors that initiate and
maintain behavior
Focus on the adaptive and maladaptive
behaviors that lead to client discomfort and
problems
Focus on observable and measurable
behaviors

Behavioral Approaches
7.27
Behavioral Approaches
Do not focus on concepts like self-esteem,
thoughts, values, the unconscious, or defense
mechanisms

7.28
CBT: Central Questions
The how question relates to building skills.
How does he change?

The what question addresses the things that
reinforce patterns of thought, affect, and
behavior.
What keeps a person doing what hes doing?



7.29
CBT Approach to Treating SUDs
Teaching clients skills that help them
recognize and learn strategies to:
Reduce risks of relapse
Maintain abstinence
Solve problems
Enhance self-efficacy

7.30
CBT Techniques
Asking questionsand teaching clients to ask
themselves questionsto explore the
relationship of their thinking to their emotional
responses to events. For example:
How do I really know those people are laughing at
me?
Are there any other possible explanations?
Could they be laughing about something else?
7.31
CBT TechniquesPart II
Explore positive and negative consequences
Teach self-monitoring
Help clients develop strategies for avoiding or
coping with high-risk situations
Help clients develop effective coping strategies
for general life challenges
Teach problem-solving skills

7.32
CBT TechniquesPart III
Homework:
Reading assignments
Keeping track of certain behavior and thoughts
Practicing new skills (behavioral rehearsal)

7.33
Cognitive-Behavioral Coping Skills
Therapy
A structured CBT approach
Each session includes:
Discussion of the rationale
Specific skill guidelines
Behavioral rehearsal (skill role-plays)
Practice exercises for a particular topic area


U.S. National Institute on Alcohol Abuse and Alcoholism. (1995). Cognitive-behavioral coping skills therapy manual: A
clinical research guide for therapists treating individuals with alcohol abuse and dependence. Project MATCH
Monograph Series, Volume 3. Bethesda, MD: Author.
7.34
Topic Areas
Topic areas:
Managing thoughts about using substances
Solving problems
Developing substance refusal skills
Planning for emergencies and coping with a lapse
Dealing with seemingly irrelevant decisions

7.35
Seemingly Irrelevant Decisions
7.36
Coping Skills Training
Helps clients look at each link in a chain of
events that led to relapse
Helps clients learn to recognize decisions that
can be the start of a process of relapse

7.37
CBT Effectiveness
Documented effectiveness for SUDs involving:
Alcohol
Marijuana
Cocaine
Methamphetamine
Nicotine
Clients maintain skills and gains for a year
after treatment




Source: U.S. National Institute on Drug Abuse. (2009). Principles of drug addiction treatment:
A research-based guide, 2nd Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author.
7.38
Small-Group Exercise: CBT
Small-group topic assignments:
Group 1: Overview of characteristics
Group 2: Primary techniques/applications
Group 3: Strengths
Group 4: Challenges


7.39
Small-Group Exercise: CBT
Summarize your assigned topic:
On newsprint for group presentation
On white paper for posting on CBT wall graphic
Use resources:
Your manuals and notes
What you already know about this EBP
Resource Page 7.2 (especially helpful for
strengths and challenges)



7.40


Lunch
60 minutes
7.41
Small-Group Exercise: CBT
Summarize your assigned topic:
On newsprint for group presentation
On white paper for posting on CBT wall graphic
Use resources:
Your manuals and notes
What you already know about this EBP
Resource Page 7.2 (especially helpful for
strengths and challenges)



7.42
Motivational Approaches
Motivational interviewing (MI)
Motivational enhancement therapy (MET)

7.43
Motivational Approaches
Change occurs in stages
Motivation for change varies over time
Motivation can be enhanced
Pre-
contemplation
Contemplation
Preparation Action
Maintenance
7.44
Motivational Approaches
Are client-centered and nondirective
Acknowledge that substances have rewarding
properties that can disguise hazards and
negative long-term effects
Help clients resolve ambivalence about
treatment and stopping substance use


7.45
Motivational ApproachesPart 2
Use the internal motivation of clients to evoke
and sustain rapid change
Include problem-solving or solution-focused
strategies that build on clients past successes


7.46
The Counselor
Acts as a coach or consultant rather than as
an authority figure
Helps client discover,
understand, and build on
past successes

7.47
Primary Techniques of Motivational
Approaches
FRAMES approach
Decisional balance exercises
Identifying discrepancies
Pacing
Personal contact with clients not in treatment

7.48
FRAMES
Feedback
Responsibility
Advice
Menus
Empathy
Self-efficacy

7.49
FRAMES: Feedback
After assessment of substance use patterns,
associated problems, and recovery capital, the
counselor provides feedback to the client
regarding personal risk or impairment

7.50
FRAMES: Responsibility
Responsibility for change is placed squarely
and explicitly on the client, with respect for the
clients right to make choices for herself or
himself

7.51
FRAMES: Advice
Advice about changingreducing or
stoppingsubstance use is clearly given to
the client by the counselor in a nonjudgmental
manner

7.52
FRAMES: Menus
Menus of self-directed change options and
treatment alternatives are offered to the client

7.53
FRAMES: Empathy
Empathic counseling is emphasized
Counselor shows:
Warmth
Respect
Understanding


7.54
FRAMES: Self-Efficacy
The client:
Develops self-efficacy
Is encouraged to change
The counselor:
Helps client explore strengths and past
successes
Identifies skills and abilities to make changes
Promotes idea that change and recovery are
possible

7.55
Decisional Balance Technique
Decisional balance is the concept of exploring
the pros and consor benefits and
disadvantagesof change

7.56
Decisional Balance Exercise
Client weighs pros and cons of changing or
not changing substance-using behavior
Counselor assists by asking the client to:
Talk about both the good and less good aspects
of using substances
Write them down in two columns on a sheet of
paper

7.57
Decisional Balancing Purpose
The purpose of exploring the pros and cons of
a substance use problem is to tip the scales
toward a decision for positive change
7.58
Identifying Discrepancies
Help clients recognize discrepancy or gap
between future goals and current behavior:
How does your cocaine use fit in with having a
happy family and a stable job?
When clients see present actions conflicting
with important personal goals, change is more
likely to occur

7.59
Pacing
Each client moves through stages of change at
his or her own pace
Counselor meets client at the stage in which
he or she is
Pushing a client at a faster pace than he or
she is ready to take may cause the
relationship between counselor and client to
break down

7.60
Personal Contact With Clients Not in
Treatment
Research shows simple motivation-enhancing
interventions like letters and telephone calls
encourage clients to:
Return for another clinical consultation
Return to treatment following a missed
appointment
Stay involved in treatment
Increase treatment adherence

7.61
Motivational Interviewing Definition
Counseling technique or style focusing on
creating a favorable climate for change in a
person-centered setting
Essence is collaborative nature:
Communicating in a partner-like relationship
Interviewer creates a positive interpersonal
atmosphere

7.62
MI Principles
Five primary principles or concepts to enhance
the client-counselor relationship are
summarized by the acronym READS:
Roll with resistance
Express empathy
Avoid arguments
Develop discrepancy
Support self-efficacy

7.63
MI Therapeutic Skills
Counselor uses four basic therapeutic skills or
methods:
Listening reflectively or responding to a clients
statement by stating back either the essence or a
specific aspect of what was said
Asking open-ended questions
Affirming
Summarizing

7.64
MI Goal
Responsibility for change is left to client in
that:
The goal is to increase intrinsic motivation to
make the change the client determines to be
important
Change is never imposed
7.65
MI and SUD Treatment
First used to improve adherence
Can be assessment strategy and therapeutic
intervention to:
Determine readiness to engage in target behavior
Explore and resolve ambivalence and resistance
Apply specific skills and strategies to create a
climate for change, based on the level of
readiness

7.66
Motivational Enhancement Therapy
(MET)
MET seeks to:
Help clients create their own motivation for
change
Consolidate clients decision and plan for change
Approach is client centered, but counseling
sessions are planned and directed by the counselor

7.67
MET and Goal-Setting
Counselors impose no absolute goal
Counselors may advise about specific goals, such
as complete abstinence
A broader range of life goals may be explored as
well



7.68
MET Concept of SUD Problems
SUD problems viewed as behaviors at least
partially under voluntary control of the client
Normal principles of behavior change apply

7.69
MET Summary
Based on principles of cognitive and social
psychology, where the counselor:
Assumes that internal motivation is a necessary
and often the only factor needed to create change
Helps clients perceive discrepancies between
current behavior and personal goals
Emphasizes clients self-motivational statements
of both desire for and commitment to change

7.70
MET Effectiveness
Researchers have found MET to be effective
for addressing the following addictions:
Alcohol
Marijuana
Nicotine











Source: U.S. National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research-based guide,
2nd Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author.


7.71
Small-Group Exercise: Motivational
Approaches
Small-group topic assignments include:
Group 1: Primary techniques/applications
Group 2: Challenges
Group 3: Overview of characteristics
Group 4: Strengths


7.72
Small-Group Exercise: Motivational
Approaches
Summarize your assigned topic:
On newsprint for group presentation
On white paper for posting on CBT wall graphic
Use resources:
Your manuals and notes
What you already know about this EBP
Resource Page 7.3 (especially helpful for
strengths and challenges)



7.73


Break
15 minutes
7.74
Small-Group Exercise: Motivational
Approaches


Presentations
7.75
Family Involvement
Family involvement is not a model, but it can
enhance outcomes
Most programs offer some family services


7.76
Family Services
Family services frequently include:
Family education
Family support groups
Family counseling


7.77
Family Involvement
Why do you think family involvement is
important in SUD treatment?


7.78
Families of Clients With SUDs
Inconsistent behaviors
Few or rigid rules
Emotional distress
Isolated or rigid roles
Medical issues in response to stress


7.79
Families Can Enhance Recovery
Family members were involved with the client
before treatment
The will be involved with the client after
treatment
Changes in family functioning can be a positive
influence on recovery



7.80
Family Involvement Goals
Learning about SUD as a chronic disease
helps family members understand:
How SUD is intertwined with family problems
SUD causes and effects from a family perspective
Family relationship patterns working against
recovery
Prepare for early recovery challenges
Relapse warning signs



7.81
Family Involvement GoalsPart II
Help family members:
Discover and build on family strengths
Find long-term support for themselves



7.82
Families Can Be Roadblocks
Family members may need treatment
themselves before they can be a resource
Many clients are from families that:
Are particularly chaotic and dysfunctional
Have multi-generational SUDs, mental disorders,
and other problems


7.83
Family Approach EBPs
Behavioral couples therapy (BCT)
Multisystemic therapy (MST) (adolescents)
Multidimensional family therapy (MDFT)
(adolescents)
Brief strategic family therapy (BSFT)
(adolescents)



7.84
Behavioral Couples Therapy (BCT)
Assumptions:
Intimate partners can reinforce abstinence
Reducing relationship stress reduces chances
for relapse



7.85
BCT Program Components
Recovery or abstinence contract
Activities and assignments to enhance
relationship
Relapse prevention planning



7.86
BCT Program Techniques
Between 15- and 20-hour-long sessions over 5
to 6 months to:
Assess use since last session
Discuss compliance with recovery contract
Discuss homework assignments
Discuss relationship problems
Present new material
Assign new homework, and then discuss it



7.87
BCT Effectiveness
BCT is effective for:
Men with alcohol use disorders and their spouses
Men and women with drug use disorders and
their significant others












Source: U.S. National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research-based guide,
2nd Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author.








7.88
BCT EffectivenessPart II
Compared to individual treatment at one-year
follow-up, BCT produces higher:
Treatment attendance
Naltrexone adherence for opioid users
Rates of abstinence
BCT also produced fewer drug-related, legal,
and family problems



7.89
Multisystemic Therapy (MST)
Intensive in-home and in-community approach
Focuses on changing thinking and behavior of:
Adolescents with SUDs
Their parents
Uses cognitive-behavioral and social-
development strategies
Concentrates on family strengths



7.90
MST Interventions
Occur in-home to overcome high drop-out
rates and focus on:
Promoting responsible behavior
Decreasing irresponsible actions by family
members
Addressing what is currently occurring in the
adolescents life
Taking immediate actions targeting specific
problems



7.91
MST InterventionsPart II
MST focuses on:
Assessing patterns of behavior within and between
elements in adolescents life that sustain problems
family, teachers, friends, home, school, and
community
Building adolescents peer relationships
Acquiring academic and vocational skills



7.92
MST Focus
Not on gaining insights into the past
Not on blaming the family or labeling parents
But on
Empowering caregivers as key to long-term
success
Holding MST counselors solely responsible for
treatment success



7.93
MST Effectiveness
MST found to:
Significantly reduce adolescent drug use during
and for at least six months aftertreatment
Reduce the number of incarcerations and out-of-
home juvenile placements




Source: U.S. National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A
research-based guide, 2nd Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author.



7.94
Multidimensional Family Therapy (MDFT) for
Adolescents
Adolescent substance use viewed in terms of
a network of influences:
Individual
Family
Peer
Community


7.95
MDFT TreatmentWith Adolescents
Individual and family sessions are held in
homes, schools, courts, or the community
The counselor and adolescent work on:
Developmental tasks, such as decision-making,
negotiation, and problem-solving skills
Vocational skills
Skills in communicating thoughts and feelings


7.96
MDFT TreatmentWith Parents
Parallel sessions with parents to:
Examine parenting styles, learning to distinguish
influence from control
Develop a positive and developmentally
appropriate influence on their children


7.97
MDFT Effectiveness
Researchers have found MDFT to be effective
for reducing the severity of:
Cannabis and alcohol use
Substance abuse-related problems










Source: U.S. National Registry of Evidence-based Practices and Programs. (2011). Multidimentional Family Therapy.
Rockville, Maryland: SAMHSA. (http://nrepp.samhsa.gov/ViewIntervention.aspx?id=16)


7.98
Brief Strategic Family Therapy
(BSFT)
Delivered in 12 to 16 sessions
Targets family interactions that sustain SUDs
and other co-occurring behaviors, such as:
Conduct problems at home and at school
Oppositional behavior
Illegal activities
Associating with antisocial peers
Aggressive and violent behaviors
Risky sexual behavior


7.99
BSFT Techniques
Family systems approach
Counselors role: To identify and change
patterns of family interaction that support
SUDs
Flexible approach adapted to range of family
situations in various:
Settings
Treatment modalities


7.100
BSFT Manual
BSFT is a manual-based, highly structured
program
Specific training is required to implement
BSFT


7.101
BSFT Effectiveness
Urban Hispanic families have been the primary
recipients
Researchers found BSFT effective for:
Reducing marijuana and overall substance use
Reducing conduct problems
Increasing family functioning


U.S. National Registry of Evidence-based Practices and Programs. (2011) Multidimentional Family Therapy. Rockville,
Maryland: SAMHSA. (http://nrepp.samhsa.gov/ViewIntervention.aspx?id=151)

7.102
Exercise: Journal Writing
What was the most important thing you
learned today?
What surprised you?
What would you like to learn more about?


7.103
Day 4 Wrap-Up and Evaluation
Thank you for your participation today.
Does anyone have questions or thoughts
before we end the day?
Please complete a Daily Evaluation Form.



7.104
Day 5: Module 7

Welcome to
your last day
of training!

7.105
Small-Group Exercise: Family-based
Approaches
Small-group topics:
Group 1: Challenges
Group 2: Strengths
Group 3: Primary techniques/applications
Group 4: Overview of characteristics


7.106
Small-Group Exercise: Family-based
Approaches
Summarize your assigned topic:
On newsprint for group presentation
On white paper for posting on family-based wall
graphic
Use resources:
Your manuals and notes
What you already know about this EBP
Resource Page 7.4 (especially helpful for
strengths and weaknesses)



7.107
Therapeutic Community (TC)
Intensive, long-term (up to one year)
residential model
Community as methodThe community as a
whole is the therapeutic agent with its:
Social organization
Staff and clients
Daily activities


7.108
TC Structure
Structured day includes ordered activities to:
Counter disordered lives of clients
Distract clients from negative thinking and
boredom
Group sessions and job functions to teach
specific behaviors and skills
Useful elements for clients with histories of
severe SUDs and criminal behavior

7.109
Key Therapeutic Factor
Researchers documented that:
Restoring warm, interpersonal relationships
reverses the damaging changes produced on
brain formation, function, and structural damage
caused by childhood neglect and abuse
With the well-recognized TC role, each
participant is considered with love and respect
and as part of a new family, while filling
affective gaps
Source: Personal communication: Gilberto Gerra, M.D., Chief, Drug Prevention and Health
Branch, UNODC
7.110
TC Model
TC model used in countries around the world
13 countries with professional associations on
every continent (except Antarctica)
The Asian Federation of Therapeutic
Communities (http://www.asianfedtc.org)





7.111
TC Model Components
A sense of community, as separation from the
substance-using environment
Peers and staff members learn new roles and
become role models for others
Work as therapy and education
Peer encounter groups, awareness training,
and emotional growth training

7.112
TC Treatment Stages
Introduction Treatment Commitment
Transition &
Aftercare
7.113
TC Introduction Stage
Help clients accept responsibility for SUD
behaviors and consequences through:
Groups
Individual counseling sessions
Educational seminars

7.114
TC Treatment Stage
Clients live and work in a supportive
community, helping one another develop
coping skills:
Social structure is hierarchical with varying
degrees of responsibility
Activities focus on normal, daily work projects and
leisure interests
Includes a creative therapy program
Outside support meetings are initiated
7.115
TC Commitment Stage
Link between treatment and reintegration
Emphasis is on:
Career development
Social relationships
Practical living skills
7.116
TC Commitment StagePart II
Support is provided for community reentry
from:
Voluntary work to full-time employment or school
From TC to transitional housing and to home in
community or back with family
Weekly support groups and counseling
Additional support from peers who have
completed the TC program
Participation in 12-step groups
7.117
TC Transition/Aftercare Stage
Requirements of:
Full-time job or school
Place to live
Support network
Family reconciliation
Coping skill development to maintain a drug-
free lifestyle, which can take many months
7.118
TC Effectiveness
Conclusions from long-term U.S. Drug Abuse
Treatment Outcome Study found those who
completed TC treatment had lower levels of:
Cocaine, heroin, and alcohol use
Criminal behavior
Unemployment
Indicators of depression



Source: National Institute on Drug Abuse (2002). Research report seriesTherapeutic community:
What is a therapeutic community. Bethesda, Maryland: Author.
(http://www.nida.nih.gov/PDF/RRTherapeutic.pdf)

7.119
TC EffectivenessPart II
Modified TCs are also effective for treating
individuals with special needs, including:
Adolescents
Women
Homeless individuals
People with severe mental disorders
Individuals in the criminal justice system





Source: National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research-
based guide, 2nd Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author.

7.120
Small-Group: TC
Small-group topics:
Group 1: Strengths
Group 2: Overview of characteristics
Group 3: Challenges
Group 4: Primary techniques/applications


7.121
Small-Group Exercise: TCs
Summarize your assigned topic:
On newsprint for group presentation
On white paper for posting on TC wall graphic
Use resources:
Your manuals and notes
What you already know about this EBP
Resource Page 7.5 (especially helpful for
strengths and challenges)



7.122


Break
15 minutes
7.123
Contingency Management (CM)
Based on the behavioral principle that
rewarding a behavior reinforces it, or makes it
more likely to be repeated
In SUD treatment, CM means that clients are
given the chance to earn low-cost incentives,
or rewards, for desirable behavior


7.124
Behavioral Perspective of SUDs
Substance use is maintained by:
The positively reinforcing effects of the substance
itself
The negative reinforcement of reliving pain of
withdrawal
Pull of dependence and its immediate
rewards are very strong

7.125
Abstinence Rewards
The process of becoming abstinent has its
own eventual rewards, including:
A healthier lifestyle
Employment and self-sufficiency
Educational opportunities
Maintaining positive relationships


7.126
Reward Motivation
It takes a long time for internal rewards of
abstinence to be experienced by the client
attempting to make major behavioral changes
So, CM uses other rewards to motivate:
Treatment adherence
Abstinence
Lifestyle changes

7.127
CM Motivation
Motivates behavior change and abstinence by:
Systematically rewarding desirable behaviors
Reinforcers are positive, pleasurable, and
rewarding events or objects
Negative reinforcers are also effective, such as
removing a fine or restriction


7.128
CM Guiding Principles
Each has unique techniques, but all are
guided by a set of guiding principles:
Identifying behavior that is observable and
measurable
Selecting desired behavior change that can meet
treatment goals
Rewarding small changes


7.129
More Guiding Principles
Additional shared principles:
Choose rewards important to clients by asking
them which would be the most desirable
Reward the targeted behavior immediately
Provide frequent reinforcers
Deliver all rewards as promised
Use escalating series of rewards to provide
greater incentive


7.130
CM Types
Several CM types with a research base:
Contingent access to privileges; for example,
through a system of levels with increasing
privileges
Onsite prize distribution
Refunds or rebates
Vouchers or other token economy systems


7.131
CM Challenge
Identify a reward for a desired behavior that is:
Practical
Available without too much cost or expenditure of
staff energy
Sufficiently powerful over time to replace or
substitute for potent, pleasurable, or pain-
reducing effects of the abused substance


7.132
Community Reinforcement (CR)
Uses social, recreational, familial, and
vocational reinforcers, rather than material
rewards or within-program privileges
Is based on the premise that environmental
resources can be effective in changing
substance use behavior
Has strong case management as an essential
component

7.133
CR Approach Plus Vouchers
Documented as an EBP:
Intensive 24-week outpatient therapy for
treatment of cocaine and alcohol addiction
Treatment goals:
Maintain abstinence long enough to learn new life
skills to sustain abstinence
Reduce alcohol consumption for clients whose
drinking was associated with cocaine use


7.134
CR Approach with Vouchers Format
Clients attended one or two individual
counseling sessions each week, focusing on:
Improving family relationships
Learning skills necessary for reducing drug and
alcohol use
Receiving vocational counseling
Developing new recreational activities and social
networks


7.135
Other Program Aspects
Vouchers were used
Vouchers could be exchanged for retail goods
consistent with cocaine-free lifestyle


7.136
Outcomes
The CR approach was found to:
Facilitate clients engagement in treatment
Facilitate increasing periods of cocaine
abstinence


7.137
Community Reinforcement: Effectiveness
CR has been found to be effective:
With a variety of adult and adolescent
populations
With a variety of ethnic backgrounds
In a variety of settings, such as outpatient and
residential programs, methadone maintenance
clinics, and specialized programs for adolescents


7.138
CM in General: Effectiveness
CM has been documented as an effective
intervention for SUDs involving:
Alcohol
Stimulants
Opioids
Marijuana
Nicotine


Source: National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research-
based guide, 2nd Ed. NIH Publication No. 09-4180. Bethesda, Maryland: Author.



7.139
Small-Group Exercise: CM
Small-group topic assignments:
Group 1: Overview of characteristics
Group 2: Primary techniques/applications
Group 3: Strengths
Group 4: Challenges


7.140
Small-Group Exercise: Contingency
Management
Summarize your assigned topic:
On newsprint for group presentation
On white paper for posting on CM wall graphic
Use resources:
Your manuals and notes
What you already know about this EBP
Resource Page 7.6 (especially helpful for
strengths and weaknesses)



7.141
Pharmacotherapy for Opioid
Dependence
Pharmacotherapy is defined as the use of
medically prescribed psychoactive substances
to treat psychiatric and behavioral conditions
Also called medication-assisted treatment
(MAT)
7.142
Pharmacotherapy Usages
Aid in acute withdrawal or tapering from
psychoactive substances
Replace an opioid, either for a short or long
term
Discourage use of an opioid by reducing its
reinforcing properties
Aid early recovery by reducing cravings or
counteracting longer-term symptoms of
withdrawal
7.143
Pharmacotherapy Background
Medications are available for alcohol, opioids,
and nicotine
Opioid medication must be prescribed by a
medical practitioner
WHO calls for combining pharmacotherapy
with counseling (CBT and CM) and case
management
7.144
MAT for Opioid Use Disorders
Uses one of the following three medications:
Naltrexone
Buprenorphine
Methadone
7.145
Naltrexone
Blocks all the effects of opioids, preventing a
person from getting high
To prevent immediate and severe opioid
withdrawal symptoms, a person must be
medically detoxified and opioid free for several
days before beginning naltrexone
7.146
Naltrexone
Compliance is often a problem, so it is seldom
used
A new, injectable form is available in the
United States

7.147
Buprenorphine (Subutex

)
Reduces or eliminates withdrawal symptoms
without producing euphoria and sedation
caused by heroin or other opioids
At high doses, can produce euphoria, so it is
often combined with another medication that
blocks these effects
7.148
Methadone Overview
Widely used
Maintenance treatment in specialized settings
Stabilized clients may receive take-home doses
7.149
Methadone Function
Methadone:
Prevents opioid withdrawal
Blocks euphoric effects of illicit opioid use
Decreases opioid craving
Stabilized clients can:
Work
Take care of families
Avoid crime and violence
Reduce exposure to HIV

7.150
Small-Group Exercise: Pharmacotherapy
Group 1: Primary techniques/applications
Group 2: Challenges
Group 3: Overview of characteristics
Group 4: Strengths

7.151
Small-Group Exercise: Pharmacotherapy
Summarize your assigned topic:
On newsprint for group presentation
On white paper for posting on CBT wall graphic
Use resources:
Your manuals and notes
What you already know about this EBP
Resource Page 7.7 (especially helpful for
strengths and weaknesses)



7.152


Lunch
60 minutes
7.153
Form new small groups of four or five people
who work in the same area
Reseat yourself in those groups
Select a facilitator to be sure everyone has an
opportunity to participate
Select a reporter
Small-Groups: EBPs
7.154
Which EBPs are you using in your organization
and area?
Which EBPs would be most difficult to implement,
based on your organizational, regional, and
cultural perspectives? What are some of the
challenges?
Small-Group Discussion: EBP
Questions
7.155

Large-Group Discussion: EBPs
What common threads did you hear in the
summaries?
What type of SUD counseling is used in your
region?
What models and practices might be most
promising to explore, given the populations
you serve?