MODULE FOUR

Intervention (Treatment)

Treatment

Exploratory use of cigarettes, alcohol, and certain illegal drugs is well within the boundaries of statistical and psychological normality (Baumrind, 1990; Shedler & Block, 1990). Even though consumption has occurred, there is no real evidence of a clinical problem; thus interventions more intensive than the large-scale prevention approaches described above (i.e., providing information and promoting psychosocial skills) would be neither appropriate nor cost-beneficial. Chronic use of drugs, however, is another matter. Addictions treatment usually requires a far more extensive scope and budget than is needed for drug abuse prevention. We will begin our review of the relevant treatment literature with the relatively circumscribed problem of cigarette addiction before moving on to other substance abuses, including alcoholism. We conclude this module with a brief discussion of pharmacological adjuncts to treatment.

Treatment of Cigarette Addiction. Many treatments for cigarette addiction have been subjected to reasonably rigorous empirical scrutiny. Three aversion-conditioning strategies (namely, rapid smoking, focused smoking, and smoke holding) stand out as primary ingredients in comprehensive treatment programs.

Rapid smoking was first described by Lublin (1969), although Lichtenstein and his associates are credited with most of the procedural refinement and validation (e.g., Lichtenstein & Rodrigues, 1977). Rapid smoking essentially consists of having cigarette users take a normal inhalation every 6 seconds until they are no longer able to do so. The procedure induces physiological discomfort through bodily absorption of greatly increased quantities of tobacco smoke, which contains particularly reactive ingredients like nicotine and carbon monoxide. Since larger doses of these compounds can strain one's cardiovascular system, the technique should only be employed in consultation with a cardiologist (see Linberg, Horan, Hodgson, & Buskirk, 1982).

Focused smoking (Hackett & Horan, 1978, 1979) and normal-paced aversive smoking (NAPS; Danaher & Lichtenstein, 1978) are risk-free alternatives to the rapid smoking procedure. Though independently conceived, both techniques have evolved in such a way as to permit a common description. Essentially, clients sit facing a blank wall and smoke at their normal rate while being cued by the counselor to focus on the discomforts of smoking, for example, bad taste, burning in the throat, feelings of light-headedness and nausea. Smoke holding is another less risky alternative; clients breath normally through their noses but hold smoke in their mouths for thirty seconds and concentrate on unpleasant sensations.

Although early research found these aversion techniques to be quite successful when deployed alone, Schwartz's (1987) review of 883 references suggests that they ought to be embedded in comprehensive programs containing additional strategies for self-management and relapse prevention. The former includes, for example, self-monitoring, stimulus control, and contingency contracting; the latter social support, coping skills, and cognitive restructuring about abstinence violations.

Treatment of Substance Abuse in General. The classic comprehensive behavioral approach to addictions treatment (e.g., Miller & Eisler, 1977) includes three generic objectives: (a) decrease the immediate reinforcing properties of drugs through, for example, aversion therapies and medications such as methadone; (b) teach alternative behaviors; and (c) rearrange the environment so that reinforcement occurs for being "off" drugs. Marlatt's model (e.g., Marlatt & Donovan, 1981) also implies the need for problem-solving skills and cognitive restructuring. The latter is employed to challenge erroneous beliefs about the effects of drugs. As might be expected, all of the individual ingredients of the psychosocial approaches to prevention discussed earlier are theoretically relevant to addictions treatment as well (Battjes, 1985; Botvin, 1986; Hansen, 1988; Stitzer, Bigelow, & McCaul, 1985). For example, since peer involvement and "self-medication" (i.e., decreasing negative affect) are frequently cited etiological correlates, training in psychosocial skills would presumably enhance social ease and reduce psychological distress (Newcomb et al., 1988).

Other approaches to addictions treatment include Pentecostal Protestantism (United States Department of Health and Human Services, 1980) and self-help derivatives of Alcoholics Anonymous. Although behavior principles are rarely if ever articulated in these literatures, they are nevertheless discernable:

A behavioral analysis shows that these groups provide a potently reinforcing group atmosphere which does not tolerate drug or alcohol abuse. New, more adaptive patterns of behavior are encouraged and reinforced through group approval and increased status within the group. Drinking buddies and addicted friends are replaced with more appropriate role models exhibiting complete abstinence. The fact that the "helping agents" were once abusers of drugs or alcohol and therefore represent successful coping models may foster imitation of their behavior and enhance their reinforcing value (Miller & Eisler, 1977, p. 392).

Regardless of its theoretical basis, most of the addictions treatment literature involves adults or at least older adolescents. Although the problem of youthful addiction may seem ubiquitous, controlled research on the effectiveness of specific treatment programs for young addicts is rare (Nathan & Skinsted, 1987). Studies that do appear in print frequently suffer from methodological inadequacies. The Teen Challenge program, for example, reported striking differences between graduates of their facilities and comparison groups on substance abuse indices (United States Department of Health and Human Services, 1980). However, since their program requires that participants be heterosexual, free of emotional disturbance, willing to give up TV, radio, and recordings, and become "born again" Christians, and since the comparison groups consisted of drop-outs of their program, their data are difficult to interpret. Conventional cannons of evaluation require that drop-outs and success cases be combined and contrasted against subjects in alternative or control treatments initially formed by random assignment. By analogy, one cannot claim success for a surgical procedure using those who died on the operating table as a control group!

There are, moreover, conceptual difficulties with extrapolating the logic and data implications of adult treatment downward to the youthful addict. Treatment programs for adults are not always well-suited for teens. The consequences of substance abuse, for example, differ with age. Adults suffer more tangible health and physical losses and are more likely to have been arrested or jailed, in contrast to youth who experience more familial friction and are more likely to have attempted suicide (Griswold-Ezekoye, Kumpfer, & Bukoski, 1986; Spieger & Harford, 1987).

Adult and youthful addicts, however, do share at least one thing in common. Treatment facilities and philosophies have evolved (i.e., exploded) well beyond their research base. In the practitioner community one typically finds three types of facilities: (a) inpatient, (b) outpatient, and (c) residential.

Inpatient facilities usually provide hospital detoxification and other supportive services to long-term chronic abusers and those at medical risk from an overdose (Rhodes & Jason, 1988). Their fees are inevitably high relative to other available programs (Griswold-Ezekoye et al., 1986). Outpatient facilities (e.g., "drop-in" centers, family service agencies, individual and group counseling centers) receive the majority of youthful referrals who are presumably, but not necessarily, less at-risk than those requiring inpatient or residential treatment (Rhodes & Jason, 1988). Residential (nonmedical) facilities are usually less costly than inpatient treatment centers; thus those serviced are more likely to have a low level of education, to have been referred by the criminal justice department, to have had previous drug abuse treatment, and to be polydrug users (Griswold-Ezekoye et al., 1986). Residents are usually required to participate in therapeutic activities and are expected to share "household" responsibilities.

Upon discharge from an inpatient or residential facility, the practitioner literature unequivocally recommends some form of aftercare services to prevent relapse. Intuitively, it would be difficult to disagree, but in truth data are relatively sparse on the differential efficacy of such services, on methods for appropriately matching people to different aftercare programs, or on the effectiveness of such services compared to no treatment at all. The practitioner literature is also replete with recommendations for various therapeutic interventions used in the foregoing facilities. In addition to the generic behavioral and psychosocial rationales discussed above, endorsements for family therapy and reality therapy are common. Despite the etiological link between family variables and substance abuse, most of the research on family treatment strategies (e.g., parenting training) suffers from multiple confounding variables (Moskowitz, 1985). Likewise, studies evaluating the effects of reality therapy (Glasser, 1969) on substance abuse have methodological shortcomings that preclude meaningful interpretations of their results (Rhodes & Jason, 1988).

Treatment of Alcoholism in Particular. The foregoing comments on the treatment of substance abuse in general apply to alcoholism as well. Nevertheless, several additional remarks are warranted. Miller and Hester (1986) reviewed 26 controlled studies and reported that inpatient services were not significantly more effective than outpatient services, and that the outcome of alcoholism treatment is more likely to be influenced by the content of the interventions than by the settings in which they are offered. They noted that inpatient costs commonly range between $4,000 and $15,000, whereas outpatient services can be had for less than 10% of that amount, "even if delivered by fully credentialed professionals at prevailing private practice rates" (p 802). They also bemoaned the fact that empirically supported treatment methods such as Azrin's community reinforcement approach remain virtually unused in standard treatment.

Azrin's program (Azrin, 1976; Azrin, Sisson, Meyers, & Godley, 1982; Hunt & Azrin, 1973; Sisson & Azrin, 1986) originally began with four treatment components: (a) placement in full-time, steady, satisfying, and well-paying jobs; (b) marriage and family counseling aimed at becoming more pleasurably and continually involved in family activities; (c) establishment of a social club for abstinent members that includes enjoyable social events and support, particularly during evening hours and on weekends; and (d) gradual engagement in pleasurable hobbies and recreational activities that provide alternatives to drinking. Hunt and Azrin (1973) reported that compared to a matched control group admitted for treatment at a state hospital, their four-component program produced significant decrements in drinking, unemployment, being away from home, and institutionalization; and these benefits endured over a 6-month follow-up period.

Subsequent modifications to the program included the addition of a Buddy system, a daily report procedure, group counseling, and a special social motivation module to ensure self-administration of Disulfiram. Azrin (1976) reported similar results, stable over a 2-year period. More recently, Sisson and Azrin (1986) evaluated methods for teaching family members of problem drinkers how to minimize their own distress, reduce their own drinking, increase the motivation of the alcoholic family member to obtain formal treatment, and assist in the treatment regimen. Their results suggest that teaching concerned family members appropriate reinforcement procedures can lead even unmotivated alcoholics to begin formal treatment. We share Miller and Hester's (1986) dismay that Azrin's long-standing and demonstrably effective program lies far outside the mainstream of standard treatment practice.

Pharmacological Adjuncts to Treatment. The rationale for using pharmacological adjuncts in the treatment of substance abuse derives in part from experimental studies showing that animals self-administer the same types of drugs that humans abuse (Johanson & deWit, 1989). Because compared to human beings, the learning history of an animal is subject to infinitely greater degrees of inspection and control, it is relatively easy to demonstrate that the animal's addiction arises from the reinforcing properties of the drug (Bigelow, Stitzer, & Liebson, 1984). These properties include, for example, those that produce euphoria when the substance is consumed and those that ward off an aversive withdrawal reaction when the substance is not available. Hence, the development of two classes of drugs used in pharmacological treatments: Antagonists avert the reinforcing properties of drugs by inhibiting the neurotransmitter effects on the postsynaptic cell; agonists facilitate the neurotransmitter effects and mimic the substance being abused, thus eliminating the need for it (Carlson, 1988).

Unlike experimental animals, the drug-taking behavior of humans is inevitably under the control of social-reinforcement variables in addition to the physiologically reinforcing properties of the drug. Thus, pharmacological products are usually viewed as adjuncts to treatment rather than as treatments per se. Most pharmacological adjuncts are specific to the type of substance that is being abused; and within a given abuse category, different pharmacological adjuncts may be directed toward different objectives. For example, Chlordiazepoxide is a new drug relevant to the alcohol detoxification process; it purportedly prevents withdrawal symptoms from occurring. Antabuse, on the other hand, produces severe nausea if followed by alcohol ingestion; it has been used in aversion therapy for alcoholics for many years. With heroin addicts, methadone arguably is the adjunct of choice (Dole & Nyswander, 1965; Schuster, 1986). Other pharmacological adjuncts to the treatment of opiate addiction include Naltrexone, an antagonist that purportedly inhibits the reinforcing properties of opiates, and Buprenorphine, a mixed agonist-antagonist which is said to prevent withdrawal and simultaneously block the opiate's reinforcing properties.

Nicotine gum has been shown to be a reasonably effective adjunct in research on comprehensive smoking treatment programs (Lam, Sze, Sacks, & Chalmers, 1987). Data supporting its use in general medical practice, however, is less convincing (Russell, Merriman, Stapleton, & Taylor, 1983).

Cessation of marijuana use is not known to produce a withdrawal reaction; and recent descriptions of a cocaine withdrawal syndrome must be considered as preliminary (Kleber & Gawin, 1986). Although no specific pharmacological adjuncts have been developed to assist in treating the abuse of either drug, anti-depressants are sometimes prescribed for the depression that may occur after quitting the use of cocaine.

Given recent success in immunizing animals against the reinforcing properties of drugs, some researchers are hoping to replicate the procedure with humans (cf. Schuster, 1986). Once developed, the serum antibodies would be effective only against the drug being inoculated against. In view of our current low level of precision in predicting which children will grow up and abuse what drug, the inevitably of toxic consequences resulting from widespread inoculation efforts raises serious ethical concerns.

Pharmacological adjuncts are not commonly used with children and adolescents, except in circumscribed ways such as in the practice of emergency-room medicine. Little is known about the short and long-term effects of these drugs on younger patients. All pharmacological adjuncts have side effects: Antabuse, for example, may produce heart failure in certain individuals following as little as 2 drinks. Some treatment adjuncts generally considered safe for adults, such as methadone, are not recommended for children because adequate research remains to be conducted before proper dosage can be prescribed.