A Behavioral Approach to the Treatment of Substance Use Disorders

Chapter 13: A Behavioral Approach to the Treatment of Substance Use Disorders (SUDs)

Introduction

  • Authors: Sarah H. Heil, Catalina N. Rey, Danielle R. Davis, Stephen T. Higgins

  • Affiliation: Vermont Center on Behavior and Health, Departments of Psychiatry and Psychological Science, University of Vermont, Burlington, VT, United States

  • Overview: This chapter explores a behavioral approach to the treatment of Substance Use Disorders (SUDs) through the lens of behavior analysis, behavioral pharmacology, and behavioral economics.

Conceptual Framework of Substance Use

  • SUDs understood as operant behavior maintained by the reinforcing pharmacological effects of drugs.

  • Extensive evidence supports that various substances (cocaine, psychomotor stimulants, ethanol, opioids, nicotine, sedatives) serve as effective reinforcers, demonstrated by voluntary self-administration across species.

  • Environmental factors (e.g., drug availability, dose, schedule of reinforcement) systematically influence drug use.

Behavioral Economics and Reinforcer Pathology

  • Behavioral economics enhances understanding of decision-making in addiction.

  • Introduces the concept of reinforcer pathology, defined by:

    1. High valuation of immediate drug reinforcers.

    2. Excessive preference for immediate rewards despite negative long-term consequences.

  • Treatments must target these aspects to reduce addictive behaviors and enhance therapeutic efficacy.

Community Reinforcement plus Vouchers Approach (CRA + Vouchers)

  • Effective outpatient treatment for cocaine dependence that combines behavioral principles with reinforcer principles.

  • Includes downloadable therapist manual for implementation.

  • Chapter will cover:

    1. Functional assessment and analysis of SUD-related behaviors.

    2. Description of CRA + vouchers treatment.

    3. Evidence supporting its efficacy.

    4. Case study application.

Prevalence and Diagnosis of SUDs

SUD Diagnosis

  • Based on DSM-5 criteria (2013), requiring two or more of the following within a 12-month period:

    1. Using the substance in larger amounts or over a longer period than intended.

    2. Persistent desire or unsuccessful efforts to cut down or discontinue use.

    3. Great deal of time spent in activities to obtain or recover from substance use.

    4. Craving or strong desire to use the substance.

    5. Recurrent use leading to failure in fulfilling obligations at work, home, or school.

    6. Continued use despite social or interpersonal problems exacerbated by the substance.

    7. Important activities reduced because of substance use.

    8. Recurrent use in hazardous situations.

    9. Continued use despite knowledge of physical or psychological issues caused or worsened by use.

    10. Tolerance to substance effects.

    11. Withdrawal symptoms.

  • SUD severity is categorized:

    • Mild: 2-3 criteria.

    • Moderate: 4-5 criteria.

    • Severe: 6 or more criteria.

    • Remission defined:

    • Early Remission: 3-12 months.

    • Sustained Remission: 12 months or more.

Prevalence of SUDs in the USA

  • Public health crisis, with 2016 National Survey on Drug Use and Health (SAMHSA, 2017) reporting:

    • 50.7% (136.7 million): recent alcohol use.

    • 23.5% (63.4 million): recent tobacco use.

    • 10.6% (28.6 million): recent illicit drug use.

    • 15.1 million: alcohol use disorder.

    • 7.4 million: illicit drug use disorder.

    • Cocaine use rose from 1.4 million (2011) to 1.9 million (2016) with stable disorder rates (≈867,000).

Functional Analysis of Cocaine and Drug Use

  • Experimental research shows:

    1. Drug use is a form of operant behavior sensitive to consequences.

    2. Drug use behavior changes based on environmental context.

Context-Dependent Reinforcement of Drug Use

  • Studies demonstrate how preferences shift between cocaine and monetary options, indicating context-sensitive reinforcing effects.

    • Key Study: Cocaine users chose cocaine over placebo, but preference weakened with higher monetary offers.

  • Study on Stimulus Control: Drug-related stimuli increase cravings and neuroactive areas, predicting relapse (Modesto-Lowe & Kranzler, 1999; Courtney et al., 2016).

  • Temporal Delays: Heavy influence on choice, as shown in studies comparing immediate versus delayed reinforcement outcomes (Roll, Reilly, & Johanson, 2000).

Behavioral Economics of SUDs

  • Individuals with SUDs exhibit more significant delay discounting, preferring immediate reinforcement and delayed losses.

  • Evaluating whether discounting influences decision-making or is a byproduct of unhealthy behaviors.

  • Traits of delay discounting may be alterable but typically serve as stable behaviors (Koffarnus et al., 2013).

Functional Assessment for Clinical Management

  • Essential intake assessments scheduled within 24 hours of contact reduce dropouts (Festinger et al., 1996).

  • Collect data on:

    • Cocaine and substance use history.

    • Treatment readiness.

    • Psychiatric functioning.

    • Social support and legal issues.

Self-Administered Questionnaires

  • SOCRATES: Measures readiness to change.

  • Cocaine Dependency Self-Test: Assesses adverse effects experienced.

  • MAST: Screens for alcoholism; 45% of those with cocaine dependence also fit alcoholism.

  • BDI: Monitors depressive symptoms; significant for assessing psychiatric risk factors.

  • SCL-90-R: Psychiatric symptomatology evaluation.

Structured Interviews

  • 10-15 min treatment description, screening through a semi-structured drug-history interview, obtaining detailed substance use history through timelines (Sobell & Sobell, 1992).

  • Used for personalizing treatment plans based on unique use patterns.

Assessment Tools

  • ASI: Quantifies severity of issues in key functioning areas.

  • Practical needs assessments to address crises affecting treatment engagement.

Treatment Components of CRA + Vouchers

Treatment Overview

  • Recommended treatment duration: 24 weeks and 6 months of aftercare.

  • Delivered via individual sessions initially, can also be adapted for group settings.

CRA Therapy Characteristics

  • Therapists should:

    • Exhibit empathy and active problem-solving skills.

    • Facilitate lifestyle changes, including recreational activities, and accompany clients to appointments.

  • Structure therapy sessions focusing on six core areas based on the client's needs.

  • Utilize functional analyses to assess cocaine use behaviors, exploring antecedents and consequences, and teaching drug-refusal training.

  • Emphasize social network development promoting a drug-free lifestyle, with a focus on engaging in healthy recreational activities.

Skill Training and Life Management

  • Provide training on time management, assertiveness, social skills, and stress management.

  • Integrate programs targeting insomnia, anger management, or vocational enhancement through initiatives like Job Club.

  • Address educational support and therapy for dual diagnosis.

HIV/AIDS Education and Compliance

  • Initial education and counseling about risks related to substance use.

  • Referral for opioid agonist treatment if applicable.

Disulfiram Therapy for Alcohol Dependence

  • Demand compliance and monitoring through an observational reporting system.

Voucher Program

Overview

  • A contingency management intervention to reinforce cocaine abstinence.

  • Urinalysis schedule established for monitoring use.

  • Vouchers accrue points for negative urine tests, escalating rewards system.

  • Implements restrictions on voucher use to ensure compatibility with treatment goals.

Clinical Supervision

  • Oversight by doctorate-level psychologists specialized in behavioral treatment.

  • Weekly meetings to review treatment plans, progress, and client cases.

Supporting Research

  • Clinical trials substantiate CRA + vouchers efficacy.

  • Meta-analyses addressing the impact of CRA and voucher systems on SUDs.

Case Study

Patient Overview: Rob

  • 32-year-old Caucasian male with cocaine and alcohol dependence.

  • Attended treatment with history of drug use escalating over time, accompanied by significant psychosocial difficulties.

Functional Assessment and Treatment Plan

  • Interventions aimed at achieving cocaine and alcohol abstinence, enhancing family relationships, and fostering social networks.

  • Treatment successes included job acquisition and engagement in positive recreational activities.

Treatment Outcomes

  • Sustained abstinence from cocaine, improved family visits, and social interactions.

  • Regular employment achieved with a stabilized schedule around recreational activities.

Conclusion

  • The CRA + vouchers approach offers evidence-based treatment, emphasizing functional analysis as a cornerstone for effective SUD interventions.

  • The chapter concludes with the call for clinicians to adapt and implement strategies discussed in practice, bearing in mind resource constraints.

Acknowledgments

  • Supported by multiple NIH grants for research and preparation of the chapter.