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12 ADVANCES IN THE TREATMENT OF OTHER PSYCHOACTIVE SUBSTANCE-USE DISORDERS: IMPLICATIONS FOR RESEARCH ON TREATMENT OF ALCOHOL PROBLEMS The alcoholism treatment field has developed largely in isolation from treatments for other addictive disorders, although there are many parallels between alcoholism and other addictive problems. This chapter highlights major advances in the conceptualization and treatment of psychoactive substance-use disorders other than alcoholism; it also considers the implications of this work for research on the treatment of alcohol problems. SMOKING The context for smoking cessation research has changed dramatically in the past 25 years. Since the publication of the surgeon general's first report on the issue (U.S. Public Health Service, 1964), evidence has mounted about the detrimental health effects of smoking. The vast majority of smokers are concerned about such effects and would like to quit (Orleans, 1985~. In addition, concerns about the health effects of tobacco smoke have led to a strong nonsmokers' rights movement, which has resulted in restrictions on smoking in public places. Smoking has become an increasingly stigmatized behavior. This climate reflects attitudes that are quite different from attitudes about alcohol use: in the case of alcohol, controversy exists about the beneficial or harmful effects of moderate doses of alcohol, and nondrinkers' rights have become an issue only in relation to drinking and driving. Most persons with drinking problems are not self-identified and are not trying to stop drinking. Thus, research on smoking cessation occurs in a substantially different social climate from alcohol treatment research, which may limit the applicability of some of the smoking research to the alcohol field. However, many of the programs, models, and variables do appear to have relevance. This chapter considers several major areas of smoking research that are relevant to alcoholism treatment research. There is a very high rate of co-occurrence of alcoholism and smoking, but the recent prominence of the nonsmokers' rights movement and the inclusion of nicotine dependence in the third revised edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R) under psychoactive substance-use disorders have increased interest in the promotion of smoking cessation among alcohol patients in treatment. Although no controlled studies have yet been reported, some treatment centers are offering smoking cessation programs, and there are a growing number of nonsmoking meetings available in Alcoholics Anonymous (AA). Nonetheless, conventional wisdom is that clients should initially focus on changing drinking and other drug-use behaviors and postpone changes in smoking or eating behavior. No data are available to substantiate this belief. The following questions represent opportunities for research on smoking cessation during alcohol treatment: -247

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What is the impact of concurrent versus consecutive treatment for changing drinking and smoking behavior? Are particular types of smoking cessation approaches most effective with alcoholic patients? What impact would a smoke-free environment have on inpatient alcohol treatment? Treatment Process Research Smoking cessation research has focused on a number of motivational, cognitive, social, environmental, and behavioral processes related to smoking cessation. This section reviews advances in research on several of these variables. Processes and Stages of Change Prochaska and DiClemente (1986) have identified five stages in the process of quitting smoking and ten major processes that may characterize change attempts for any personal problem (Prochaska, 1984~. Their research suggests that different processes are used at different stages of change. They have recently begun to test treatment and self-change materials that are specifically geared to different stages of change. Alcoholism treatment research has done little to systematically modify treatment approaches based on different degrees of readiness for change. Although a number of approaches have been developed for the early identification of those with drinking problems (e.g., Lewis and Gordon, 1983; Babor, Ritson, and Hodgson, 1986), techniques that address the unique clinical needs of these populations have not been carefully evaluated, and treatment research has not focused on matching a treatment method to a person's stage of readiness for change. Moreover, alcoholism treatment research has not systematically evaluated the change strategies alcoholics actually use in order to determine which interventions might be effective at different stages in the change process. The following questions represent opportunities for research on processes of change: Do persons with drinking problems go through identifiable stages of change and use unique processes at different stages? Can treatment methods be developed to teach clients change techniques that are most relevant for their stage of change and that effectively move clients from one stage of change to the next? Do certain types of informational feedback (e.g., health information) have a unique effect in getting people to change their drinking behavior? Cognitive Predictors of Smoking Cessation Several investigators have examined the relationships between cognitive variables and smoking cessation. Self-efficacy (see Bandura, 1977) is a cognitive mechanism that is postulated to underlie behavior change. Efficacy expectations, which are situation specific, are believed to determine whether coping behaviors are initiated and sustained, especially in the face of obstacles lo change. In contrast, outcome expectancies refer to expectations about the probable consequences of behavior rather than the individual's belief in his or -248

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her ability to engage in the behavior. A third cognitive variable, attribution, has also been examined in relation to smoking cessation. Attributions for change (locus of control) may be either internal, in which case the client feels primarily responsible for change, or external--the client attributes change to an external agent (e.g., a drug). These three cognitive variables have been studied as factors that might predict success in initiating or maintaining smoking cessation. Several research groups have found that higher self-efficacy at the end of treatment is consistently related to positive treatment outcomes at the point of follow-up (DiClemente, 1981; Godding and Glasgow, 1985; Gregory, Etringer, and rondo, unpublished; Velasques et al., unpublished). ' ~ ~ ~ ~ ~ ~ in addition, a generalized belief in the ability to quit strongly predicted long-term abstinence (Mothersill, McDowell, and Rosser, 1988), even though outcome expectancies have not been found to predict long-term changes in smoking (Goading and Glasgow, 1985~. Studies of attributions for change have found that ax-smokers who have successfully stopped smoldng are more likely to attribute the causes of success or failure to internal reasons than are those who have continued smoking (Harackiewicz et al., 1987~. Epstein and colleagues (1987) found that 12 months after treatment, those who maintained smoking cessation continued to make more internal attributions for change than did those who had relapsed. This study also demonstrated that attributions could be changed and maintained through therapeutic interventions. It should also be noted that there is a significant difference in the locus of control for change propounded by providers of smoking cessation treatment and by some alcohol treatment providers. Programs that utilize the AA philosophy emphasize the importance of giving responsibility for change to a higher power, an outlook that would appear to be different from the internal attribution.c for chance suggested by the smoking literature. it, Cognitive research points to the role of beliefs in smoking cessation. A high level of self-efficapy, a generalized belief in one's ability to change, and internal attributions for change are all positive predictors of the outcomes of smoking cessation attempts. Although none of these variables accounts for the majority of variance in outcomes, all of them contribute to it. Similar variables are beginning to be examined in alcoholism treatment research studies, and specific measures of self-efficacy (Annie, 1988), outcome expectancies for alcohol use (Brown et al., 1980), and drinking-related locus of control (Donovan and O'Leary, 1978) have been developed; however, more research into cognitive variables should be encouraged. O ~ The following questions represent opportunities for research on cognitive variables: Do self-efficacy and outcome expectancies predict success in changing and in maintaining changes in drinking behavior? If self-efficacy and outcome expectancies predict positive treatment outcome, what treatment techniques or settings can most successfully affect these variables? What is the relationship between attributions for change and successful treatment outcome? -249

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Antecedents to Relapse and Coping Skills In recent years, investigators who study treatment of addictive behaviors have generally shifted their focus from the initiation of change to the maintenance of change. Relapse, the antecedents to relapse, skills for avoiding or coping with relapse, and the mechanisms that underlie relapse have become important research areas (Marlatt and Gordon, 1985~. This research has spanned most addictive behaviors. In smoking research, a distinction has been made between the antecedents that lead to full smoking relapse and the antecedents that end with a return to abstinence. Early studies reported that a preponderance of antecedents involved negative affect or withdrawal symptoms (Ossip-Klein et al., 1984; Shiffman, 1985~. Full relapsers appear to respond to different kinds of situations than do temporary lapsers or those who experience a temptation to smoke but do not do so (O'Connell and Martin, 1987~. Coping has been conceptualized as a mediating variable between exposure to a potential relapse situation and the choice of relapse or continued abstention. Relapsing smokers do not appear to be deficient in overall coping skills (Abrams et al., 1987), but relapsers evidence higher anxiety in smoking-specific situations and are less skillful in coping with them, especially when they involve interpersonal elements (Abrams et al., 1987~. Smoking in response to a potential relapse situation appears to be primarily determined by the coping response used rather than by the type of relapse situation (Shiffinan, 1985~. Recent research (Glassman et al., 1988) suggests that smokers with a history of depression have lower success rates in quitting smoking. The presence of depression might affect the smoker's ability to use coping responses when confronted with high-risk situations for relapse. Research on the antecedents to drinking relapse actually preceded research on antecedents to smoking relapse. However, smoking researchers have extended this research in two fruitful directions: (1) the examination of different coping responses and antecedents for those who continue to smoke or those who resume abstinence and (2) studies of the relative effectiveness of different types of coping responses. The following questions represent opportunities for research on relapse and coping studies: Are different types of relapse situations and coping responses associated with different outcomes or drinking episodes? Are different types of coping responses utilized at different stages of successful change in drinking? Does the presence of a diagnosable depressive disorder affect the alcoholic's ability to use coping responses to avoid relapse? What social system variables influence the use of coping responses in potential relapse situations? Social Support Higher levels of social support are known to be associated with better physical and psychological functioning. The mechanisms by which social support influences psychological health are not well understood, but a number of investigators have developed partner-involved treatment interventions. Results of the effectiveness of these interventions have been mixed (McCrady, 1986~. In the smoking field, early research focused on the -250

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relationships between naturally occurring partner behaviors and successful smoking cessation and maintenance. The frequency of social support in itself has not been found to predict successful smoking cessation (Harrow et al., 1986~. Positive partner support has been shown to be associated with successful smoking cessation and maintenance, and negative partner behaviors are associated with unsuccessful quit attempts (Mermelstein, Lichtenstein, and McIntyre, 1983; Coppotelli and Orleans, 1985~; however, attempts to change partner behaviors to increase support have not yielded improved maintenance of smoking cessation (Lichtenstein, Glasgow, and Abrams, 1986~. Studies have also examined the effectiveness of enhancing other sources of support for smoking cessation and maintenance, for example, coworkers. These studies have also found little evidence for improved long-term maintenance of change as a result of attempts to enhance coworker support (Lichtenstein, Glasgow, and Abrams, 1986~; however, higher levels of negative or nonsupportive social interactions have indeed been found to correlate with relapse (Glasgow, Klesges, and O'Neill, 1986~. Research has not yet addressed the impact on successful quit attempts of establishing a smoke-free home or workplace. A number of recent studies (reviewed in Orleans, 1985) have examined the effectiveness of spouse- involved alcoholism treatment. Although most of these studies have yielded promising results, the smoking literature suggests two additional areas of research: (1) studies of types of partner behaviors that are naturally associated with different treatment outcomes and (2) studies of other aspects of the alcoholic's social environment. The following questions offer opportunities for research on social support studies: Are certain partner behaviors associated with more and less positive alcoholism treatment outcomes? If these behaviors can be reliably identified, can they be taught, and will such a treatment intervention affect treatment outcome positively? What characteristics and behaviors of social support networks outside of the family are associated with more and less positive treatment outcomes? Can effective treatment interventions be designed to enhance the support behaviors of the alcoholic's naturally occurring social environment? Motivational Factors A number of motivational factors are associated with successful smoking cessation. Health concerns, expectations of improved future health, and a feeling of personal vulnerability to health risks are strong correlates of successful cessation (Orleans, 1985~. Successful quitters report that they desire a greater sense of self-maste~y, self-esteem, and self-approval and that they associate these feelings with successful smoking cessation (Orleans, 1987~. In contrast to continuing smokers or recidivists, successful quitters report that they expect to succeed, expect quitting to be easier, and expect more benefits from quitting (Orleans, 1985~. Some smokers also appear to stop for altruistic motives, such as concerns about the impact of their smoking on others, or because they want to set a positive example for their children (Orleans, 1987~. Smoking researchers have redefined motivation by examining specific components of the desire to quit smoking, including personal beliefs about health, the perceived psychological benefits of quitting, expectations about the quitting process, and concerns about others. Defining motivation in terms of cognitive and affective variables implies that these -251

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components of motivation may be amenable to intervention. Similar to Prochaska's work on stages of change, motivational studies suggest particular treatment interventions that could target specific aspects of motivation. In the alcoholism field--with exceptions, such as Miller (1985~--motivation has generally been seen as a global construct rather than as a specific set of factors. Because of the common perception that alcoholics who are actively dunking have high levels of denial of their problems, interventions to affect motivation have usually involved external coercion. Relatively little attention has been given to methods of altering the internal components of an individual's motivation. The following questions represent opportunities for research on motivation studies: Do specific health beliefs or positive expectancies about the benefits of decreasing or stopping drinking positively affect an alcoholic's decision to decrease or stop drinking and to maintain change? Do "altruistic motives" (concern for others) predict successful changes in drinking? What interventions will successfully affect the motivational factors that are most associated with successful change in drinking? Treatment Studies on Smoking Cessation Two recent reviews of the literature on smoking cessation treatment methods offer comprehensive summaries of this literature (Schwartz, 1987; Kamarck and Lichtenstein, in press). The highlights of these reviews are summarized here. Schwartz (1987) described seven approaches to smoking cessation treatment and two innovative large-scale approaches (which are described in the following section on unique, programmatic strategies). For each approach he reviewed the empirical literature and then estimated median success rates at 6 and 12 months. The approaches included self-care, educational and group programs, medications, nicotine chewing gum, hypnosis, acupuncture, and behavioral techniques. The five methods with the best success rates are noted below. 1. Self-care approaches to smoking cessation have included individually developed cessation approaches, the use of brief instructions or advice, and the utilization of smoking cessation aids (e.g., filters), self-help guides, or Quit kits.n Almost a dozen studies in this area find an average success rate of 18 percent one year after attempting to quit (Schwartz, 1987~. 2. Educational programs, clinics, and groups have proliferated in the last decade. Such programs are offered commercially and by public service organizations and show median one-year success rates of approximately 25 percent (Schwartz, 1987~. 3. Medications to overcome the smoking habit (e.g., clonidine), and medications to minimize withdrawal have both been evaluated. The average rate of successful quitting and maintenance is about 18 percent for medication studies (Schwartz, 1987~. However, a recent report (Glassman et al., 1988) found much higher rates of short-term success for clonidine-treated subjects than for placebo-treated subjects (64 versus 29 percent at four weeks), as well as continued higher success rates six months after treatment (29 percent of those on clonidine were still abstinent, compared with 5 percent of those on placebo). This study yielded unusually low abstinence rates in the placebo group, however, and therefore requires replication to increase confidence in the results. -252

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4. Nicotine chewing gum was developed to reduce withdrawal symptoms in the first weeks after smoking cessation and has yielded successful one-year quitting and maintenance rates ranging from 29 to 49 percent, compared with 4 to 37 percent for placebos (Tonnesen et al., 1988~. The average success rate after 12 months was 11 percent for nicotine chewing gum treatment, but the rate rose to 29 percent when nicotine chewing gum was combined with behavioral therapy (Schwartz, 1987~. A more recent review (Hughes, 1988) updates Schwartz's review, reporting that in three of four new studies nicotine chewing gum in combination with behavior therapy yielded better treatment outcomes than nicotine chewing gum alone. 5. Behavioral methods have been evaluated in studies of individual treatment methods and in studies that combine multiple treatment methods. Aversive smoking procedures have been used in attempts to reduce the reinforcing value of smoking by pairing it with aversive stimuli. Techniques have included rapid smoking, smoke holding, and focused smoking. Rapid smoking alone has produced an average 12-month success rate of 21 percent, smoke holding has yielded a 6-month success rate of 33 percent, and focused smoking has yielded an average 26 percent success rate at one year. When rapid smoking is combined with other behavioral procedures, the average success rate rises to 30.5 percent at the one-year follow-up point (Schwartz, 1987~. Behavioral approaches have also introduced techniques to help people stop smoking and cope with abstinence flora cigarettes. Nicotine fading (Foxy and Brown, 1979) is a technique in which the smoker gradually reduces nicotine intake over several weeks by switching to cigarette brands with progressively lower amounts of nicotine. This procedure, when used as a prelude to smoking cessation, has yielded average successful quit rates of 25 percent over six months (Schwartz, 1987~. Self-management techniques to cope with abstinence from cigarettes are similar to those used with other behavioral problems and have included self-monitoring, stimulus control, contingency management, desensitization, relaxation, and self-control packages. Recent studies have combined aversive smoking procedures with behavioral self-management techniques, yielding success rates of 32 percent over six months and 40 percent over one year (Schwartz, 1987~. In summary, the highest one-year success rates come from multiple-component, behaviorally based treatment programs that specifically combine rapid smoking with other behavioral treatments And nicotine gum with behavior therapy (Schwartz, 1987~. Several factors differentiate smoking cessation treatment from alcoholism treatment. First, self-help groups have played a more limited role in smoking cessation. Second, smoking researchers show a greater respect for smokers' stated desire to quit son their own" and have attempted to understand that process and develop materials that will aid the self-change process. In contrast, many clinicians and researchers in the alcoholism field believe that alcoholics experience Loss of control" and "denials of their problems, which casts doubt on the possibility of self-directed change. Although there are a number of self-change oriented books and tapes for drinkers, this approach has met with limited acceptance. Third, a pharmacologically active but relatively safe alternative to tobacco is now available, and its effectiveness is being evaluated. Fourth, many of the most robust approaches, which are well accepted in the smoking field, have been derived from behavioral approaches to treatment. Although much of the empirical work on the effectiveness of alcoholism treatment has been derived from a behavioral perspective, these techniques have not been widely applied. Fifth, some novel aversive smoking procedures have been developed that appear to have a positive impact on treatment when combined -253

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with additional treatment elements. Finally, nicotine fading, an approach to nicotine withdrawal that is radically different from current approaches to alcohol withdrawal, has been introduced and used with success. The following questions, suggested by smoking treatment studies, represent opportunities for further research: What is the effectiveness of currently available self-change materials for drinkers, and for whom are these materials most effective? Would different types of self-change materials be more appropriate for certain types of drinking problems? What methods would increase the availability and acceptability of empirically tested self-change materials for drinkers? Can a pharmacologically active alternative to alcohol be developed that would decrease the symptoms of a protracted abstinence syndrome without having addictive or other potentially harmful side effects? What would be its role and effectiveness as a treatment agent? ~ What would be the outcomes of large-scale clinical trials of multiple-component behavioral programs for alcoholism treatment? Unique and Programmatic Approaches to Smoking Cessation Several novel approaches have been used to bring smoking cessation information and materials to the public. These approaches have in common a shift from traditional treatment models, which require clients to seek assistance, to models that make materials accessible in settings with which smokers are already involved. Many of these programs are similar to those described in Chapter lo on the early identification of brief interventions for alcohol problems. Physician Counseling Most physicians feel that it is their responsibility to help their patients quit smoking (Schwartz, 1987~. However, only 22 to 25 percent of smokers report that their physician has advised them to quit (Schwartz, 1987~. A number of programs have been developed to teach physicians the skills needed to facilitate smoking cessation. The highest reported quit rates (Schwartz, 1987) are for physician interventions with cardiac patients, with a median one-year quit rate of 43 percent. Simple physician advice, taking as little as one minute, will yield median quit rates of 6 percent; physician advice coupled with other interventions (e.g., additional information, questionnaires, feedback about health effects, careful guiding of quit attempts) results in one-year quit rates of 22 percent (Schwartz, 1987~. Formal evaluations of physician interventions to assist patients to change their drinking are relatively few. An increasing amount of medical education on alcoholism (Gottlieb, Mullen, and McAlister, 1987), alcoholism-related training materials (Liepman, Anderson, and Fisher, 1984), and self-directed texts are now available (e.g., from the American Medical Society on Alcohol and Other Drug Dependencies); films directed toward physicians have also been developed (e.g., Kinney et al., l986~. Yet controlled evaluations of the effectiveness of ~ . . . . ~ ~ . . . cilia ~uu~a`~tat ~tUtt~ aici `~111g, alla most twin Ine exception of Krlstenson and colleagues, 1983, for example) have focused on alcoholism rather than heavy drinking. In addition, most provide a broad knowledge base about alcoholism but less specific ~ ~ ~ LO ~ ~ ~^ ~* ~ ~ ~Ott_ ~ _ ~B. ~ ~ _ _ ^ a__ __ ~An_ ~. ~* ~- -254

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information about how to intervene. An exception to this is the World Health Organization's Amethyst Project (Babor et al., 1987), which is currently developing and evaluating focus" interventions for nonalcoholic patients. The following questions represent opportunities for physician and primary care studies: What is the electiveness of simple physician advice, alone or combined with other interventions, in decreasing drinking in nonalcoholic, heavy-drinking patients? (See Elvy, Wells, and Baird, 1988, for a recent report of such a study.) For alcohol~ependent patients, what is the effectiveness of simple physician advice to stop drinking or to seek treatment? How effective are physician interventions that are developed uniquely for patients with alcohol-related diseases (e.g., liver disease, pancreatitis)? What components are necessary, and what is the most effective sequencing of these components, in physician interventions with alcoholic patients? Special Populations The final area of innovation in the delivery of smoking cessation programs is the development of methods for reaching underserved populations. Blacks have the highest smoking rate of any major ethnic or racial group in the United States, along with very high rates of morbidity and mortality from cardiovascular disease and cancer. There are currently several ongoing projects directed at black smokers that include efforts to reach black inner-city smokers through physician advice and quitting aids, televised smoking cessation clinics and in-person classes (which target black women in public housing projects), clinics for Head Start mothers that are led by trained lay counselors, and combined prevention and quit-smoking programs for black communities (U.S. Department of Health and Human Services, 19881. In one of the most innovative programs (U.S. Department of Health and Human Services, 1988), researchers are working with a black-owned insurance company to deliver smoking cessation materials to policyholders. No outcome data are available yet from any of these studies, but they provide unique perspectives on the delivery of services to underserved populations. The innovative methods described above for the delivery of smoking cessation programs to black smokers could be replicated and evaluated for use in treating drinking problems among blacks and other ethnic/racial minority groups. The following questions represent opportunities for special population studies: What types of alcoholism programs attract and retain the highest proportions of potential subjects who are minority group members? What is the relative effectiveness of alcohol treatment materials that are specially tailored to the target population, compared with generic materials? What are the outcomes of treatment programs that are uniquely designed to reach the minority group member, compared with existing treatment programs? OTHER DRUG DEPENDENCIES There has been a significant increase in the range and quality of treatment studies in the field of drug dependence over the past 10 years similar to the increase seen in smoking -255

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research. There has also been a move toward the evaluation of rehabilitation Worsts rather than a focus on detoxification procedures. Treatment and research efforts in the field of drug dependence have always been ' relevant to the field of alcohol dependence. Now, however, the growing group of mixed alcohol- and drug~ependent (particularly alcohol plus cocaine) patients presenting for treatment and the growing reliance among drug dependence treatment providers on methods and procedures similar to those that were traditionally used for alcohol dependence (e.g., AA, relapse prevention, breathalyser screening, disulfiram) bring these two fields even closer and suggest several avenues for future collaborative treatment and research efforts. This section reviews some of the research into drug dependence that is most pertinent for future studies relating to the treatment of alcohol dependence. Use of Psychotherapy in the Treatment of Drug-Dependent Patients In a study of cocaine-dependent patients, Siegel (1984) described using frequent supportive psychotherapy sessions, self-control strategies, and liberal use of hospitalization during initial "detoxification. This treatment employs external controls initially to separate the user from the use-fostering environment and then gradually facilitates the internalization of controls through psychotherapy. Half of Siegel's sample of 32 heavy cocaine users dropped out, but 80 percent of those remaining were cocaine free at the n~ne-month follow-up point. More recently, Rounsaville, Gawin, and Kleber (1985) described their adaptation of interpersonal psychotherapy for ambulatory treatment of cocaine abusers. Gawin and Kleber (1984) reported the outcome for four patients who received a version of this treatment. Although three of these patients completed at least 12 weeks of treatment and cocaine use was reduced, only one patient was entirely abstinent. Although both of these treatment attempts used professional psychotherapy as an inteIventiorl directed primarily at the symptoms of drug use (in these cases, cocaine), other studies have used psychotherapy to address the significant psychiatric problems that are often seen concurrently among substance abusers. This practice reflects the view that "underlying" or coexisting psychiatric problems of these individuals may have fostered the substance use or reduced the efficacy of the primary substance abuse treatment. There has been recognition for some time of the growing population of substance-dependent individuals with significant psychopathology (Rounsaville et al., 1983; Rounsaville, Gawin, and Kleber, 1985) and the limited improvement these patients show in traditional treatment programs (McLellan et al., 1983, 1984; Powell et al., 1985~. For this reason, there has been a movement during the last five years toward the use of standard psychiatric interventions with this population. Two major individual psychotherapy studies were conducted in parallel by groups at Yale (Rounsaville et al., 1983) and at the University of Pennsylvania (Woody et al., 1983~. Both studies showed professional psychotherapy to be superior to standard rehabilitation counseling, although this difference was statistically significant only for the University of Pennsylvania subjects. Results from the University of Pennsylvania series of studies showed that two types of psychotherapy significantly reduced drug use and illegal activity and increased employment compared with drug counseling (Woody et al., 1983~. Additional analyses' of these data showed that the "psychiatrically severer opiate addict (current symptoms of depression, anxiety, etc.) was not helped by standard counseling -256

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alone but was significantly helped by the additional therapy (Woody, McLellan, and Luborsky, 1984). Finally, additional analyses of patient diagnostic groups within this sample suggested that opiate-dependent patients with a DSM-III diagnosis of antisocial personality disorder were virtually unaffected by the additional treatment (Woody et al., 1985~. This failure to find improvement in antisocial patients despite the addition of professional treatment is quite consistent with similar studies from the alcohol literature (Stabenau and Hesselbrock, 1984; Powell et al., 1985~. Group psychotherapy continues to be the most common form of intervention used with alcohol and other substance~ependent patients. Research into the use of individual psychotherapy has demonstrated the value of professional, manual-trained, supervised therapy in producing favorable outcomes among drug-dependent patients. The methods used in these forms of therapy are generally supportive, educational, and insight oriented. By contrast, group therapy, as generally practiced in alcohol dependence treatments, is not manual guided or supervised, may or may not be professionally guided, and often uses a confrontational approach. The following are opportunities for alcoholism treatment research suggested by psychotherapy research in drug dependence: Research is needed to evaluate the role of manual-guided or supervised procedures in the performance and efficacy of group psychotherapy for alcohol-dependent patients. Although there have been several studies attempted of psychotherapy with alcoholics, few have used manual-trained and supervised therapists, verification of the integrity of the therapy that was delivered, or examination of multiple outcome measures. Would the generally positive results of psychotherapy with drug-dependent patients be replicated with alcohol-dependent patients if these Quality assurance. procedures were instituted? More focused studies are needed in this area to evaluate the role of psychotherapy~ies) as a primary treatment for an alcohol problem (research to date suggests a limited role) as opposed to a treatment for depression, anxiety, or relationship problems that coexist with alcohol problems and often lead to relapse. (Data from the drug dependence field suggest that psychotherapy may play an important role in this context.) Modern psychiatric practice commonly combines pharmacologic and psychotherapeutic methods in the treatment of certain disorders. The use of psychotropic medications has sometimes presented philosophic problems for traditional alcohol treatment programs, and for this reason in many studies psychotherapy has been tested against a particular pharmacotherapy. Studies are needed that combine these two types of interventions in alcohol-dependent patients. Conditioned Factors in Substance Abuse Treatment The phenomenon of craving is poorly defined and poorly measured but clearly significant in the relapse to alcohol abuse following treatment. Research in both alcohol- and drug-dependent populations indicates that craving for a substance can be elicited reliably by the presentation of stimuli associated with the substance. In an attempt to understand the persistence of addictive behaviors despite treatment attempts, several investigators have studied the conditioned responses produced by stimuli associated with opioids and other drugs. In particular, stimuli that have been repeatedly -257

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paired with drug administration (drug paraphernalia, drug using/buying locations, mood states) can become classically conditioned Reminders that trigger arousal, drug craving, and sometimes even withdrawal signs and symptoms (Childress, McLellan, and O'Brien, 1984, 1985; McLellan et al., 1986~. Conditioned craving and arousal in response to these reminders have been demonstrated in both opiate and cocaine abusers (Childress, McLellan, and O'Brien, 1984, 1985, 1986~. An experimental treatment that has been developed based on these findings is designed to reduce the ability of these cues to promote craving and arousal by repeatedly presenting them in laboratory and clinical settings and not following them with drugs. These extinction procedures have been shown to reduce opiate- or cocaine-related arousal and drug craving but only after a long series of exposures, usually 30 sessions (Childress, McLellan, and O'Brien, 1986~. These studies of conditioned factors in drug dependence parallel findings of conditioned physiological responses in alcoholics after the presentation of alcohol-related cues (Ludwig and Stark, 1974; Meyer et al., 1981) and in cigarette smokers when smoking cues are presented (Pomerleau and Pomerleau, 1984~. Findings from this research underscore the potential importance of conditioned factors in explaining relapse to drug use and give evidence of the complexity of the application of these factors in a controlled clinical intervention (see Blakey and Baker, 1980~. There is widespread recognition that alcohol-dependent patients often have concomitant marijuana, cocaine, or other substance abuse problems. The prevailing treatment philosophy has been that total abstinence from all such substances is necessary and that even casual use of one substance will rapidly reinstitute use of the coheres). It is possible that the presentation of drug-related cues (e.g., pipes, bags of cocaine-like material) to these patients would result in eliciting a conditioned craving for alcohol. This technique could provide validation and an explanatory mechanism for this clinical observation and could be useful as an educational intervention for these patients. Much more research is needed to develop treatments for conditioned factors associated with relapse. Evidence from drug-dependence studies indicates that 30 days of inpatient abstinence-oriented treatment does not appreciably affect the strength of conditioned craving and withdrawal phenomena. There is a clear relationship among relapse prevention techniques (cognitive efforts designed to teach alternative responses in the presence of cues associated with alcohol use), extinction techniques (efforts designed to weaken the strength of learned responses to alcohol-associated cues through repeated, nonreinforced exposure), and covert sensitization techniques (efforts designed to change/reduce the reinforcing properties of the cues associated with alcohol) (see Miller and Dougher, in press). The following are opportunities for research suggested by investigations into conditioned factors associated with drug-dependence relapse: More work is needed to identify the physiological parameters of craving and to determine the extent to which it is physiologically and subjectively similar across different substances of abuse, especially alcohol. Further work is also needed to determine the conditions under which craving is elicited and the treatment procedures that will reduce or diminish its effects. In addition, studies designed to address conditioned relapse cues through the combination of relapse prevention, extinction, and covert sensitization techniques could be valuable. -258

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Psychopharmacological Treatments for Drug Dependence The study of pharmacological agents in the treatment of drug dependence has been an especially active field over the past several years. There has been extensive study of medications designed to reduce the immediate and protracted symptoms of withdrawal from drugs of abuse such as nicotine, benzodiazepines, and opiates. These drugs have been evaluated, and the implications for their use in alcohol detoxification are reviewed in Chapter 13. There are separate types of pharmacological agents that have been developed and tested by drug abuse treatment researchers, each of which has a different therapeutic goal. The first type comprises medications that alter the effects of drug administration. These medications are designed to block reinforcement from drug administration (e.g., naltrexone for opiate dependence) or to attenuate its reinforcing effects; they may also attenuate abstinence symptoms (e.g., desipramine for cocaine dependence). The second type of pharmacological agent includes such medications as anti-depressants, anxiolytics, and antipsychotics, which alleviate the psychiatric symptoms and disorders that are often associated with drug dependence. Although these treatments were developed for drug abuse, it is possible that the medications may have a role to play in the treatment of alcohol dependence (these issues are discussed at length in Chapter 9~. Medications That Treat the Associated Psychiatric Symptoms of Drug-Dependent Individuals It has been noted that depression is more common among opiate addicts, whether methadone maintained or untreated, than among matched community samples. For this reason, one line of research has focused on evaluating the efficacy of tricyclic antidepressant medications (e.g., doxepin or desipramine) in depressed, methadone-maintained patients (Woody et al., 1983, 1985; Woody, McLellan, and Luborsky, 1984~. One study (Woody et al., 1985) compared doxepin with a placebo in methadone-maintained patients just beginning treatment and found that both groups improved but that those receiving doxepin improved more quickly than those receiving the placebo. A follow-up study compared doxepin, desipramine, and a placebo in clinically depressed, methadone maintained addicts who had been stabilized on methadone for at least two weeks. This study showed again that all patients improved but that the doxepin-treated patients improved more quickly than those receiving either the placebo or desipramine. These results indicate that antidepressant medications can be helpful in reducing the intensity of depressive symptoms and the length of the course of depressive illness in methadone-maintained patients. More recent research by Arndt and her colleagues (1988) with the growing population of cocaine-abusing, methadone-maintained opiate addicts follows the work of a Yale group (Gawin and Kleber, 1984) using the antidepressant desipramine. Although the results are still preliminary, the study's initial findings appear to support the role of this antidepressant medication in reducing cocaine craving and the amount (but thus far not the frequency) of illicit cocaine use in this population. It is uncertain whether the apparent reduction of cocaine craving results from a reduction of anxiety and depression in these patients or whether desipramine has a direct effect on the reinforcing potential of cocaine. The combination of pharmacological agents with a behavioral or social support program stressing abstinence has regularly produced philosophical problems for alcohol treatment staffs. The availability of seemingly effective medications and the clinical indication for -259

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their use in multiproblem populations provide impetus for the study of optimum ways to combine these approaches in the treatment of alcohol dependence. The following are opportunities for research suggested by studies on agents that treat the associated psychiatric problems of drug-dependent patients: There have been few controlled teals of antidepressant medications for depressed alcohol-dependent patients that might reduce symptoms of depression and increase engagement and compliance with other aspects of alcohol rehabilitation. Given the number of depressed alcohol-dependent patients commonly seen in rehabilitation treatment settings, this may be an important area of study. Research with cocaine-dependent patients suggests that desipramine can be effective in reducing cocaine craving and use (e.g., Gawin and Kleber, 1984~. Desipramine has also been shown to be an effective antidepressant medication irrespective of substance abuse. Desipramine may thus have a role to play in the treatment of the growing population of alcohol-dependent patients who have concurrent problems of depression, cocaine dependence, or both. Further research is needed to evaluate this possibility. There is a large and poorly studied population of patients with concurrent problems of schizophrenia and alcohol dependence. Little is known about this group. Treatment, whether pharmacological or psychotherapeutic, has been largely unsuccessful. Research is needed to develop and evaluate combined pharmacological/ psychological interventions that would address both psychiatric and alcohol-use disorders in the context of a complete psychosocial treatment program. More research is needed on the efficacy of combined pharmacological and psychotherapeutic treatments for patients with alcohol abuse and psychiatric disorders. Some of the failures of each treatment modality may be due to problems that could be alleviated with the addition of a second modality. CONCLUSIONS This review of the psychoactive substance-use treatment research literature points to several common themes across the body of treatment research on addictive behaviors. The review also identifies several areas of major focus in research on other psychoactive substance-use disorders that are different from treatment research in the alcohol field. Five major conclusions can be drawn. 1. There is a significant comorbidity of nicotine dependence and alcohol dependence and a significant comorbidity of other psychoactive drug dependence and alcohol dependence. The high comorbidity rates for these conditions suggest the need for research into the common processes that may underlie these dependence disorders. High comorbidity rates also suggest the need for research on the development of effective approaches to treat multiple psychoactive substance dependencies within the same treatment protocol. 2. Several common theoretical issues are a focus of research across psychoactive substance-use disorders. Research on processes and stages of change, relapse, coping skills, and conditioning factors (especially in craving) have proceeded across the range of psychoactive substance-use disorders. 3. Several treatment approaches are common across different psychoactive substance-use disorders. Approaches that combine pharmacotherapies with psychological treatments, treatments based on social learning principles, brief physician interventions, cue exposure ~. ~ . . ~ -260

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and extinction procedures, 28 day inpatient treatment programs, and self-help groups have all been applied to the treatment of more than one psychoactive substance-use disorder. 4. Several approaches to change have been used more often in the treatment of other psychoactive substance-use disorders than in the treatment of alcohol problems. These approaches include: Self~irected change procedures. Smoking cessation researchers have focused on smokers' expressed desire to quit without formal programs and have developed materials and methods to enhance self~irected quit attempts. Similar work in the alcohol field has been minimal. Behavioral approaches. Behavioral methods are among the most commonly applied approaches to smoking cessation and the treatment of other drug dependencies. The use of behavioral approaches has been more limited in the alcohol field. Change process research. Smoking cessation researchers have made significant advances in the study of the processes associated with successful smoking cessation. Relatively less emphasis on change processes has characterized alcohol treatment research. Psychotherapy. Psychotherapy research, using state-of-the-art methodology and well-specified treatment protocols, has been carried out successfully in a number of drug treatment studies. Comparable research is lacking in the alcohol field. Pharmacotherapies. Research on pharmacotherapeutic approaches to treatment has gained wide acceptance in the fields of smoking cessation and treatment of other drug dependencies. Resistance to the use of psychoactive drugs has impeded acceptance of comparable research in the alcohol field. Concomitant psychiatric disorders. Active research on the treatment of patients with coexisting psychiatric and drug dependence disorders has yielded important data. Comparable studies in the alcohol field are lacking. 5. The data suggest reasons for optimism. Treatment research studies on other psychoactive substance-use disorders offer reasons to be optimistic in that the differential effects of various treatments have been demonstrated. Overall, formal treatment and other procedures for promoting change appear to make a difference in patient/client rates of successful change. REFERENCES Abrams, D. B., P. M. Monti, R. P. Pinto et al. Psychosocial stress and coping in smokers who relapse or quit. Health Psychology 6:289-303, 1987. Annis, H. M., and C. S. Davis. Alcohol dependence: Cognitive assessment procedures. In G. ~ Marlatt, and D. Donovan, eds. Assessment of Addictive Behaviors. New York: Guilford Press, 1988. Arndt, I. O., L. Dorozynski, ~ T. McLellan, and G. E. Woody. Desipramine treatment for cocaine abuse in methadone-maintained patients. In L.S. Harris, ed. Problems of Drug Dependence: Proceedings of the 49th Annual Scientific Meeting, the Committee on Problems of Drug Dependence, Inc., Philadelphia, 1987. NIDA Research Monograph No. 81. Rockville, MD: National Institute on Drug Abuse, 1988. -261

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