Evidence-based Behavioral Treatments for Substance Use Disorders

Cognitive Behavioral Therapy-based Approaches

While different variations of cognitive behavioral therapy (CBT) interventions have been developed for SUDs, the common theoretically based thread of each of these approaches is that our thought processes, emotional responses, and behaviors are all interconnected. Marlatt's cognitive-behavioral model, grounded in social learning theory and the tenets of operant conditioning, forms the basis of this approach, which can be offered in both individual and group treatment modalities. Length of treatment using CBT is variable, with protocols ranging from six to 12 weeks in duration (e.g. ).

Using CBT, clients learn to understand their substance use within a functional analysis framework. As part of the functional analysis, clients explore the antecedents and consequences of their substance use. Subsequently, clients build the necessary skills to recognize different situations or states (antecedents) that are associated with their specific substance use patterns. Next, clients learn to identify and avoid high-risk situations (i.e., those that increase the likelihood of relapse). The treatment also focuses on teaching a variety of behavioral and cognitive coping skills for when high-risk situations cannot be avoided. These include techniques including distraction, recall of negative consequences, and positive thought substitution. Additionally, some approaches include social skills training (e.g., ). Specifically, assertiveness training and role-playing skills (e.g., how to refuse substance when offered) are methods used to facilitate adoption of new coping strategies.

Clients are educated about the treatment model at the initiation of therapy and collaboration between the client and therapist is encouraged through the selection of treatment goals. Further, treatment includes “homework” (i.e., structured practice outside of sessions), which can include scheduling activities, thought recording and challenging, self-monitoring, and interpersonal skills practice (e.g., ). Sessions typically follow a structure that includes reviewing homework from the previous session, discussing new information or a new skill, practice of the skill in session, and assignment of homework for the following week. These treatments are concentrated primarily on the client's present and future experiences. A potential advantage of CBT approaches is that the client learns skills that can be helpful to reduce problems in areas beyond substance use, such as management of anxiety and depressive symptoms, although these symptoms are not directly targeted.

According to a recent review of the literature in the Clinical Practice Guideline for the Management of Substance Use Disorders by the U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD ), CBT approaches have been found to be as effective as other active interventions and treatment as usual for individuals with alcohol, stimulant, and cannabis use disorders. Additionally, evidence supports using CBT in combination with pharmacotherapy and/or other evidence-based psychosocial interventions for individuals with alcohol, opioid, and cannabis use disorders. Of note, while CBT was found to have additional benefits for individuals in methadone treatment, its added benefit for office-based buprenorphine is unclear. Additionally, CBT approaches have been modified for tobacco cessation and are recommended to be included in treatment, based on clinical practice guidelines. Importantly, CBT approaches are well supported empirically; nevertheless, a systematic review indicated that outcomes may vary as a function of different aspects of the interventions and populations for which they are targeted.

Contingency Management

Contingency management (CM) uses positive reinforcement for clients who abstain from substance use or for successfully meeting another predetermined treatment goal (e.g., treatment attendance). Based on operant conditioning principles, CM clients receive incentives for attaining treatment goals, thereby improving the likelihood that these behaviors will be repeated in the future. This intervention approach aims to increase the positive consequences from reduced and discontinued substance use, providing incentives in the face of some of the difficulties that are typically experienced in early recovery (e.g., clients may suffer from withdrawal symptoms, loss of peer groups, etc.). Additionally, to increase effectiveness, the rewards provided are delivered frequently and immediately after the desired behavior is objectively observed (e.g., drug-free urine sample) and consistently over time. CM is not considered a stand-alone treatment, rather it is used in conjunction with other behavioral treatments, such as CBT or the community reinforcement approach (CRA, see more details below ).

Incentives may comprise a variety of items, and since they need to be effective for each individual, they can be customized to appeal to diverse clients. However, the vast majority of CM programs use vouchers or some type of item with monetary value given that it is generally universally rewarding. Some techniques used to increase treatment attendance and reduce client drop out include providing a “priming” reward and explanation of the process at intake that is not contingent on a treatment goal to introduce clients to the program, giving a bonus for attending the first session after the initial intake, and providing client successive rewards with escalating values as they continue to meet treatment goals. It is important that the incentives are of sufficient magnitude for CM to be successful. Generally, research indicates that the higher the monetary value of the incentive, the more likely treatment goals will be met, although there is emerging evidence of a potential limit of higher monetary values leading to improved treatment outcomes (e.g., ).

If the treatment goal is abstinence, urine samples frequently serve as the objective measure of compliance. At the beginning of the program, urine samples should be collected at least twice a week, with the frequency decreased as the client demonstrates continued success in the program. Alternatively, urine samples can be collected randomly to decrease the likelihood that clients can plan for an upcoming test. Urine or saliva samples can also be used to detect nicotine over a several-day period, but are not useful if the client is using nicotine replacement products as part of treatment. Detection of alcohol can be more difficult to ascertain given that is quickly exits the body. Typically, breath alcohol level is the most commonly used means of acute alcohol consumption. However, there are new methods for detecting alcohol consumption that may improve treatment compliance as consumption can be monitored across longer periods of time (e.g., testing for ethyl-glucuronide and transdermal alcohol sensors [e.g., Secure Continuous Remote Alcohol Monitor [SCRAM] bracelets]). Both breath alcohol and breath carbon monoxide can be used to test for these substances within the past few hours and can be monitored remotely using a camera on a computer or cell phone (e.g., ). The testing for cannabis can additionally be a limitation of this method as it has slow clearance in urine ; giving rewards for just providing urine samples at first may be a good treatment approach until the urine samples are clear of cannabis if abstinence is the treatment goal.

Empirical evidence supporting the efficacy of CM programs is robust (e.g., ) with strong support for its effectiveness for the treatment of opioid, stimulant, and cannabis users. However, a meta-analysis found that once the incentives of CM have discontinued the treatment effects begin to fade, a finding that has been documented with clinical trials including long-term follow-up (e.g., up to 52 weeks of treatment ). Additionally, in light of the fact that the longer clients are abstinent during CM treatment the better their outcomes, it is recommended that clients remain in CM for an extended period of time (e.g., 6–12 months ). CM is effective both as an individual and group treatment and has been found to be effective in populations that historically have been difficult to treat (e.g., clients diagnosed with antisocial personality disorder and homeless populations with co-occurring psychiatric conditions). A limitation of CM can be the cost of the treatment; however, intermittent reinforcement schedules, where clients receive rewards only sometimes after goals have been met, have also been found to be effective.

Community Reinforcement Approach (CRA). CRA is a multidimensional treatment based on CBT principles, but with a focus on the environmental contingencies that influence the client's behavior. CRA is most effective when including CM. The objective of this approach is to create a sober living environment that is more rewarding than the context in which the client actively uses substances. To do so, CRA targets familial, social, occupational, and recreational events. CRA combines approaches in that it uses techniques to increase the client's motivation to abstain from substance use, assesses the client's substance use pattern, puts in place positive reinforcement for sobriety, teaches new coping skills, and involves significant others in the treatment process. CRA is considered a first-line treatment for alcohol and stimulants.