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National Institute on Drug Abuse -  NIDA NOTES
Treatment Research
Volume 13, Number 3 (July, 1998)

Drug Addiction Treatment Conference Emphasizes Combining Therapies

By Steven Stocker, NIDA NOTES Contributing Writer

Drug addiction can often be treated best through a combination of behavioral and pharmacological treatments and social service interventions, according to speakers at NIDA's National Conference on Drug Addiction Treatment. The conference, held in Washington, D.C., in April, attracted more than 800 drug abuse treatment researchers and service providers, leaders of professional organizations, criminal justice and law enforcement personnel, representatives from State drug abuse agencies, and public policymakers. The conference was presented as part of NIDA's Treatment Initiative, which is designed to improve the quality of the Nation's drug abuse treatment (see "NIDA Launches Drug Abuse Treatment Initiative," NIDA NOTES, July/August 1997).

Research is showing that drug addiction therapy that combines different approaches is often more effective than therapy that uses only one approach, said NIDA Director Dr. Alan I. Leshner. "When all is said and done, the ultimate cure for drug addiction will probably involve a combination of biological and behavioral treatments and social services," he said.

At the conference, Dr. Mary Jeanne Kreek of Rockefeller University describes the health benefits of methadone treatment combined with behavioral treatments.


This approach of treating drug addiction by combining biological and behavioral therapies stems in part from studies showing that addiction is both a biological and a behavioral disorder, Dr. Leshner said. "What science has taught us is that drug addiction is a result of an interaction between an individual's biological vulnerability plus his or her experiences plus environmental factors plus, of course, drugs. The final result is a changed brain," he said. Viewing drug addiction as exclusively biological or behavioral is too limiting, he cautioned. "Let us not pit biology against behavior. These are not opposing viewpoints."

Combining medications with behavioral treatments can have an additive effect on therapy because the different treatments work on different aspects of addiction, said Dr. Bruce Rounsaville of Yale University in New Haven, Connecticut. Medications, such as methadone or medications that treat psychiatric disorders, can increase the chances that patients will stay in treatment. Psychotherapy can then help motivate patients to abstain from drugs and help them develop healthier lifestyles, said Dr. Rounsaville. Several speakers examined behavioral therapies that are proving effective in treating drug addiction.

Dr. Kathleen Carroll of Yale University School of Medicine described cognitive-behavioral therapy (CBT), a comparatively brief intervention that helps cocaine-dependent individuals become abstinent from cocaine and other substances. In CBT, patients learn to recognize and avoid the situations in which they are most likely to use cocaine. They also learn how to cope with their urges to use cocaine and to deal with their psychological, occupational, and other problems. "Drug use requires skills involving getting the money to buy drugs, getting the drugs, and other activities," said Dr. Carroll. "In CBT, the patient learns that he or she has the capacity to learn skills that are healthier and more productive," she said.

Another effective behavioral approach involves rewarding patients for staying abstinent, according to Dr. Maxine Stitzer of Johns Hopkins University in Baltimore. For example, patients can be given vouchers as a reward for drug-free urines. The vouchers can be exchanged for healthful goods or services valued by the patients.

In family therapy for drug addiction, the therapist suggests ways that family members can help their addicted relatives stop abusing drugs, said Dr. José Szapocznik of the University of Miami School of Medicine in Miami, Florida. In one situation, for example, a mother ordinarily may allow her adult drug-abusing daughter to stay with her for several days in between drug binges, despite her misgivings about the daughter's drug abuse. In family therapy, the therapist might encourage the mother to set limits for her daughter, such as allowing her to stay only if she agrees to remain abstinent. In addition to helping an addict, family therapy also has the potential for reaching other members of the family who may themselves have problems with drug abuse, said Dr. Szapocznik.

Dr. Herbert Kleber of Columbia University in New York City reported on detoxification techniques that help opiate addicts cope with withdrawal symptoms when they stop using opiates. Newer techniques include the use of a combination of the opiate treatment medications buprenorphine, clonidine, and naltrexone and the use of anesthesia or heavy sedation. Detoxification is only the first step in treating opiate addicts, Dr. Kleber stressed. "You should measure success not only by the level of comfort during withdrawal but also by how many patients go on for further therapy," he said.


At NIDA's treatment conference, Dr. Kathleen Carroll of Yale University describes how cognitive behavioral therapy can help patients learn to avoid situations in which they are likely to use cocaine.

Other speakers discussed the challenges of providing drug abuse treatment for special populations. For example, individuals with both severe mental disorders, such as schizophrenia, and drug abuse disorders should be treated for both conditions concurrently, said Dr. Robert Drake of Dartmouth Medical School in Hanover, New Hampshire. This is best accomplished by multidisciplinary case management teams that might include a psychiatrist, a mental health case manager, a substance abuse specialist, and a vocational specialist who can address the patient's needs in an integrated fashion. This approach yields a number of benefits, including fewer relapses and hospitalizations and a higher functional status, said Dr. Drake.

Many drug-abusing adolescents also have a mental disorder, such as conduct disorder or depression, said Dr. Paula Riggs of the University of Colorado Health Sciences Center in Denver. These disorders contribute to the severity of the drug abuse disorder and should be treated concurrently, she said.

Drug abuse treatment can have health benefits in addition to reducing drug use, according to several speakers. Dr. David Metzger of the University of Pennsylvania in Philadelphia described numerous studies demonstrating that drug abuse treatment reduces the rates of HIV infection, by reducing both syringe sharing and risky sexual behaviors. Dr. Mary Jeanne Kreek of Rockefeller University in New York City presented data showing that, among injection drug users in New York City, methadone treatment, when combined with appropriate behavioral treatment, is reducing rates of both HIV infection and hepatitis B and, to a lesser extent, hepatitis C. Methadone treatment can also improve the health of addicts by normalizing immune function and the levels of stress and sex hormones, all of which are altered by drug abuse, Dr. Kreek said.

Thirteen million people in the United States currently abuse drugs, and 4 million are compulsive drug abusers, said General Barry McCaffrey, director of the Office of National Drug Control Policy, in the keynote address. The goal is to reduce the percentage of the U.S. population that is abusing drugs to under 3 percent by 2007, he announced.

NIDA NOTES - Volume 13, Number 3

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