See discussions, stats, and author profiles for this publication at: https://www.researchgate.net/publication/238298731 Psychological interventions for drug abuse: A critique and summation of controlled studies ARTICLE in CLINICAL PSYCHOLOGY REVIEW · JANUARY 1994 Impact Factor: 7.18 · DOI: 10.1016/0272-7358(94)90035-3 CITATIONS READS 5 7 3 AUTHORS, INCLUDING: Ron Acierno Medical University of South Ca… 146 PUBLICATIONS 5,441 CITATIONS SEE PROFILE Brad Donohue University of Nevada, Las Vegas 109 PUBLICATIONS 1,302 CITATIONS SEE PROFILE Available from: Brad Donohue Retrieved on: 12 January 2016 Clinical Psychology Review, Vol. 14, No. 5, pp. 417-442, 1994 Copyright 0 1994 Elsevier Science Ltd Printed in the USA. Au rights reserved 0272-7358/94 $6.00 + .oO Pergamon 0272-7358(94)00020-4 zyxwvutsrqponmlkjihgfedcbaZYXWVUTS PSYC HO LO G IC AL INTERVENTIO NS FO R DRUG ABUSE: A C RITIQ UE AND SUMMATIO N O F C O NTRO LLED STUDIES Ron Acierno, Brad Donahue, and Evan Kogan zyxwvutsrqponmlkj C e nte r fo r Psy c ho lo g ic al Studie s, No va So uthe aste rn Unive rsity ABSTRACT. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Empirical evaluations of treatmentsfor abuse of substances other than alcohol are reviewed and critiqued. M ethodological strengths and deficits of treatment- outcomestudies are delineated, and interpretation of reported results is considered in light of thesefactors. In large part, intervention strategiesfor which controlled outcome evaluations exist can be divided into those conceptualized along classical conditioning lines (e.g., learning principles (e.g., extinction and stimulus avoidance) and those derivedjom operant contingency contracting and community reinforcement). W hereas stimulus- avoidance techniques appear to be relatively more e# ective than pure extinction trials in reducing drug use, the e&acy of operant method? has been most strongly supported. M oreover, componential treatment packages in which contingent reinforcement is applied to both reductions in drug use and increases in stimulus-avoidance behaviors evince the most dramatic e&e&s. Additional research that addresses the methodologicalshortcomings of contemporary studies is needed. The DSM - III- R (A PA , use of a substance, at least 1 month. 1987) although somewhat Illicit use of controlled methamphetamines continues vaguely defines substance abuse as the continued such use repeatedly & Harwood, easily acquired crack-cocaine, considerably (Gold, Dackis, increase in cocaine-related more, government-monitored Correspondence Southeastern over a period of cocaine, heroin, and 1990). are in clear or probable need of treatment M oreover, since the introduction of cheap, the number of repeat and adolescent users has also grown Pottash, Extein, hospitalizations treatment should be addressed University, particularly to be a significant problem in the United States. Indeed, it is estimated that almost 5.5 million Americans for drug abuse (Gerstein results in problems substances, to Ron 3301 College A venue, & W ashton, of 200% facilities Acierno, report Center Fort Lauderdale, 417 1986), with a concomitant over the previous decade. a 500% increase for Psychological FL 33314. Furtherin clients Studies, Nova 418 R: Acierno, B. Donohue, and E. Kogan served, to over 1 million in 1989 (NIDA, ing treatment from many methamphetamine, private 1989), and this did not include patients receiv- or nonreporting use of both marijuana zyxwvutsrqponmlkjihgfedcbaZYXWV facilities. and heroin In addition is increasing to cocaine and again after a brief decline. Pharmacological and desipramine treatments of drug abuse, such as methadone maintenance for cocaine abuse, have proven to be largely ineffective for heroin in reducing illicit drug consumption when employed in isolation (O’Brien et al., 1988). However, several reported case studies involving successful application of psychological interventions (Boudin, 1972; Crowley, logical treatments unlike 1986; Wolpe, depression, therefore, substance abuse is wholly may be more amenable designed to alter maladaptive The 1965) exist. The relatively for this disorder may be a function following greater success of psycho- of its entirely overt nature. comprised to modification of observable that are specifically review of psychological treatment-outcome and critique studies for drug abuse that have achieved minimal levels of experimental cally, each of the considered studies employed designs to support inferences ies, or evaluations evaluations Rawson, of therapeutic causality. (i.e., justifies Castro, Ling, controlled and uncontrolled relative efficacy therefore, places an emphasis on methodological While clinical of recently and experimental and randomized frequently reports, between thereby assignment neglected. conducted factors, include rather than no-treatment of treatment measures;. integrity; (g) multiple sional dependent controls; adequacy, case stud- diagnosis); (e) published specified subject relevant to some important inclusionary populations comparison protocols; measures, are (i.e., groups (d) assessments (f) objective measures criteria areas of interest subject specifications; dependent Our review, intervention. treatment dependent 1985; between to which conclusions be made. (b) active treatment treatment (h) repeated differences studies attend other equally Moreover, & O’Brien, as well as treatment-outcome of a particular outcome (c) standardized conceptually-related measures; the extent use of: (a) standardized subjects meet a specified DSM - III- R criteria. McLellan, can appropriately such as clearly to condition, These Childress, limiting treatments the overall effectiveness the majority uncontrolled 1991) have not addressed regarding results, in determining Specifi- from critical review are AB studies), these rather restrictive reviews on this topic (e.g., McCann, Excluded control. or multiple-baseline for alcohol abuse. The existence of several well-controlled of drug abuse treatments Obert, either between-groups simple time baselines of treatments earlier comprehensive and, by interventions behavior. is a detailed those reports employing That is, behaviors dependent rather than unidimenand (i) follow-up assess- ments. The importance ous when making diagnostic of standardized comparisons and operationally-defined of clinical efficacy both within-study or severity measures, subject populations across treatments. (between-groups) is obvi- If subjects differ on and between-study evaluations of interventions are necessarily confounded by subject differences, and statements regarding the relative efficacy of treatments are somewhat weakened. With regard to the second point, Eysenck employ Whereas no-treatment (1992) control has described groups effects of time are controlled as therapist attention of specific treatments Moreover, Carroll, treatment-comparison rather shortcomings than beyond nonspecific conditions of controlled comparison therapeutic and Gawin (1991) with disorders studies that interventions. in these studies, effects of nonspecific are not. Because any intervention Rounsaville, active factors such contains these factors, the efficacy components remains unknown. noted the failure to employ for which unrealistic, inappropriate, and potentially unethical. Repeated assessment of treatment integrity, either through several treatments recording active exist is devices or inde- 419 Psy chological Interventions for Drug Abuse pendent raters, is essential in assuring noted finding that most therapists, scores the importance ment integrity increases are made. Furthermore, of obtained the confidence but is particularly members Indeed, exclusive of this population reliance further bias reports. utes to increasingly response complete enhances change. immediate period The of time. importance maintained. Relatedly, Psychiatry is clear and may rapid, the general and Addictive of treatment employment of repeated, sequence with delayed, consensus 2 provide summaries Subjects marijuana, of the degree in the following cocaine, but massive improvements. Finally, on the minimum (e.g.J ournal effects with to Authors) may be inclusion Therapy of fol- gains are posttest duration of Behavior to which reviewed reports abused benzodiazepines, training sonal psychotherapy one treatment for pub- and Experimental and follow-ups for durations Tables of 1 and studies address these important (i.e., a wide variety of illicit substances, and heroin. relapse prevention), for substance techniques, in two classes of apparently conditioning creased nonreinforced ing-treatments) principles in nature. to drug-related stimuli include interper- Notably, Indeed, at least applica- condition- Interventions derived into those that emphasize techniques strategies behavior in- stimuli (i.e, extinction/ counterconditionto increase systematic avoidance for drug use (here called “ stimulus-avoidance” purely operant gencies within which drug-taking effective treatments. can be subdivided and those that employ In contrast, contracting, based on the laws of both operant and associative exposure discriminitive including classes reviewed contingency studies was behavioral ing, has resulted from classical Treatment abuse, and supportive psychotherapy. in each of the reviewed tion of behavioral ments). rather criteria. stimulus avoidance conditioned a of thera- in that an intervention less than 24 weeks produce results that are only suggestive of improvement. experimental Clearly, is preferable in the same positive change over a longer minor Instructions Behaviors effects. studies reveals the extent to which treatment is 24 weeks (6 months) mea- of results and contrib- permits analysis of the temporal an intervention is because and civil losses when demand work and family satisfaction of this point is obvious, in outcome Indeed, results endeavor, where objec- to bias self-report personal/ familial, descriptions to one resulting to one that produces low-up assessments lished research, is wholly inappropriate that only reduces drug use. Similarly, effects is preferable preferable in any empirical the clinical relevance and accurate than simple pre/ post-test assessments, peutic approach. is essential of experimenter that reduces drug use and increases to an intervention causality replication Along slightly different lines, use of several related dependent sures to assess treatment treatment of therapeutic and subject motivation the direction treat- Treatment permits independent on self-report often risk vocational, they admit drug use. In addition, and measuring abuse treatment-outcome tive measures exist and are readily available, often evident. techniques of the empirical of change relevant to substance The frequently two or more interventions. of interventions measures protocols. “ do the same thing” under- with which statements standardization of objective treatment to compare results, which is the mainstay Incorporation to treatment of orientation, of both standardizing in reports purporting standardization adherence regardless zyxwvutsrq have focused on restructuring of treat- the contin- operates. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQ EX T I N CT I ON , COU N T ERCON DI T I ON I N G, AN D ST I M U LU S AV OI DAN CE I N T ERV EN T I ON SFOR DRU G ABU SE Initial justification drug abuse associated for use of extinction was provided stimuli by several to reliably and counterconditioning-based studies that demonstrated elicit conditioned responses interventions the potential in drug users. for of drug- For example, Study Experiment Design n RoEman et al. (1988) 110 Maculiffe 168 (1990) $ Carroll et al. (1991) 42 Stitzer et ai. (1982) McCaul et al. (1984) 10 20 Budney et al. (1991) 2 Higgins et al. (1991) 25 Higgins et al. (1993) 38 Azrin et al. (1994) 82 TX Integrity Assessed TABLE 1. Basic Study Characteristics zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIH TX TX Specified in Rept . Standardized Active TX Comparison Group Standard Dx Assigned Objective Dependent Measures Used Repeated Dependent Measures Used Collateral Report Used No No No Yes No No Yes Yes Randomized BetweenGroups No No No No Yes Yes No Yes Randomized BetweenGroups No No Yes Yes No Yes Yes No Randomized BetweenGroups Yes Yes Yes Yes NO NA Yes Yes zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA ABA WithinSubject Yes No Yes No Yes Yes Yes No Randomized BetweenGroups Yes Yes Yes Yes NA Yes zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Yes No Multiple Baseline Across Subjects and Behaviors No No Yes Yes Yes Yes Yes No NonRandomized BetweenGroups Yes NO Yes Yes Yes Yes Yes Randomized No BetweenGroups Yes Yes No Yes Yes Yes Yes Randomized Yes BetweenGroups zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Related Dependent Measures Used No Yes Yes No Yes Yes No NO Yes 421 Psy chological Interventions for Drug Abuse Ehrman, Robbins, mals, evinced drug cravings, (e.g., Childress, decreased and videotapes these responses conditioned cocaine were specific responses to drugs have been behaviors. drug use (Childress, (Bickel & Kelly, tenstein, (McLellan, & Kelly, conditioned McLellan, O’Brien, Childress, & Ternes, indicating stimuli. 1986). that Similar users (Childress, In addition to the drug stimuli have also been shown to effectively cues include mood states associated locations 1987), interceptive/ somatic (Wikler, use (e.g., cash in pocket) Childress, McLellan, Erhman, cues, of cocaine-related & O’Brien, 1948), elicit with past sensations other drug users and situa- (Caudille & Erhman, & Marlatt, 1990), 1975; Lich- drug paraphernalia 1990), and other drugs (e.g., alcohol) (Bickel 1988). Obviously, behavior the magnitude is potentially alter substance exposure and extent of conditioned enormous. Therefore, trials that are comprehensive spontaneous disappointing occurrence (relapse) among and may be the result of insufficient recovery of previously relapse because viously the stimulus extinguished Griffiths, Bigelow, class is difficult properties substance-abuse & Henningfield, if not impossible always performed imaginally effects are generalized stimuli is necessarily weaker conditioned treatments are employed of drug-use to replace is essential. That reinforcing thereby limiting the number following similar to this stimulus trials are almost or analogue producing exposure a relatively trials. Counter- weaknesses. of drug ingestion techniques, valences. These and drug- exposure treatments, discriminitive pre1977; the extent to which inherent qualities nonreinforcing) of conditioned full reinstate of imaginal in vivo, in counterconditioning rather than neutral (i.e., strategies, extinction is, salience behavior completion, & Liebson, exposure In addition, As with extinction-based However, treatment trials. Furthermore, Griffths, and nonreinforced of drug abuse suffer from related stimuli with aversiveness. take on negative, (Bigelow, settings, stimuli are is made more likely after an initial less than that of stimuli experienced conditioning extinction 1980), to achieve. or is likely. Such of the drug itself can effectively behavior or in analogue inhibition response during extinction behavior to in vivo situations. interventions stimuli drug-use to extinguish stimuli must include If all discriminitive of the undesired drug users following exposure extinguished endeavoring to these discriminitive and multi-faceted. recovery is typical stimuli that control drug-taking treatments abuse that occurs in response not addressed, related behaviors types of heroin Natale, &O’Brien, geographic to drug 1977; heart rate, in drug-preparation shown to exist in heroin Ehrman, These discriminitive 1988), tions conducive to similar and under the control 1986; O’Brien, itself, several second-order drug-taking when engaging users, but not nor- and increased in a pipe and heating it) or when exposed to audio cocaine users did not exhibit such use. Moreover, when exposed & O’Brien, found that cocaine and skin resistance, substance depicting of responding McLellan, (1992) and feelings of withdrawal, placing a cocaine-like patterns & O’Brien skin temperature to drug- these stimuli As is the case with stimuli triggering drug abuse often exceeds that which is feasibly add.ressed in session. Although effectiveness been demonstrated, controlled of extinction (O’Brien evaluations presented preliminary et al., of pure abuse have been published. techniques 1988; extinction However, O’Brien in reducing et al., 1990), self-reported or counterconditioning O’Brien, Childress, case study results indicating craving has to date, no acceptably treatments McLellan, that adjunctive for drug and Ehrman (1990) extinction/ exposure sessions were moderately effective in reducing drug abuse, but specific drug-use data were not reported. Similarly, Gotestam and Melin (1974) employed covert extinction (in which subjects imagined ingesting drugs and not getting high) to successfully reduce amphetamine methods, zyxwvutsrq abuse in three of four female heroin Duehn and Shannon (1973) treated addicts. Using seven poly-drug counterconditioning users (e.g., LSD, mari- TABLE 2. Specific Study Characteristics zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJI Subject Mean Age (years) Drug Targeted Treatment 32.5 THC StimulusAvoidance vs. Supportive Counseling 12 weeks, mean 7.5 sess Retrospective selfand sig. other report, taken prepost-test Maculiffe (1990) 31 Heroin StimulusAvoidance vs. NO-TX Control 12 months, mean 4 months (# sess NA) CarroII et al. (1991) 26 Cocaine StimuiusAvoidance vs. Interpersonal therapy 12 weeks, (# sess NA) Retrospective oelfreport of drug use, employment, crimindlity, take 6- and 12.months post-test Self-report, taken weekly, but not reported in repeated format, ASI Stitzer et al. (1982) 28 Benzodiazepines Study Roffman et al. (1988) Types TX Length Contingent 12 weeks, Contracting for (24 sess.) Abstinence Dependent M easures Objective urinaiysis taken Pxiwk Pormat of Dependent Measures Follow Up Results Use over 30 days Stim avoidance; 36% abstinent 1 month zyxwvutsrqponmlkjihgfedcbaZYXWVUT pre-test vs. use at follow-up, THC use reduced from 27 to 8 days/ month. Supover 30 days of follow-up portive: 25% abstinent at follow-up, THC use reduced from 26 to 13 days/ month. Percent abstinent No true fol. Stim avoidance: 34% abstinent at Gmo., 30% abstinent at 12over 6month pre- low-up, tx ceding assessment offered mo., employment up. Control: continuperiod 20% abstinent at 6-mo, 15% abstinent at 12 month ously Percent subjects achieving 3 consec. weeks abstinence. Percent subjects abstinent last 3 weeks of treatment WeekIy u~n~ysis data for each subject reported repeatedly over tx and 3mo. follow-up None Stim avoidance: 51% attained 3 consec weeks abstinence, 43% abst. for last 3 weeks tx. Interpersonal tx: 36% attained 3 consec weeks abstinence, 19% abst. for last 3 weeks tx. Average 6 weeks OveraIl, 88 % urines positive during baseline, 47 % positive during contingency, 91% positive during posttest. 60% subjects evince clear reductions in benzo use during contingency. M&au1 et al. (1984) 29 Budney et al. (1991) 32 Higgins et al. (1991) 30 Higgins et al. (1993) 29 None Contingency Contracting and Methadone vs. Methadone Control 13 weeks Objective uriualysis, PSQ Percent abstinent each week, number of consecutive opiate-free urine specimens Sequential application of contingency contracting 28 weeks Objective urinalysis, taken 4xiwk Ah urinalysis data land5 for each subject re- month ported repeatedly over each phase of tJc Cocaine Contingency Contracting/ Comm. Rein. vs. 12-step Counseling 12 weeks, (# sess NA) Objective urinalysis, taken 4xiwk # of consecutive weeks abstinence, overall percentage of cocaine-free urines None Cocaine Contingency Contracting/ Comm. Rein. vs. 12-Step counseling 24 weeks (36 Objective urinalysis taken 3xIweek sess) % of subs abstinent each week of treatment reported repeatedly, # of consecutive weeks abstinence None Heroin Cocaine, THC Contin. Contract: 50% subj. with 11 or more conset opiate-free urines, % sub. opiate-free each week sig greater than controls over active Methadone tx. Methadone Cont. : So’+% sub with 5 or less consec opiate-free urine. PSQdiscomfort scores efevated. Systematically increasing contingent reinforcement: 100% cot. -free urines when cont. directed to cot., gains maintamed during F.U.. 93% THC-free urines, onfy when cont. directed to THC. THC use resumed when contingencies removed Contin. Contract: 10 sub achieve I -mo. abstinence from cot, 92 % urines cocaine-free 12-step: 3 sub achieve l-mo. abstinence, 78% urines cocaine-free Con&Contract: 70% subjects abstinent at week 12, 50% at week 24,74% subjects achieve l-month abstinence from cot Ill-Step: 18% subjects abstinent at week 12, 5% at week 24, 16% subjects achieve lmonth abstinence. TABLE 2. Continued Subject Mean Study Arzin et al. (1994) Age (years) 28 Drug Targeted Treatment Types TX Length Dependent Measures Format of Dependent Measures Follow Up 12 months Objective urinaly% of subjects abs- No true folContingency Cocaine, tinent each month, low-up, tx Contracting/ sis, taken lxfwk, THC, zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA self-report daily overall mean num- given conStimulus ConBenzo- , ber of months abs- tinuously trol vs. Supuse, sig- other reHeroin, tinent, days perportive Counport daily use (if LSD, sehng any of above indic- month of use amphet ative of drug use, subjects considered to have used). Various standardized questionnaires Results ContinContract: 37% subjects abstinent all drugs at month 2, 65 % abstinent all drugs at month 12,6.2 months overall abstinence, ave 2.1 days use/ month of any drug 12Step: 20% abstinent all drugs at month 2, 20% abstinent all drugs at month 12, 2.6 months overall abstinence, ave. 5.4 days use of any drug 425 zyxwvutsrq PsychologicalInterventionsfor Drug Abuse zyxwvutsrqponmlkjihgfedcbaZYXWVUT juana, and amphetamines) with covert sensitization found that LSD use was diminished. egy employing faradic portive counseling, reducing presence dent measures shock during combine C O NTRO LLED contrast to and marijuana, of additional treatments extinction techniques, use. and is also inherently regarding is considered reinforcement response) a convincing and is therefore through places, etc.). To date, several empirical have been performed. earliest controlled marijuana abuse. Roffman, evaluation Subjects and a mean marijuana on subject report nogen Simpson, reported current alcohol definition provided) and (c) evinced That is, only a relative minority are problematic abuse are “ pure” marijuana 1986). abusers, substance Furthermore, average level of education were matched prevention ments. (employing Excluded from for and the incidence abusers (b) than normals (Kandel, of this sample in The latter two of overall treat- of mood and anxiety for drug disorders is Karus, & Davies, were employed, therefore, and the that individuals from the typical drug user. on the basis of gender and randomly were comprised were treatment; seeking treatment was 14 years. It appears, avoidance no DSM-III participation psychopathology. of individuals fully 85% completed stimulus Both interventions the Although in that they limit generalizability in this study sample may differ significantly Subjects provided treatment to the study was contingent other substance-abuse significant criteria Yamaguchi, (1988) prevention alcohol or drugs other than marijuana ment results. among people, interventions lifetime history of cocaine and halluci- use. receiving exclusionary higher relapse of that Consequently, stimuli (e.g., and Whitaker of 18 years. Admission 90 % of subjects reported the 90 days before treatment; relatively trials. of stimulus-avoidance of use in the past 90 days. who: (a) were concurrently “ abused” (no operational exposure the potential to be beyond were 84 males and 26 females with a mean age of 32.5 years use duration use and 63% individuals Stephens, the conditioned However, is considered of drug-associated of an avoidance-based of 50 episodes diagnoses were assigned, or imaginal from than the drug-use-leading-to- in nature.] evaluations is derived can be made that the stimulus is, in fact, a discrimi- behavior avoidance stimulus- stimuli. As with Here, however, (rather associative analogue skills are taught to facilitate systematic depen- TREATMENTS treatments argument in that a conditioned stimuli to elicit drug-use which is extinguishable lack of the efficacy of extinc- interventions, of stimulus-avoidance [Although to elicit the urge response multiple discriminitive studies, of objective to drug-related nitive stimulus for a response that leads to reinforcement. stimulus sup- effective in both in vivo, and imaginal. zyxwvutsrqponmlkjihgfedc counterconditioning-based operant, and strat- with inpatient and absence weaken conclusions the rationale nausea) to be moderately In all of these components, have as their goal reduced exposure tenets of classical conditioning. procedure in conjunction C LASSIC AL C O NDITIO NING - BASED extinction avoidance trials, amphetamine procedures, STUDIES: (in this case, imaginal an aversive counterconditioning and Smith (1992) treatment to seriously tion and counterconditioning In exposure was found by Frawley cocaine, control, Furthermore, strategies) assigned or supportive to either relapse counseling treat- of ten 2-hour group sessions provided over 12 weeks by male and female therapist teams. Sessions were audiotaped to assure appropriate delivery of treatment. Skills training to facilitate avoidance of conditioned elicitors of drug-use behavior served as the primary component ment. Specifically, subjects were encouraged typically drug use, as well as external playing 131), preceded was employed and to practice to “ demonstrate avoidance of the relapse prevention treat- to identify and avoid both the behaviors assertive of interoceptive stimuli responses that triggered to temptation urges and cognitive that drug use. Role by others” (p. reminders of use. 426 and E. Kogan zyxwvutsrqponmlkjihgfedcbaZYXWV R. Acieno, B. Donohq Planned systematic Additional avoidance procedures of high risk situations employed ments” (no further clarification included regarding In contrast to the avoidance-based support intervention Finally, specificity treatment, subjects in the social networks to limit that many “ themes” of the relapse prevention the authors indicated in preparation and the implication assign- was provided). to use their existing interpersonal reported groups “ that could be taken and encouraged. and “ homework the use of these techniques tion were also discussed in the social support treatment, was performed. was discussed training relapse prevention were encouraged drug use. The investigators relaxation training conclusions (p. condi- no active skills training that “ suggestions” for quitting” that avoidance given in both groups limits, somewhat, however, were 131). given Lack to both of treatment in the form of suggestions regarding the differential was effectiveness of either treatment. Relevant dependent drug use, obtained ment, and at l-month tion. No repeated more, although differences, measures or objective assessments Subjects differential were performed attrition treatment in both conditions of subjects supportive counseling treatment termination of treatment and 25% not statistically in daily use frequency investigators indicated Unfortunately, problematic collateral pre- to posttreatment no specific collateral report correlations, tion. Notably, substances Results neither of this evaluation, dependent (27.1 to 8.1 days/ month use). The 0.81 with subject reports. report data were provided for each condition. (a) which group, if either, evinced reported had any effect on subject and conclusions the investigators although moderately for the aforementioned measures strengthened quently, a significantly This is higher subject- rate of drug use was relapse preven- or collateral use reports for other than marijuana. caution data were within-group reported greater extent (or at all) in subjects receiving treatment social However, (26.4 to 13.0 days/ month and (b) whether collaterally to a significantly receiving in the month following condition reports of use correlated in that it is not known: diminished extreme that collateral attrition sessions. Over- of subjects significant). use) than did subjects in the social support condition group were not pro- noncompleters. that they had not used marijuana (difference Further- no between conditions treat- termina- treatment. an average of about 7.5 treatment analyses revealed that subjects in the relapse-prevention greater reduction during data revealed in experimental relapse prevention reported reports of daily effects with both the extent of differential received receiving verbal for the go-day period preceding daily drug-use between groups, and the subject characteristics all, 36% and collateral for the 30-day period following treatment analysis of pretreatment confounding subject at pretreatment post-treatment, data regarding vided, thereby included retrospectively, indicated reported longer assessment positive, Moreover, time about the relative efficacy samples follow-up for only the first 30 days following marijuana must be interpreted use of reliable would of each treatment. that they had conducted the present study’s conclusion effective in reducing reasons. significantly Indeed, interviews treatment that an avoidance-based have although for 6 months, termination. intervention with or objective Conse- is somewhat use is merely suggestive. The second study reviewed (McAuliffe, 1990) also employed stimulus-avoidance strategies to facilitate abstinence in heroin addicts who were completing inpatient addiction treatment. Whereas interpretation of outcome data from this experiment is obviously confounded by pretreatment drug-use levels (i.e., subjects were abstinent or nearly abstinent at pretest), results are still relevant, given the high rate of relapse among heroin users and the extremely large sample sixty-eight subjects were obtained and Hong Kong (no dramatic size employed in the evaluation. from a large pool of inpatients differences between One-hundred in both the United sites were reported States on any variable, 427 zyxwvutsr Psychological Interventionsfor Drug Abuse hence all following comments refer to the combined sample). Eighty-three sample were male, with a mean age of 3 1 years and mean heroin-use Subjects had received participation three avoidance-based nonspecific assessment sessions, relapse prevention attention-placebo control, treatment ment program. of subjects of 3.5 past “ treatments” Subjects confound patients condition or existing treatment through in the control condition alternative into outcome treatments results. ducted twice per week in 1.5-hour master’s level psychologist were randomly drug struct them social sponsored networks meetings associations but the proportion dependent employment, 12. These data were collected objective demands Impressively, the 6-month of subjects respectively). receiving importantly, friendships, employment. required to To recon- attend Furthermore, In the second meeting and modeling strategies. Notably, sessions However, point, retrospective months 19 months counselors and report use, of heroin 1 through 6, and 7 through respectively. at the final interview Therefore, reported an active treatment experi- for an average that data were available for 98% of subjects total abstinence at the 12-month was reported treatment of of subjects at follow-up by significantly in the relapse-prevention subjects and 9% condition, the authors indicated 22.7 more days of opiate use during this 6-month absolute point. greater than in the control group (34% of active-treatment heroin use. Although treatment, depen- the differential who received no known treatment. and for 78% 13% but detected drug use validity of the primary when considering who received of subjects relapse-prevention fol- were audiotaped to corroborate particularly An additional 53% each to both vali- posttreatment, in the relapse-prevention continued group- intersession using opiates less than once per month during this period (i.e., controls reported jects reported and or collateral reports, were obtained was performed For the first 6 months of treatment, trols reported subjects’ urine sampling). the investigators numbers were and sessions, stimuli that patients were taught skills and holidays. at about 8 and placed on subjects vs. 20%, subjects protocols relative to control subjects, follow-up techniques, nondrug-related were encouraged. included appears questionable, about 4 months, initiate over posttreatment measures, subject self-report (a urinalysis dent measure a was con- integrity. measures for only the 3 days preceding or less). moods, positive peer motivation treatment and illegal behavior Again, no repeated in treatment nondrug-related in relapse prevention manualized reviewed to assure treatment Relevant members participation structured, introducing intervention In therapist-directed locations, with users, on weekends addict provided date and increase menter training addict. friends, and acquire and activities thereby One session each week was led by a extensive “ safe” people, with other group week, a recovering lowed with for and “ erect w alls” against discriminitive such as drug-taking environments, to control were offered referrals, was not reported, group meetings. to sever relationships to nonuse No in an active treat- chains that had led to use in the past. Specifically, to enable relocate use, was employed an condition. simple participation whereas the second session was led by a recovered behavioral prior to to either control The relapse-prevention who had received subjects were taught how to identify assigned or a no-treatment addiction effects produced who pursued triggered of 7 years. for drug addiction in the present study. Following potential an average percent of the duration mean number of con- 5 days use and 71% of that control sub- period than did subjects of days of use per month by subjects in each condition was not provided, thereby precluding a more fine-grained analysis of results. Data for the second 6 months of follow-up were moderately similar to the first: total abstinence relapse-prevention Additionally, 6% was reported condition of subjects by significantly greater numbers than in the control condition receiving relapse prevention (30% of subjects in the vs. 15 %, respectively). and 4% of controls reported R. Acierno, B. Donahue, and E. Kogan zyxwvutsrqponmlkjihgfedcbaZYXWV 428 using opiates less than once per month during this 6-month of relapse-prevention 81% of controls). subjects reporting Although statistically tions in drug use resulting ingly impressive. Considering subjective evident in subjects ment relatively reported follow-up that remained they periods (56% 30 % employed, Commendably, tended duration. cally relevant Additionally, dependent nearly abstinent over, retrospective, analysis integrity that occurred that subjects up to 8 months was significantly However, of the primary prior to assessment. achieved effects, although vention, do not appear to be clinically statistically avoidance Rounsaville, results. More- measure. Indeed, it of daily drug use level of experimenter amounts of As a result, in favor of the avoidance-based a controlled and interpersonal criteria inter- of pure stimulus-avoidance were male, personality disorder, 68% the study were individuals: abuse diagnosis; were unmarried, and 20% 26% met DSM-ZZZ on psychotropic (d) with a life history of schizophrenia substance-abuse average background assigned treatment. relapse Seventy-four criteria (c) evincing for antisocial from substance severe suicidal (e) who were court ordered were three graduate counseling. or interpersonal at percent of Excluded abuse was not the primary medications; (mean and had ingested for mood disorder. or mania; The therapists prevention initiation. met DSM-ZZZ of 5.5 years in substance-abuse to either with 42 outpatients abuse disorder, criteria (a) for whom cocaine (b) maintained to reduce cocaine use. Carroll, group design to assess the relative psychotherapy for cocaine least 14 g of cocaine in the 3 months prior to treatment domly dependent efficacy or by the subjective, than for control subjects. so. Again, clini- of abstinent of treatment Furthermore, significantly employed age 26 years) who met DSM-ZZZ attend for an ex- analysis of within-group recall patterns strategies have also been employed and Gawin (1991) efficacy of relapse prevention ideation; treatments is only weakly supported. Stimulus subjects selection greater for subjects who had invested considerable treatment and relapse preven- was verified and supplementary, were able to accurately time and effort in the relapse-prevention treatments (44% specified effects was made tenuous nature treat- 12-month no between- assessments in this study precluded of between-group and uncorroborated is highly unlikely demand standardized, and conducted were collected. subjects for participation However, effects, and may have served to limit generalization accurate 6- and days than did control subjects. employed of subjects treatment measures both than did controls were evident. at pre- relapse prevention during respectively) more “ crime-free” large number who were unemployed receiving was who were em- on self-report measures of criminality, the present investigators with an exceptionally subjects of incarceration significantly effect of treatment That is, subjects employment employed, Finally, overall reduc- were not overwhelm- no differential at pretest. of subjects acquired and 45% in frequency tion subjects reported treatment had treatment the number to about 66% (vs. to the control condition, so. Regarding proportions respectively). group differences superior measures of employment, greater period. Notably, heroin use increased from the relapse-prevention who had been employed ployed at pretreatment treatment, continued to students with an Participants psychotherapy were ranfor drug abuse. As in earlier relapse-prevention interventions, skills training to achieve systematic stimulus avoidance was provided in,which patients were taught to identify and avoid high risk situations for both craving urges. In the interpersonal interpersonal problems and use and to develop psychotherapy and conflicts treatment, related adaptive ways of relating to and functioning strategies to control subjects were encouraged to identify to drug abuse, effective and to develop increasingly with others. Both treatments were conducted in 12 hourly sessions over a 12-week period. Although treatment manuals were employed, no sessions were audiotaped, thereby precluding verification of treatment integrity be- 429 Psy chological Interventionsfor Dmg Abuse tween conditions. conducted The Cocaine of cocaine The relevance treatment Craving investigators these results were not reported maintained rather than objective fied. However, this position under court-ordered experimenter drug that because: and (b) only one instance self-report of urinalysis urinalysis with which random urinalysis concordance urinalyses were in the data presented. The and not under court were in conflict, study participants, the investigators were preformed, Furthermore, subject attrition questionnaires, the aforementioned even weekly urinalysis self-report would produce false dependent the Addiction urinalysis variable Severity was scheduled is, therefore, but not performed. Index (ASI) was obtained monthly throughout to assess general impact of drug abuse on a variety of psychosocial Although a large majority of subjects use of these drugs following treatment Interestingly, only authors removed tion in cocaine interpersonal 55% (24) one individual use.” Whereas substances of subjects completed not statistically 12 treatment significant, data were collected, analysis of the time course of therapeutic in terms of percentage of subjects (defined recovery, change. not known when the cessation treatment measures second, these measures is relatively unknown. Indeed, treatment as subjects and recovery. days use overall) identically, as treatment 3 weeks) duration and a subject may be produced In contrast, are entirely a subject drug-free. For example, in local illicit drug supplies or temporary shortcomings in relapse prevention treatment abstinence, of it is abstinent subjects are considered to have abstinent for the too gross and impact of to have achieved chosen to be indicative relevance, other than subjects’ reductions regarding poor indicators abstinence of reported versus 36% both short4 84 days use) are both classified, too brief to be of clinical inadvertent absti- using once every 3 weeks (i.e., using each day (i.e., by factors short-ten subjects using cocaine fully 75% of the duration failures; third, the duration is entirely thus outcome at any time during who remain of the study (63 days use during weeks 1-9) are considered term abstinence from Unfortu- treatment of short-term That is, initially to continued to the same extent reduc- use for the 3 consecutive are exceedingly of drug use occurred. who evince increased drug use in response Instead, as 0 days cocaine first, with the measure for several reasons: condition. weeks, occurring clinical outcome entire 12 weeks of treatment; and the of drop-outs in each group achieving These from treatment sessions, the number weeks prior to study termination). benefited rates of these results were not reported, (defined as 0 days cocaine use for 3 consecutive and short-term to cocaine, were not reported. therapy was nearly twice that of the relapse-prevention was measured treatment) in addition the dimensions. from the study because he evinced “ no substantial nately, although daily drug-use preventing abused The suspect. In addition to drug use treatment Caveats subject’s do not state the was quite high, and the authors did not report the number sessions for which random validity of the primary (i.e., subject to desire to reduce about 50% of the time for an individual using the drug on 1 or 2 days each week. of missed nence, while not drug use, were most definitely therapists’ use of of drug use was justi- inflated. That is, because cocaine cannot be detected in the body after about 3 days of nonuse, negatives and was urinalyses measure because and frequency measure, random and self-report because Moreover, is potentially Although as the primary to report reduced evident). dependent (a) subjects were self-referred effects (in both treatments, use was clearly frequency index of the quantity or included seems unsupported demand demand by the fact that one therapist served as the study’s primary to subjects each week during treatment. also performed, order, is increased groups. and Use scale, a self-report use and craving, administered of this concern in both experimental zyxwvutsrq of abstinence in that nonuse decision/ training for this to remain lasting 3 weeks can result from temporary financial dependent of subjects restrictions measures of the patient, aside, 57 % of subjects in interpersonal psychotherapy R. Acierno, B. Donahue, and E. Kogan zyxwvutsrqponmlkjihgfedcbaZYXWV 430 were classified as having achieved Additionally, apy subjects achieved short-term subjects were stratified ences emerged. Among term recovery. provements ment, at some point during the study. during the relatively more severe users (defined median therapy value on the ASI), subjects achieved versus 0 % of interpersonal On the measure of general differences drug, psychological, legal, (in favor of relapse-prevention 54% subjects severity (e.g., and 54% achieved the ASI), but significant of short- small im- subscales (i.e, medical, family/ social), treatment) differ- of relapse prevention abstinence, psychotherapy addiction When between-group as those individuals with short-term were noted for both groups on all self-report alcohol, psychother- the final 3 weeks of treatment. to severity of use, more dramatic scores above the study-sample’s prevention abstinence subjects versus 19 % of interpersonal recovery according versus 9% of interpersonal relapse short-term 43 % of relapse prevention employ- between-group were evident only on the psychologi- cal severity subscale. Notable features active-treatment of this study include comparison condition, use of standardized, and additional sures in addition to simple use rates. Furthermore, ized through ever, the use of DSM-III-R the moderate interpreted for the following high (43%) f or a treatment sures of drug use were reported. ployed to determine of change, the proportion failure to collect response subjects) follow-up treatment treatments must be attrition were lasting only 12 weeks; (b) no objective mea- gross measures short-term limits a population of self-reported abstinence or recovery impressive]; conclusions treatment efficacy, is exceptionally high. interventions in the pure stimulus-avoidance supported (about (c) the investigators’ about for which recidivism of drug abuse has not been thoroughly use were em- [Even with these poor measures was not exceedingly In sum, it appears that efficacy of relatively was standard- (a) rates of subject to treatment. data severely with cocaine abusers, an mea- As with earlier studies how- relapse-prevention reasons: of subjects achieving half the relapse prevention particularly Instead, therapeutic treatments, the subject population assignment. success of avoidance-based with skepticism disappointingly diagnostic specified clinically relevant dependent thus far. OPERANT INTERVENTIONS FOR DRUG ABUSE: CONTINGENCY CONTRACTING In contrast ments to extinction endeavor and stimulus-avoidance to alter contingencies Both reinforcement for abstinence and punishment cluded in contingency contracts. Boudin application of contingency can-American, doctoral period and was very motivated implemented (1972) contracting student. interventions, that exert influence subject to remaining or therapist abstinent, times per day and report current tary expenditures. the contract suspicion reported throughout subject. Although standards aspects of outpatient-therapist doctors. (1986) one instance during of amphetamine employed In addition to the KKK. treatment bank account. contingency three all mone- use 1 month after No future use was was in contact with the are inappropriate by today’s to be positive. In a second results appeared to a wide variety was in a $50 to call her therapist which the therapist of Boudin’s conduct, contract and provide receipts documenting and a $50 check was mailed the 12 months several case study, Crowley medical activities, Afri- over a 3-year of drug use resulted f rom a preestablished in- case study abuse in a female, amphetamines the subject was required The subject reported was initiated are typically to reduce her use of drugs. A contingency in which self-report treat- behavior. an early uncontrolled had abused payment by the subject to the Ku Klux Klan (KKK) In addition for nonabstinence presented to reduce amphetamine The operantly-based over drug-taking contracting to reduce drug abuse in 15 of other treatments (e.g., detoxification, Psy chological Interventions for Drq supportive counseling), use resulted licensing quency the doctors entered in the mailing board. Notably, at all during into a contingency of a “ surrender of license” drug use was measured of which was not provided). Results the 2 years of follow-up, 431 Abuse through indicated agreement letter random urinalysis (the fre- that seven patients did not relapse and four others experienced Four letters were mailed to the licensing in which drug to the state professional only brief relapses. board. CONTROLLED STUDIES: OPERANT CONDITIONING-BASED TREATMENTS Interestingly, the aforementioned rather than reinforcement ment for abstinence Bigelow, Liebson, case reports of positive response has been more widely reported. and Hawthorne “ supplemental” benzodiazepine rently enrolled in an outpatient 28 years and average jects were included actually methadone history Following positive alteration included staff members contract gency management). postbaseline a 3-month and all subjects were performed results, subjects thereby Considering pines during the prebaseline reinforcement contingency the contingency These appeared though only benzodiazepine decrease as increase for reduced during benzodiazepine use of nontargeted reported evaluation both individual, levels when contingencies mild improvement of subjects’ This number was reduced in that for 60% direct control use was targeted, the contingency system over benzodiazepine effects over were in effect. across the levels. to 47% when the again to 90.5 % when assessment. of the sample, of the contingency illicit use of contract. Al- rates of other drug use were as likely to period. was not evident. of the contingency and as well urine tested positive for benzodiaze- and was then increased impressive, of drug in benzodiazepine- over baseline assessment. ingestion measures contingency, evinced 88.4% to be under no contin- of within-subject Hence, contract substitution Furthermore, drugs and the failure of several subjects following termination contingency objective prebaseline, was no longer present during the postbaseline benzodiazepines (i.e., behaviors was in effect, results are seemingly by clinic for drug-free in their benzodiazepine-use and one individual group percentages, provided to baseline As mentioned, permitting therapy reinforcement Six of 10 subjects evinced clear reductions showed no clear change three time samples, doses, or a selfwere included in for 12 weeks for six subjects, twice weekly throughout positive urine over both pre- and postbaseline Three was implemented take-home return the investigators trial (subjects of these urinalyses). contract supportive data were available Commendably, sub- use on at urine were made available. of contingent was followed by a monitored of treatment. assessment or more contingency received study. Cessation weeks for the other four subjects. periods. a 3-month use on 80% for each benzodiazepine-free Postcontingency as group urinalyses the duration with an average age of dose by 20 mg. No negative consequences for the entire use (urinalysis) urine on were 10 males concur- program the choice of $15 cash, two methadone urine (after 3 months) and for l-10 withdrawal To assure clinical significance, given during period, reinforcers of their methadone the contingency Subjects maintenance for benzodiazepine the initial baseline in which immediate Reinforcers case study, Stitzer, within-subjects of benzodiazepine-free addicts. of 10 years. response reinforce- in the study only if they tested positive for benzodiazpine of twice weekly urinalyses tested an ABA reinforcement use in heroin addiction of negative In a controlled employed (1982) design to evaluate the effects of contingent least 50% used punishment to reduce drug use. However, to maintain serve to demonstrate use. However, gated by the small sample size and lack of between-group of other drugs subjects’ continued treatment gains the control of the these positive results are miticomparisons in this controlled zyxwvutsrq R. Acierno, B. Donohue, and E. Kogan zyxwvutsrqponmlkjihgfedcbaZYXWV 432 case study. Moreover, use drugs) nonresearch atypical contingency to which this particular (1984) detoxification period, detoxification Subjects were 20 male IV heroin of 7.5 years. (urine improvement samples from over the prebaseline to the clinic were replaced the study, randomly assigned to participate received detoxification during weeks urine was produced. independent daily counseling of the contingency the PSQ of withdrawal received each group were included of urinalysis $10 and a take-home reinforcers were withheld and the pacontract are sessions, provided only to subjects in sessions were not “ neutral” costs, and may have reduced drug use in a manner contracts. symptoms control sub- regardless Note that effects of the contingency a 60-item opiate use provided Both groups however, in the event that an experimen- who used opiates. These additional related) response ments also included specimen, and were sessions and provide daily urine samples by effects of daily counseling condition stabilization, weeks 4-9, conditions. sessions, condition specimen, until an opiate-free nontreatment contracting urine. Additionally, an opiate-positive during At the end of week 3, subjects a urine subjects in the experimental to attend the experimental more evincing were required Following conditions in the clinic’s weekly counseling tient was required variety 10-13. participants methadone. under double-blind dose for each opiate-free confounded the first 3 weeks of Note that the relatively procedures, their $5 each week for providing tal subject produced urine over a 2-week “ predetoxiurine during in that only those individuals to either control or contingency results. In contrast, age of 29 period were selected for participation. reduced by placebo continued potentially opiate-positive each day to receive dosages were gradually evincing in into the study was contingent were taken twice weekly). In accord with general outpatient methadone users with an average Entrance followed by at least three opiate-free “ severe” users were excluded (i.e., not to controlled case study, McCaul, Stitzer, Bigelow, and a controlled group design to evaluate the relative efficacy of a plus contingency management treatment and simple urinalysis monitoring on subjects’ provision of three consecutive jects payment may be applied of their original with opiate abusers. to report (i.e., employed years and an average use duration lication contract intervention based clinical settings. In an extension Liebson the decidedly limits the extent in addition to twice-weekly inventory on a l-3 which requires point scale. Although daily urine samples, in the data analyses. Urinalysis of opiate-free urine for each condition, fine-grained analysis of the time course of therapeutic tive opiate-free urine samples. ing weeks 4-9, followed by placebo maintenance and Friday subjects urine of data were reported each week, permitting in: (a) a moderately effects, and (b) number (Note that active methadone assessto rate a experimental only the Monday percentages urinalyses, respondents detoxification and contingency/ control of consecu- occurred dur- conditions over weeks 4-13.) Results showed that 90% baseline. Over whereas only methadone specimens weeks 4-7, 65% of urine of the control dosage reduction was decreased samples were opiate-free contingency contracting subjects’ continued urine subjects contained for both groups, each week until between-group nificant (both groups producing about 30% opiate-free for both groups during maintained these no opiates. the percentage differences were no longer sig- urine at week 12). Additionally, 80 % of experimental versus 60 % of control subjects’ urine were opiate-free but these rates fell to 35 % and 20 % for the experimental number respectively, of consecutive more consecutive fewer opiate-free as of “ clean” urine fication (weeks 4-9), conditions, gains, However, during detoxiand control during placebo opiate-free clean urines, samples. maintenance (weeks 10-13). On the measure of subjects produced 11 or urines, 50% of experimental whereas Interestingly, 60% of control subjects half of the experimental produced subjects only five or relapsed only when their methadone dosage reached by this time. On the PSQ consistent decreases significantly zero, whereas all of the control subjects However, (week 8), discomfort when methadone scores increased On initial it appears slightly effective in reducing that the contingency with methadone. However, by the fact that differential experimental but not control gains during was still provided, subjects placebo highlights inferences following is, reinforcing mained unaltered. Whereas Therefore, ment for drug abstinence greatly must be supplemented Higgins, Delaney, forcement, combined years, diagnosed, Kent, according abuse. Additionally, juana for at least 15 years. (1991) methods and Higgins, techniques, criteria, subjects Friday, with cocaine immediately During That preceding patients management, (Sisson dependence during irrespective As mentioned, consecutive procedure: negative cocaine-free report of subjects’ phase for the urine resulted would, sporting training of $10.00 activities for in substance-abuse the payment according for to the following each consecutive cocaine- one, and four consecutive (abstinence with cash voucher for various was delivered potency, was worth $1.50, be rewarded for each use. The therapist for both reinforcer more than the previous were exchanged sessions (e.g., payment increased in bonus payments therefore, strategies were initiated were directed only to cocaine use. with 3 months and increase urine specimen 1 P-week period reinforcement four times per week (Monday, of voucher urine was systematically was worth $0.75 Vouchers strategies, 1989) on drug use. Notably, of evidence of marijuana to maintain cocaine-negative $1,038.24). and subjects was other retrospective procedures in the form level psychologist the first negative specimen and mari- the week prior to (made at the end of each treatment management reinforcement urine, was a Master’s treatment. gains for stimulus avoidance & Azrin, the first 12 weeks of the study, a.ll intervention is, contingent perrein- period). however contingency cocaine-negative contingent for at least 3 years and mari- had used cocaine and significant attendance stimulus contingency w ill extend treatment and included urinalyses and Saturday) drug use and employment subject; techniques were made repeatedly of the reinforce- et al., (1991) increased to assess the effects of contingency assessments reonly so that the relative employed Wednesday, qualities gains. However, to the study. A multiple baseline design across both behaviors reinforcement following contract As a result, admission and community of other rein- are effective the reinforcing each subject had used cocaine Both of reinforcers et al., subjects were two males, aged 28 and 35 to DSM-III-R juana reinforcement the level of contingent of treatment by to maintain increased programs that systematically with stimulus-avoidance users. In Budney of subjects contingent of reinforcers. & Bickel these gains the contingency with stimulus avoidance tests of the hypothesis cocaine and marijuana to counter enhancing impact potential of drugs is reduced. Budney, through maintenance contracting formed preliminary was were received assess the potency management strength reinforcing Failure were significantly offered systematically the relative regarding counseling even though of opiates contingency potentiates increases procedure urges) caused by the absence reinforcers are of sufficient drugs themselves. salience qualities Predictably, when contingencies relapse. administration, forcers. cessation. of causality the need to continually and address drive states (i.e., methadone management rates of individual being offered, That for the control during detoxifica- opiate use for a very short period of time when administered are weakened treatment unaffected slightly during placebo administration. inspection, in conjunction dosages had been significantly group. Rates of drug use other than heroin were relatively tion, but increased relapsed both group’s scores were elevated during baseline and showed during detoxification. reduced 433 zyxwvutsrq Drug Abuse Psychological Interventionsfor covered goods, dinner certificates, etc.). over the entire payments totaling in the community Clinic staff made R. Acierno, B. Donohue, and E. Kotan zyxwvutsrqponmlkjihgfedcbaZYXWV 434 all purchases. In addition, which community patients reinforcement attended twice weekly behavior (e.g., job training, related hearsed. the initial 12-week period, a “ maintenance” Following cocaine-free therapy etc.) were altered and subjects urine sample (collected sessions were reduced and stimulus avoidance techniques intervention and Fridays). sessions in increased particiwere re- was initiated were given one lottery only Tuesdays to 30 minutes therapy training, pation in nondrug in which contingencies activities, relaxation ticket for each Additionally, per week. The maintenance behavior period lasted 3.5 weeks for subject 1 and 7.5 weeks for subject 2. At week 15.5 for subject 1 and 19.5 for subject 2, the original reinforcement reinforcement rates were again reinstated was now made contingent for 12 weeks, however, on provision of both cocaine and marijuana-free urine specimens. Results were impressive which cocaine abstinence 96% cocaine-free of this phase. for both subjects. was reinforced, urine samples, In terms subject 2 produced (i.e., of marijuana THC-free samples, specimens. treatment phase. Follow-ups However, subject while subject 30 days rather urine 2 produced (subject 2) days marijuana Significant session, 96% 100% only 21% (subject use (i.e., Both significantly cocaine-free decreased rates samples and 92% specimens and 100% 24 days of the final 30 days of this reports subjects termination. were made for only the produced an average use, but 0 days cocaine introduction across behaviors) 1 and 5 months after treatment and reported and 1) and 7.5 abstinent for cocaine, sequential cocaine-free working retrospective 4 months. at both follow-ups 100% rates and evinced were conducted than positive 1 produced the 3.5-week at marijuana 1 provided Both subjects reported at the final follow-up previous and subject 2 provided rates. Following directed low cocaine-use use. Specifically, THC-free subject During at their original of contingencies both subjects maintained urine. phases, both subjects remained to use marijuana across subjects), use, though, THC-free week (subject 2) maintenance but continued the initial phase of the study in and both subjects worked at least 22 of the final 30 days of marijuana only 9% During subject 1 provided 90% cocaine-free/ THC- of 4.5 (subject use for the preceding other reports and subject reports were in agreement during 1) and 30-day 15 period. all phases of the study. Dramatic application reductions in drug use were evident for both subjects of the contingency of increasing contingencies to infer causality the previously a necessary management procedure, across two classes of drug use. Unfortunately, solely to the systematically reviewed study by McCaul, but not sufficient component increased Stitzer, reinforcement, Bigelow, of an effective management the independent characterized strategies is known, by systematically increased it is impossible and Liebson abuse. That is, although the effect of contingency reinforcement sequential the control which, in light of treatment of community contracting following thereby demonstrating (1984), program may be for drug over and above the effect effects of contingency reinforcement are not. In a second study with cocaine users, Higgins et al. (1991), employed a nonrandomized, between group design to evaluate the relative efficacy of an identical contingency contracting/ community counseling. (b) were informed In response brief. Subjects intervention and standard 12-step substance the study’s 25 patients were: (a) not randomized of the nature sented to participate biases. reinforcement However, of the treatment in the study, thereby to these experimental averaged and had used cocaine in the 12-step treatment they were to receive before confounding weaknesses, 30 years of age, met DSM-III-R for a mean reported using significantly of 6 years. and they con- review is somewhat criteria for cocaine dependence Participants and the behavioral abuse noted results with self-selection the following in the behavioral more cocaine in the week prior to treatment condition to condition, condition condition than did subjects contained significantly 43.5 zyxwvutsr Pry chologicai intementionsfar zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQ DmgAbuse greater of IV zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA ccxaine users. Assessments were performed as in the previously numbers described study, and results were reported and overall percentage not permit examination “ significantly may have shown initial abstinence significantly more behavioral the 12 weeks of treatment. receiving behavioral cocaine-free treatment (11 of 13) than On the measure produced the behavioral condition, and six subjects respectively, g-weeks 12-step (the latter greater use as achieved highly impressive, subjects were not randomly was performed, therapy controlled proving and zero patients, coilected results must be interpreted assigned to condition. discussed specimens, with extreme Furthermore, 92% of However, more efficacious caution because no follow-up assessment improvements case study were also produced significantly in abstinence were cocaine-free. and noted effects may not have endured. in the previously with behavior only Indeed, cocaine versus three patients versus 78 % of 1.2~step urine specimens was used to groups on this measure). Considering patients of consecutive of this measure 4 weeks consecutive abstinence, program. abstinence, numbers even when missed urinalyses form dropout between 10 subjects achieved in the Although do 12-step (5 of 12) patients of continuous significantly to be cocaine-free the effects of differential behavioral these measures and subjects considered followed by increased urines than did subjects in the 12-step program, tests were considered eliminate change, progressed. Importantly, completed weeks of abstinence Unfortunately, of the time course of therapeutic improved” the treatments in terms of consecutive of clean urine for each group. noted in this evaluation, than the typically offered 12” step intervention. Recently, Higgins shortcomings et al., (1993) ment/ community reinforcement seling for cocaine abuse. R diagnosis or a disabling Thirty-four on opiates or sedatives, condition, Study route of cocaine participants administration, status, and scores on the ASI, The or standard behavioral avoidance contingency Caucasian when possible, of a significant assigned other, Each consecutive procedure again approach specimens. cocaine-free In the event of a cocaine-positive urinalysis, production levels to their “ pre-reset” nent for the entire earlier studies by Higgins’ contingency management formed of urinalysis forcers. 12-week In addition, period, group, therapists procedures, subjects’ results and provided job training, of five consecutive subjects earned during predetermined, competing-response l-12, urine sample with a bonus cocaine-free urine sam- values. By remaining of $997.50, all purchases. significant increas- weeks vouchers were reset to the equivalent supervised stimulus- was worth $1.25 more than reinforcement ples restored voucher manage- combined clean urines were rewarded the original $2.50 level. However, contingency to employment with systematically Specifically, urine specimen the previous one, and every three consecutive $10.00. according to either the contingency subjects were given purchase vouchers of $2.50 for the first cocaine-negative they provided. for males with a abuse counseling. reinforcement urine of 6 years were selected unemployed, management for cocaine-free dementia, area within 6 with a mean age of 29 years, a mean were matched, and randomly Exclusionary (b) presence of psychosis, presence 1 P-step substance aspects of the community ing reinforcement criteria were: (a) a ZISM-i11- use duration unmarried, manage- abuse coun- age of 18 years. and (c) plans to leave the geographic were typically high schooi education. methodological of contingency 12-step substance and (b) a minimum male and 4 female individuals Subjects ment treatment comparison and standard of 4 g per week, and a mean participation. gender, counseling dependence, medical use magnitude the aforementioned between-groups In this study, subject inclusionary of cocaine criteria were: (a) dependence months. have addressed in a well controlled To abstiAs in expand others were immediately individuahzed training (i.e., contingent community the inreinrein- 436 B. Donohue, and E. Kogan zyxwvutsrqponmlkjihgfedcbaZYXWV R. A&no, forcement), and treatment stimulus-avoidance package. During that cocaine-negative reinforcement techniques weeks 13-24, urine samples were reinforced was again contingent or absence 12-step substance for weeks 13-24. group meeting vention, abuse treatment and one l-hour Forty-two session frequency the 12-step treatable model, disease. was reduced patients Supportive therapy impact of patients’ additional family that disulfiram and maintained Therapists was supplemented AIDS, therapeutic addiction were invited relations. Participants substance condition in substance lectures and vid- sessions During Dependent counseling experience. and counselor psychologist were reported In the 12-step condition, with 3 and 8 years screening, performed both in terms of percentage and total weeks of continuous grained analysis of treatment days) and once-per-day As in previous condition, program). condition with 84% retention Wednesdays, Unfortunately, of subjects and 58% completing significantly completing percentages from cocaine from vouchers counseling. to lottery continuous cocaine-free weeks abstinence, 74 % of behavioral for at least 4 consecutive subjects remained other than cocaine, cocaine-free pants, respectively, between-group from contingency positive for marijuana. and altering in no immediate reviewed report. Approximately reinforcement treatment 18% of subjects receiving versus 5% of subjects were respectively. On the variable of versus 16 % of 12-step subjects remained weeks; and 42 % of behavioral for 16 consecutive no significant of the urine specimens conditions, for in the behavioral- tickets resulted At the 24th week, 50% and the 12-step (vs. 26% (vs. 11% for the 12-step of the study. Indeed, 70 % of subjects receiving contingency management/ community were abstinent at the 12th week of treatment, versus roughly in the behavioral as constant use. higher for the behavior- of subjects reinforcement increase in cocaine use, as was the case in the previously 12-step substance-abuse more tine- after the second week of therapy, in large part, for the duration contingencies at each subject or (for a total of 24 12 weeks of treatment 24 weeks of treatment greater were abstinent was significantly these gains were maintained, abstinent in to be cocaine- of subjects abstinent abstinence. (for a total of 168 days) were scored equivalently Moreover, treatment therapists experience Mondays, effects. That is, use of cocaine once-per-week studies, treatment the 12-step program) with 5 respectively. measures included urinalysis Results were and a female master’s level counselor significant other reports of daily drug use were not collected, thereby precluding therapy to attend but only one subject was Subjects who failed to provide urine specimens were considered week of treatment, the to discuss the were expected were a male doctoral-level abuse counseling, level social worker abuse counseling, and Fridays. to all patients, but on that drug. with 1 year of substance-abuse were a master’s was available to is an incurable by educational to attend inter- According and the disease model of addiction. members therapy in the behavioral years experience positive. program. of one 2.5-hour for weeks 13-24. that cocaine was patients self-help meetings and identify a personal sponsor by week 12. Therapists informed referred subjects Session frequency reinforcement to once-per-week drug use on family use only, and percent of behavioral consisted so Note that session each week. As in the behavioral were counseled eotapes about cocaine dependence, 9th week of treatment, initially individual of cocaine and Fridays. also received disulfiram therapy as part of the community The were altered For the first 12 weeks of treatment, 1-hour behavior therapy sessions on Mondays then reduced to once-per-week in the behavioral contingencies with $1 .OO lottery tickets. on the presence that use of other drugs was not considered. attended were also included reinforcement versus 5 % of 12-step weeks. When considering differences management use of drugs existed, with 28% and the 12-step program and 18% partici- 437 Psy chological Interventionsfor Drug Abuse The short-term traditional relative 12-step efficacy counseling missed urine tests were considered urinalyses were confounded step substance-abuse receiving behavior uals to relapse, therapy. patients were using cocaine. condition More study, even though treatment was largely demonstrated ing addicts to remain citizens) is questionable. potential incorporation program Cognizant of more (provided socially by significant has been implemented 12- individ- that nonattending at the 6-month addicts procedure, behavior feasibility of pay- to do that which is expected of this fact, the experimenters and politically acceptable of discussed the means of contingent others, etc.) into the behavioral and evaluated point of the control over cocaine-use management paying (i.e., based on traditional of cocaine-dependent assumptions abstinence Although by the contingency abstinent receiving over because is the fact that only half of subjects in the to maintain was ongoing. ordinary reinforcement investigators’ disturbing treatment However, fewer sessions than did subjects high propensity validates continued Subjects significantly The extremely largely evident. it is possible that measures attendance. attended behavioral was clearly cocaine-positive, by treatment counseling though, behavior-therapy of the multi-component substance-abuse treatment. Such a by Azrin et al., (in press) and is discussed next. The critique final is a review many ways to interventions incorporated several significant sults in a large-scale, avoidance componential behavioral tive group counseling Criteria procedures period prior to the first clinic contact, the investigators for substance the study sample is unknown. because 32% used many individuals Fifty-three other This hence, assess- subjects met the clinical relevance percent of the sample used cocaine, users). and unmarried, were considered whether of subjects were 56 males and 26 females with illicit substances were poly-drug adults, male, unemployed, 93 subjects by an urge- techniques. and (b) the initial l-month did not indicate abuse or dependence, Participating an average age of 27.5 years. and management re- stimulus abuse. Unfortunately, marijuana, encouraging into the study were use of illegal drugs at least one time during: ment period. criteria in to typically offered supportive/ nondirec- (a) the 30-day DSM - III- R similar study. Specifically, were complemented of contingency therapy was compared Although that produced clinical outcome application for substance for inclusion efforts. and his group, Azrin et al., (in press) modifications controlled reinforcement and expanded completed by Higgins procedural long-term, and community control strategy of our recent employed (note that percentages Overall, subjects who used cocaine eligible for treatment, 57% used exceed 100 were predominantly and marijuana. results were reported Although for only the 82 individuals for whom 12 months of data were available. Following an initial l-month sures were collected, Therapy rently or the Supportive available matched counseling for assignment for problem guidelines construct than mea- to either the Behavior When several participants assessment, were concur- they were divided assignment of 46 subjects in the behavioral the componential urge-control, 1.5 hour sessions. is, rather treatment. after baseline assigned into pairs within the pair. The condition and 36 subjects in condition. As mentioned, avoidance, period in which all dependent were randomly severity and a coin flip determined final study sample consisted the nonbehavioral baseline/ assessment eligible participants Stimulus-avoidance providing through behavioral and contingency subjects discussion intervention management techniques with general and persuasive “ risk” lists of conditioned zyxwvutsrq included strategies were standardized relapse problem modified conducted stimulus in weekly and proactive. That prevention/ stimulus-avoidance solving, subjects stimuli that had been associated were trained to with drug use in the 438 zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA R. Aciemo, B. Donohue, and E. Kogan past (e.g., people, places, situations, use had never been associated. etc.) as well as “ safe” lists of stimuli with which drug Each evening, subjects were required to record the amount of time spent with each risk and safe stimulus so that overall daily amount of time in risk situations was quantifiable and known, for the next day comprised exposure to conditioned The urge-control ior with functional incorporated to effectively alternatives. consequences Specifically, (e.g., were taught, modelling and avoidance list, find an acceptable Finally, contracting expanded of both covert reduce sensitization and replace drug-seeking subjects were taught to recognize urge strength engage in a competing if at home watching through a “ daily planner” in order to actively and behav- early signs engage in covert rehearsal of several individualized of drug use. Once subjects were taught to quickly “ functional” elements reduce drug craving of drug-use urges and to immediately negative subjects completed safe activities stimuli known to elicit drug use. procedure response competition In addition, only of planned had been reduced behavior or arrested, that was either “ fun” or television when they perceived rehearsal, to immediately an urge, subjects refer to the stimulus safe activity and engage in it, etc.). and in contrast to previously reviewed treatments in which contingency was directed specifically to drug-taking behavior, the current investigators contingency management competing nondrug-related avoidance recording and planning nique with a significant subjects forms, as measured Azrin et al., (in press) employed contingent others, and attending for successive reinforcers and modified, of the urge control tech- school or employment each day. reductions in the amount recording forms. of time Note that contract to increase subjects’ motivation Rather were highly according of of the stimulussignificant that competed abstinence. reinforcement others, notifying by stimulus-avoidance behaviors iors, as well as to simply maintain systematic daily completion as well as rehearsal the contingency to engage in stimulus-avoidance significant to include included time with significant at all times, were reinforced spent in risk situations, for all subjects, These other, spending others of their whereabouts Additionally, procedures behaviors. directly with drug-use than employing individualized, to subject standard provided and significant-other behavrewards largely by agreement, each week. The weekly supportive 1.5-hour treatment sessions. for drug abuse was conducted This monly used in nonbehavioral expression intervention group counseling of feelings and discussion weekly drug-theme was designed topics, facilitated for drug abuse. of drug-related desires. Significant session in this treatment Subjects supportive therapy on request. tored by: (a) audiotape (b) presence Notably, recording of a nonparticipating both training program for both conditions and experience counselors during type of program. Unfortunately, in each treatment condition confounding Several training the investigators were equally individual was moni- random review of the tapes, and (c) use of treat- procedures. or graduate treatment students who had modality. The in the new procedures did not indicate experienced outcome results with individual differences dependent of and in both conditions group sessions, graduates in their respective were given additional discussion were also offered integrity of sessions and subsequent were college initiated com- encouraged others were invited to attend one group ment manuals and a session checklist of specific treatment Therapists during features of other group members, condition treatment observer format Counselors experiences, reactions to comments provided praise for abstinence per month. in a group to incorporate or educated, behavioral specific to that whether thereby therapists potentially between therapists. measures were employed to assess effects of treatment on rates of Specifically: ( a ) weekly urinalysis (during active treatment drug use and related areas. periods), (b) subject, and (c) significant-other report were employed to detect drug use. Psy chological Intervedons for Drug Abuse For purposes of data analyses, an individual was considered of these three indices reflected drug use of any kind (i.e., of use, or significant-other 1981), adults by the Marital-Couple both of which included by the subject and the spouse/ parent. Depression Inventory dance, number Also measured of institutionalizations, were reported month, (BDI). in terms overall mean number days-per-month During baseline “ maintenance satisfaction of months (O-100%) regarding days worked, of police contacts. in each condition abstinent days of nonuse Naster, & Azrin, the was assessed by the Beck were number of subjects Scale (Azrin, for subjects school attenDrug-use using in each condition of any type of drug), data drugs each and mean (mea- number of drug use. and active treatment and standardized request), or self-report were assessed Scale (Besalel Depression and number of percentage as 30 consecutive Happiness a report of overall relationship sured Happiness 1973) and for youth by the Parent-Youth zyxwvutsrq to have used drugs if any one positive urinalysis, report of use of any drug). Family relationships for married/ cohabitating & Jones, 439 dependent periods, measures phase” (not a true follow-up, all dependent measures, drug-use were collected because including data were collected monthly. subjects urinalyses, During still received were collected weekly, the treatment treatment monthly. on As a result, relatively more emphasis was placed on report data of subjects and their significant others during this period. Although extended abstinence groups received resulted a mean of 15 treatment achieve treatment-length indicated provision jects using (any type of) drugs decreased drug-using subjects receiving duration of the study period. point, conditions subjects and 35% of 6.2 months supportive-counseling abstinence. subjects average of 5.4 days-per month, Average number improvements increased Satisfaction (any measure drug other to 2.1 days-per-month use was also statistically subjects reported drug use was employed. nondrug-use the latter intervention. behaviors) However, and serve to temper these extremely at Moreover, abstinence of daily drug use, than marijuana) for behavioral significantly an subjects. greater for Additionally, behavioral differential and in favor therapy evinced alcohol use, and displayed behavioral treatment rating of abstinence of positive urinalyses, use of stimulus-avoidance 46% treatment im- with subjects. a very conservative Moreover, of subjects showed were also evident, receiving reduced from the componential of all drugs, and (b) absence competing, drugs at over the point, between of 2.6 months with reports of previous authors who employed to reduce drug use. Indeed, of sub- the proportion progressively differences an average of general functioning Specifically, and Marital Positive effects resulting facilitate The subjects (3.8 vs. 2.2 days use-per-month). treatment. sive and consistent decreased On the fine-grained compared school and work attendance, proved Parental In contrast, used drugs at 2-month point. to in general. the proportion period, whereas behavior-therapy used hard on several measures of the behavioral 63% evinced of days of marijuana supportive counseling failing for each month after the second month. counseling from all illicit drugs over the 12-month an average treatment Specifically, significant in both Whereas in this “ as needed” man- condition, 11 months. the behavioral supportive for 12 months, and subjects during the first month to 80 % , and remained at the 12-month were statistically receiving of treatment counseling for the subsequent 6-month frequency, that which is available to outpatients that, in the supportive that general level (+ 6%) was offered to all subjects in session sessions over 12 months. standardization, ner more closely approximates Results treatment in reduction application techniques appeared requiring: or self- or significant-other of contingency (i.e., are very impres- contingency direct, management contingent to result in increased several shortcomings contracts (a) nonuse report of strategies to reinforcement long-term of efficacy for of the present study are evident positive results. First, objective drug use assessments 440 R. Acierno, B. Donohue, and E. Kogan were not consistently rather utilized during the maintenance than weekly urine therapy was conducted a group format. confounded tests were performed in individual As a result, by treatment performed, and the enduring phase of the study (i.e., during this period). sessions while supportive treatment modality zyxwvutsrqponmlkjihgfedcbaZYXWV type (behavioral (individual nature of the treatment’s counseling Third, behavior was provided in vs. supportive) vs. group). monthly, Second, was potentially no true follow-up was effects are unknown. CONCLUSIONS After a brief decline, prevalence of drug abuse and dependence is again increasing in the United States. Although no consistently effective and validated pharmacological treatments for these disorders exist, several behaviorally-based interventions (both associative and operant) have been subject including marijuana, empirical evaluations heroin, have attended less methodologically specification, to controlled cocaine, relevant measures, with various experimental criteria, comparison types of drugs, Notably, (in part) to many frequently use of active treatment relevant dependent evaluations and benzodiazepines. several neglected, including subject and groups, use of objective and incorporation of follow-up of these but nonethetreatment and/ or clinically assessments (see Tables 1 and 2). Techniques inforced based on associative exposure acquisition to stimuli of strategies elicit drug-use learning that control theory have relied on either prolonged drug to reduce or eliminate behaviors (stimulus (i.e., results have been produced to 43% of subjects extinction), any occasion avoidance/ control). positive reporting abuse for exposure In controlled by pure avoidance-based abstinence at treatment dependent measures of change were not employed nonre- or conversely, to stimuli that studies, only mildly interventions, termination. with 36% However, in these evaluations, objective hence, the validity of these results is compromised. In contrast to stimulus-avoidance abuse have been employed occurs, so that nonuse behaviors tions of operant treatments lus avoidance control of simple contingent onstrated heroin, effective only when contingent ing qualities of drug urges. renegotiated contingent increase cantly forms a stimulus’ expanding addition to reinforcement reinforcing reducing quality, the absence or eliminating effective in reducing contingency operant tech- Although the short-term behaviors has been dem- (i.e., of what one should increasing because contracting by stimulus-avoidance are appears or can greatly to be signifi- strategies. However, of behaviors that behaviors), in what one should do, as well as not do) appears abuse. Such componential drug usage to fully one-third standard, salience of stimulus avoidance reinforcing or repeatedly than to include reinforcement specific reinforcement substance Evalua- than studies of stimu- to be more effective Furthermore, contracting of abstinence behavior users, these programs use of systematically when complemented compete with drug use (e.g., reinforced. studies utilizing outcome. and marijuana appears of reinforcement. the focus of contingency for substance are of sufficient potency to counter the reinforc- As a result, reinforcement outcome over stimulus-abuse cocaine, reinforcers reinforcing more effective more sophisticated of treatment reinforcement treatments within which drug-use and systematically treatment measures for benzodiazepine, nonindividualized are specifically Notably, objective operant contingencies have been relatively interventions. niques have included interventions, to restructure to be most efficacious behavioral treatments the level of use obtained in were with alterna- tive treatments. From this review, progressed beyond it is clear that the psychological its nascent stage. Indeed, treatment large, well-controlled of substance outcome abuse has evaluations 441 zyxwvutsrq Psy chological Interventionsfor Drug Abuse of a variety of treatment strategies have been performed. if they are to build on existing research, However, discussed here and satisfied to only a limited extent by existing evaluations integrity. should Moreover, diagnostic through employ highly and diagnoses the use of structured stance-abuse treatment and vocational Importantly, treatments interviews). including indices drug-abuse treatment research, in all future at least 12-24 months substance-abuse Relatedly, are essential of anxiety, Specific posttreatment effective componential to replication under even greater experimental rigor. exceptionally efficient, treatments and rewarding battery. indicator follow-up employed of treat- assessments the true efficacy future recommendations the seemingly potent, and family the sine qua non of contemporary in determining treatments (e.g., related to sub- depression, and are thus needed to verify the significance interventions. manner measures must serve as the central and common studies. duration treatment, by existing and defined along particular into each study’s assessment use of repeated objective dependent measures, new of treatment in a standardized In addition, should be incorporated requirements studies. Specifically, and measures must be identified should be obtained clinical outcome, functioning ment response produced standardized subject populations categories future investigations, must address several methodologic of of any of clinical effects include subjecting by Higgins’ and Azrin’s groups If past results are again obtained, for this devastating societal problem w ill have been validated. We thank N. H. Azrin Ph.D. for his thoughtful comments on an earlier version of this manuscript. zyxwvutsrqponmlkjihgfedcbaZYXWVUTSRQPONMLKJIHGFEDCBA Acknowledgements- REFERENCES American Psychiatric Washington, Azrin, E., Association. (1987). Diagnostic and stafisticol manual jar mental disorders (3rd. ed. rev.). DC: Author. N. H., McMahon, & Galloway, P. T., Donahue, E. (in press). B. C., Besalel, Behavior therapy V. A., Lapinski, for drug abuse: K. J., Kogan, A controlled E. S., Acierno, treatment outcome R. study. Behaviour Research and Therapy. Azrin, N. 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