LAAM has low abuse potential, but its use is rare because of some findings of potential adverse effects on the cardiovascular system, regulatory and insurance issues, and clinic acceptance [ 24 ]. Buprenorphine hydrochloride is a partial agonist, semi-synthetic opioid analgesic. It recently has been made available to trained and certified physicians and pharmacies.
It has been shown to have a high affinity for the mu opioid receptor. It is safe, long acting, and has a mild dependence potential. In three trials it has been shown to reduce heroin use. The combination of naloxone which reverses the effects of opioids and is used to treat acute opioid-related states and buprenorphine also is available.
Naloxone has been shown to reduce the abuse potential of buprenorphine. Buprenorphine and buprenorphine-naloxone were approved by the FDA in [ 24 , 25 , 35 ]. Naltrexone directly blocks opiate receptor activity receptor antagonist and was approved in the s for the treatment of opiate and later for alcohol use disorders. Naltrexone reduces the pleasurable, positive effects of opiates. In RCTs, it has been found to reduce substance use and the amount of illicit substances used per episode [ 19 , 29 ].
For states with regulatory restrictions on methadone, or for groups where diversion may be a concern for example, physicians , it is used more frequently [ 23 ]. No pharmacological agents are approved by the FDA for treating cocaine or other similarly acting stimulants , cannabis marijuana, hashish , or benzodiazepine use disorders. There have been many scientific advances in the past 5 years in the identification of multiple cannabinoid receptors, and research is underway to explore reciprocal pharmacological agents [ 36 ].
There are over 65 medications in development for cocaine addiction [ 23 ]. Much of the focus involves the dopaminergic system, dynorphinergic kappa opioid receptors, and dynorphin. Because people with these disorders often have co-occurring mood or anxiety disorders [ 37 ], many of these patients likely receive antidepressant or anxiolytic medications.
Although the following is not an exhaustive list, it does include most behavioral therapies that generally are acknowledged to have comparatively strong empirical support and which have been specified adequately. Unlike pharmacotherapies, many behavioral therapies can be used across a range of substance use disorders with fairly little adaptation [ 38 ]. Behavioral couples therapy BCT , or behavioral marital therapy, is a behavioral treatment for both alcohol and drug use disorders that has been in development since [ 39 ].
It uses behavioral principles and contracting to reinforce abstinence and the appropriate use of medications eg, naltrexone. It has been found to increase abstinence, improve relationship functioning, and decrease domestic violence in both male and female identified patients [ 40 — 44 ]. Brief interventions for alcohol use disorders have been developed for use in settings other than addiction treatment programs, such as in primary care practices.
These interventions generally consist of screening, assessment, advice, and greater frequency of follow-up visits [ 45 , 46 ]. This relatively minimal clinical effort has been shown to have powerful effects on patient alcohol use. To date, these approaches have not been evaluated widely among individuals with drug use disorders [ 47 , 48 ].
It has been shown to reduce drug use, enhance treatment compliance, and improve family relationships [ 49 , 50 ]. Although the intervention generally is conducted with families, some evidence supports its utility with a single person [ 51 ]. Cognitive—behavioral therapy CBT is based on principles of cognitive psychology and social learning theory and teaches patients to develop new cognitive and coping skills for substance use behaviors.
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In both of these projects, CBT was found effective in reducing alcohol and drug use and in supporting improvement in other life domains. Moreover, CBT appears to be associated with durable effects that have been shown to increase after the termination of active treatment [ 56 — 58 ]. Social and coping skills training and relapse prevention are adaptations of CBT [ 59 — 62 ]. Contingency management CM is a treatment approach that involves systematically reinforcing abstinence, usually with tangible goods or money in exchange for drug-free urine toxicology or treatment compliance.
This intervention has been studied carefully by Higgins et al for people with cocaine use disorders [ 63 — 65 ], and robust positive outcomes implementing modifications of the approach also have been found for combined opiate and cocaine use disorders [ 66 — 68 ], alcohol use disorders [ 69 , 70 ], and marijuana use disorders [ 71 ]. Individual and group drug counseling were manual-guided interventions developed for the NIDA Cocaine Collaborative Study [ 72 , 73 ] and designed to replicate as closely as possible, within a manual-guided format, the treatment approaches most routinely delivered in the community.
Within different formats, both interventions focus on a direct problem solving to initiate abstinence, identify triggers and prevent relapse, and facilitate step group involvement [ 74 , 75 ]. Both formats demonstrated positive effects on substance use and associated problems. Miller and Rollnick [ 76 ] launched the approach termed motivational interviewing based upon the stages of change model of Prochaska and DiClemente [ 77 ]. Modifications of this approach have been studied and found to yield positive substance use and treatment outcomes, such as with college student drinkers [ 80 ], persons with schizophrenia [ 81 ], and adolescent cannabis users [ 82 ].
Several reviews describe the effectiveness of this approach in a range of populations [ 8 , 83 — 85 ]. Multi-dimensional family therapy MDFT was developed for adolescents with drug use problems and involves the adolescent, parents, and other social systems [ 86 ]. The intervention has been found to have positive effects on substance use, behavioral problems, and family functioning [ 87 ]. In addition, it recently has been found effective in a multi-site RCT with adolescent marijuana users [ 88 ].
Psychodynamic supportive—expressive psychotherapy SE as developed by Luborsky et al [ 89 ] focuses on substance use within the context of the person and interpersonal relationship difficulties.
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SE has been found to be an effective intervention for opiate use disorders, especially when delivered by skilled therapists [ 90 ] and in controlled settings such as methadone maintenance. More recently, it also has been shown to be effective with cocaine abusers who are concurrently alcoholic [ 93 , 94 ]. Pharmacotherapy and psychotherapy have distinct modes of action, time to effect, target symptoms, durability, and applicability. Each has some limitation when used alone. The combination has been found to enhance outcomes for opiate, alcohol, and cocaine use disorders [ 93 , 95 , 96 ].
Understanding that many who suffer from substance use disorders have heterogeneous resources, problems and preferences, these methods can be integrated both philosophically and in practice [ 95 , 97 ]. Addiction treatment services research assumes that people with substance use disorders have a range of problems, degrees of severity, resources, and strengths. This is featured in substantial work with alcohol [ 98 ] and drug treatment services [ 99 ].
As McKay and Weiss report, a distillation of service research findings is complex [ ]. Three of the most significant findings are: Simpson et al [ , ] have documented the importance of duration of treatment, derived empirically at 90 days or more on average, in association with positive outcomes. This finding is consistent with the physiological, psychological, social, and behavioral attachments to the substance of abuse and the time necessary to construct new substance-free physiological processes, social connections, and cognitive skills.
Using an instrument designed to measure patient problems and severity on multiple dimensions the Addiction Severity Index , McLellan et al [ — ] found that when services are matched to problem areas, both naturalistically and prospectively, outcomes on these dimensions improve. This is consistent with the mental health services research of Drake et al [ ], who have demonstrated the importance of integrating services for people with co-occurring substance use disorders and severe mental illness, although this practice has not been explored fully in addiction treatment settings and research.
With the availability of a broader array of treatment alternatives and intensities, reliable and objective assessment increasingly is seen as crucial in guiding rational treatment decision-making [ ]. Such an assessment should include: NIDA recently outlined 13 principles of effective treatment including information on many of the treatments cited previously [ ].
Similar outcomes and common themes in the behavioral and psychosocial treatments have led many to speculate about the nonspecific or nontechnical factors in all effective therapies. Factors such as the therapeutic alliance, enhancing positive expectancies, inspiring hope, and conveying a deep understanding have been outlined as nontechnique-based agents of change.
A presentation and discussion of this issue are beyond the scope of this article. Undoubtedly, these factors are key ingredients to effective psychosocial treatments of all varieties and the foundation upon which the technical aspects of manual-guided treatments are built. These qualities should be remarkable qualities among those who seek to become therapists, and then cultivated and nurtured in those who enter the field.
The differences on these dimensions likely account for the consistently found variations in therapist effectiveness within any given approach [ — ]. Specific to substance use disorders, among the similarities in varying psychosocial interventions, Rounsaville and Carroll [ ] identified the following common tasks: Nathan and McCrady [ ] made similar observations of common ingredients to effective addiction treatments: The research to practice gap is well documented in the field of addiction treatment [ — ].
Currently, an individual or a family member seeking treatment for an addictive disorder is not likely to be offered a treatment drawn from the extensive list of well-studied and empirical evidence-based practices provided previously. How, and whether, an evidence-based intervention is translated and implemented into routine clinical settings may be the final element of evaluating its evidence base. For example, an intervention could not be considered effective in clinical practice if it is found to be too costly to do, ethically untenable, too complicated to implement, not economically supported, not suitable for regular patients, or too complex for most clinicians to learn.
Efforts are now underway to transfer research-developed practices into community settings through the NIDA Clinical Trials Network and numerous bridging the gap meetings and conferences [ ]. Dissemination research has become an important field of interest [ , ], beyond the field of addiction to all technology transfer activities [ ]. Consensus about conducting an intervention to prescribed levels of adherence and competence is emerging [ ], and models of training are being developed and compared [ , ]. Once trained in an EBP, how clinicians implement and sustain the practice is a critical aspect to dissemination research.
Systematic efforts are underway to address the effectiveness of treatments as practiced in the real world. This is embodied in research to assess practitioners for their attitudes toward certain practices, including medications [ ], manual-guided therapies [ , ], treatments for co-occurring disorders [ ], or specific interventions [ ]. Backer [ ] and Lehman et al [ ] have advanced this clinician assessment to include readiness for change for new practice implementation. Implementation researchers such as Drake et al [ ] may provide addiction research with more developed measurement, methodologies, and strategies to address barriers and facilitators to practice adoption and sustainability.
There are inherent complexities in evaluating EBPs for substance use disorders: Although substantial work is underway to evaluate effectiveness in the real world, clinicians and individuals with substance use disorders and their families should be cognizant of the burgeoning array of effective treatment alternatives that are available. National Center for Biotechnology Information , U. Psychiatr Clin North Am. Author manuscript; available in PMC Jun Carroll , PhD C, d. The publisher's final edited version of this article is available at Psychiatr Clin North Am. See other articles in PMC that cite the published article.
Scope of review This article reviews current methods used to evaluate strength of the empirical evidence supporting the efficacy of specific therapies. Evaluating practices using hierarchy of evidence models Evidence is ubiquitous, inherently biased, and complicated to evaluate. Table 1 Models for evaluating the hierarchy of evidence.
Open in a separate window. Efficacy testing by RCT including active control and bioequivalence, involving several hundred people. Effectiveness testing 0 the intervention in routine conditions using RCT using typical patients, clinicians, settings, a broad range of outcomes, geography, populations, and practices. Postapproval marketing and surveillance study ongoing voluntary examination of evidence for adverse reactions, long-term impacts, comparisons with new products, and applications to new populations.
The FDA model delineates guidelines for drug chemistry, properties, manufacturing, controls, and dosage developments. Rigorous experimental designs and protocol adherence, including double-blind RCTs, are essential features. This evidentiary method is appropriate for medications, may not be implemented without modification, and may be unsuitable for evaluating behavioral therapies [ 17 , 18 ].
As defined in Table 1 , these four models define a hierarchy within which to evaluate the evidence for a treatment for substance use disorders. The next section reviews pharmacological and behavioral therapies for substance use disorders that have been evaluated by these experimental clinical research standards. The limited scope of this review does not permit evaluation of the quality of the research conducted with any intervention, nor the range of the potential applications or limitations for these treatments regarding diverse groups of patients, settings, or therapists.
Evidence-based practices for substance use disorders This article focuses on treatments with a documented clinical evidence-base. Table 2 Evidence-based practices for substance use disorders by hierarchy of evidence model. Pharmacological therapies Over the past decade there have been many scientific advances in neuroscience, neurobiology, and in technologies to map and study brain structures and processes.
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Pharmacotherapies for alcohol use disorders Disulfiram. Acamprosate Acamprosate has been found to be associated with reduced craving and consumption of alcohol through agonist activity at gamma -aminobutyric acid GABA receptors and inhibitory activity at N-methyl-d-aspartate receptors [ 25 ].
Pharmacotherapies for opioid use disorders Methadone Methadone treatment for heroin users dates back to the s [ 33 ], and it was approved by the FDA in Levo-alpha acetylmethadol Levo-alpha acetylmethadol LAAM is an opioid agonist analog, which approved for the long-term maintenance of opiate dependence disorders by the FDA in [ 23 ]. Buprenorphine Buprenorphine hydrochloride is a partial agonist, semi-synthetic opioid analgesic. Naltrexone Naltrexone directly blocks opiate receptor activity receptor antagonist and was approved in the s for the treatment of opiate and later for alcohol use disorders.
Pharmacotherapies for other drug use disorders No pharmacological agents are approved by the FDA for treating cocaine or other similarly acting stimulants , cannabis marijuana, hashish , or benzodiazepine use disorders. Behavioral or psychological therapies Although the following is not an exhaustive list, it does include most behavioral therapies that generally are acknowledged to have comparatively strong empirical support and which have been specified adequately.
Behavioral couples therapy Behavioral couples therapy BCT , or behavioral marital therapy, is a behavioral treatment for both alcohol and drug use disorders that has been in development since [ 39 ].
Brief interventions Brief interventions for alcohol use disorders have been developed for use in settings other than addiction treatment programs, such as in primary care practices. Brief strategic family therapy Brief strategic family therapy BSFT has been developed for Hispanic adolescents and their families. Cognitive—behavioral therapy Cognitive—behavioral therapy CBT is based on principles of cognitive psychology and social learning theory and teaches patients to develop new cognitive and coping skills for substance use behaviors.
Contingency management Contingency management CM is a treatment approach that involves systematically reinforcing abstinence, usually with tangible goods or money in exchange for drug-free urine toxicology or treatment compliance. Drug counseling individual and group Individual and group drug counseling were manual-guided interventions developed for the NIDA Cocaine Collaborative Study [ 72 , 73 ] and designed to replicate as closely as possible, within a manual-guided format, the treatment approaches most routinely delivered in the community.
Multi-dimensional family therapy Multi-dimensional family therapy MDFT was developed for adolescents with drug use problems and involves the adolescent, parents, and other social systems [ 86 ]. Please let us know about other resources you have found helpful. This website reports on substance abuse and addiction research, therapies, news, and events of interest to both healthcare professionals and patients, focusing in particular on the science of methadone used in opioid addiction treatment. A Workshop Facilitator's Guide. Promotes implementation of evidence-based practices for prevention in communities around the country.
Discusses evidence based psychological treatment approaches. This handbook, sponsored by the Iowa Practice Improvement Collaborative PIC Project, suggests some concrete ways of bridging the gap between research findings and clinical practice by providing guidance on identifying, implementing, and maintaining evidence-based practices.
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