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By incorporating CM, healthcare providers can leverage the principles of operant conditioning to promote sustained abstinence and encourage engagement in comprehensive treatment programs.
August 23, 2024
We can discern the complexities and potential of these integrated methods through an in-depth exploration of FDA-approved pharmacotherapy combined with behavioral interventions like counseling and contingency management. Each treatment modality offers unique strengths, and when combined, they provide a framework for addressing the diverse needs of individuals struggling with addiction. This discussion introduces evidence and practices for these treatment strategies and their impact on creating long-term recovery and improved quality of life for those affected by SUD and CSU.
Concurrent substance use (CSU) and concurrent substance use disorders (SUD) pose significant challenges not only to individual health but also to public health at large, affecting families and communities. These issues require a nuanced approach to treatment, yet research on the most effective practices remains limited. The Substance Abuse and Mental Health Services Administration (SAMHSA) has identified three promising approaches through literature review and expert consensus: FDA-approved pharmacotherapy paired with counseling, contingency management combined with pharmacotherapy and counseling, and Twelve-step facilitation (TSF) therapy also paired with pharmacotherapy and counseling.
To qualify for inclusion in SAMHSA's guidelines, treatment practices needed to meet several stringent criteria: they had to be clearly defined and replicable, target substance use reduction as a primary outcome, be currently in use, demonstrate evidence of effectiveness, and have accessible resources to ensure effective implementation. The evidence review for each practice involved an analysis of published research, assessing the impact of the treatment on multiple substance classes such as marijuana, alcohol, opioids, stimulants, and benzodiazepines.
Once a positive screen is identified, a comprehensive assessment follows, encompassing a detailed history of the client’s mental function, substance use behavior, trauma, health history, and home life. This thorough assessment, whether structured or semi-structured, enables clinicians to tailor treatments specifically to the client’s needs. The integration of these approaches demonstrates the importance of a holistic view of addiction treatment, where pharmacotherapy, counseling, behavioral interventions, and structured support systems work in tandem. Each component addresses different facets of addiction, providing a comprehensive treatment plan that can adapt to the complexities of individual cases.
FDA-approved pharmacotherapy, when combined with counseling, provides a healthy approach to treating individuals with alcohol or opioid use disorders (AUD and OUD) and addressing concurrent substance use. Pharmacotherapy involves the use of medications sanctioned by the FDA to help mitigate substance use, and it is delivered alongside behavioral therapy to enhance treatment outcomes. This dual approach is particularly effective for individuals battling AUD or OUD, as it addresses both the biological and psychological facets of addiction. Several medications have received FDA approval for the treatment of AUD and OUD. A physician or a qualified licensed healthcare clinician tailors the choice of medication, dosage, and duration of treatment to each individual. These decisions are based on a comprehensive evaluation of factors, including the specific diagnosis, the individual's psychiatric and substance use history, their preferences, and the availability of treatments. Such personalized care ensures that the pharmacotherapy regimen is optimally aligned with each patient's unique needs, enhancing the likelihood of successful outcomes.
However, the administration of certain medications follows specific regulatory guidelines. While pharmacotherapy for AUD and the use of naltrexone for OUD can be widely administered, buprenorphine and methadone for OUD are subject to stricter regulations. Methadone can only be dispensed by federally certified and accredited opioid treatment programs (OTPs), whereas buprenorphine can be prescribed by a range of waivered practitioners across different settings, including primary care outpatient clinics and OTPs.
This integrated approach of combining FDA-approved pharmacotherapy with counseling not only addresses the physical aspects of addiction but also supports the emotional and psychological recovery process. By leveraging both medical and therapeutic interventions, this method offers a comprehensive pathway to recovery, facilitating lasting change and improved quality of life for individuals grappling with substance use disorders. Two studies have explored the effectiveness of combining FDA-approved pharmacotherapy for opioid use disorder (OUD) with counseling, specifically focusing on individuals dependent on both cocaine and opioids. (See research from SAMHSA here.) While these studies provide some support for this treatment combination, they were not methodologically rigorous enough to warrant a high or moderate study rating, resulting in an emerging evidence classification for this approach. In both studies, participants were treated with either buprenorphine or methadone and received regular, individual counseling.
In the first study, participants received standardized counseling based on interpersonal psychotherapy on a weekly basis. This form of therapy focuses on addressing interpersonal issues that may contribute to substance use, thereby supporting recovery through improved social functioning. The second study employed the community reinforcement approach (CRA), a behavioral therapy technique combining counseling and skills training. CRA aims to help clients set long-term goals and engage in positive, drug-free activities. Participants in this study received counseling twice weekly during the first 12 weeks and weekly during the last 12 weeks, providing a structured yet flexible support system.
Both studies were conducted in outpatient settings, offering a practical glimpse into real-world applications of these treatment modalities. The demographics of the participants varied, with one study predominantly involving Black individuals, while the other included a more diverse group, with half the participants being White and one-third being Black. In both cases, two-thirds of the participants were male. Participants were generally excluded if they had dependence on substances other than nicotine, a co-occurring mental disorder, a significant physical health condition, or were pregnant or breastfeeding.
This study lasted for 13 weeks. The other study, which included both buprenorphine and methadone as treatment options, spanned 24 weeks and involved a multidisciplinary team comprising doctoral-level psychologists, a psychiatrist, and an experienced addiction counselor, all trained in the community reinforcement approach. Participants in both studies received individual behavioral therapy at least once a week, ensuring consistent therapeutic support throughout the treatment period.
These studies stress the importance of combining pharmacotherapy with counseling to address the complex needs of individuals with co-occurring cocaine and opioid dependencies. While the evidence is still emerging, structured counseling approaches like interpersonal psychotherapy and CRA, alongside pharmacological interventions, represent a promising avenue for better treatment outcomes. This combination not only helps manage the physiological aspects of addiction but also provides essential psychological and social support, facilitating a more comprehensive recovery process.
Contingency management (CM), combined with pharmacotherapy and counseling, is a potent behavioral intervention grounded in operant conditioning theory, which posits that external reinforcement schedules can shape behaviors. This theory explains how individuals learn new behaviors, with CM specifically reinforcing positive behaviors through prizes, privileges, or monetary incentives such as gift cards and cash. Reinforcement typically occurs via contingent prize draws or vouchers, with the number of prize drawings and voucher values increasing as positive behaviors accumulate.
This can be achieved through two primary methods: dually or wholly contingent reinforcement, which requires urine specimens negative for multiple or all substances, or "split" contingent reinforcement, which rewards abstinence from each substance independently. The vouchers used in CM can be monetary or non-monetary, exchangeable for goods and services. Moreover, CM can act as an initial "buy-in" for other behavioral interventions, encouraging increased attendance in counseling sessions and adherence to pharmacotherapy, which can lead to long-term therapeutic benefits.
CM is versatile and can be implemented in various healthcare settings, including residential and outpatient care. It is often provided alongside other treatment services, such as pharmacotherapy and individual or group counseling. In recent years, CM approaches have been adapted to include mobile and web-based applications, improving accessibility to substance use treatment for hard-to-reach populations. This adaptability allows CM to meet the diverse needs of those seeking treatment for CSU and SUD.
This approach not only addresses the immediate challenges of substance use but also supports lasting recovery through structured, positive reinforcement, making it a valuable component in the arsenal against addiction. The integration of FDA-approved pharmacotherapy with various counseling and behavioral interventions forms a potent approach to treating substance use disorders and concurrent substance use. The emerging evidence supporting the combination of these treatments underscores their efficacy in promoting sustained abstinence and recovery. As research continues to evolve, the focus remains on tailoring these interventions to meet individual needs, ensuring that those battling addiction receive comprehensive, empathetic, and effective care. This approach not only addresses the immediate challenges of addiction but also encourages lasting recovery, offering a pathway to a healthier, substance-free life.
