By Charles R. Schuster and Kenneth Silverman

Over the past 30 years, a range of behavioral interventions for drug dependence have been found effective in diminishing drug use (Childress et al. 1985; Stitzer et al. 1985, 1989); unfortunately, those interventions have not been widely adopted by treatment providers.

The purpose of this chapter is to discuss methods that might facilitate the widespread applications of behavioral treatment interventions that have been shown to be efficacious in controlled studies.

This topic, which has been referred to as knowledge utilization, is not a problem confined to the drug abuse treatment field but rather is an issue that is common to all science-based applied activities, from engineering to medicine.

This is basically a problem of how behavioral change can be best achieved, not in clients seeking treatment but rather in treatment practitioners and in the researchers who are developing, evaluating, and disseminating the new treatment approaches. Why is this area of importance to both researchers and practitioners?

First, utilization of new behavioral interventions could result in significant improvement in the success of prevention or treatment practitioners. In addition, the public, the legislatures, and the insurance companies that pay for treatment increasingly are demanding accountability, asking, “Does it work? Are there more cost-effective procedures?”

It is also of importance to researchers, whose support ultimately rests on the perception of society, and especially Congress, that research does have some practical value. It is true that fundamental research is of importance for knowledge generation in its own right; humans are unique in their inquisitiveness about how the world works, and societies should support scientists whose work allows us all to vicariously express this need.

However, it is also a fact that society is increasingly demanding accountability, asking, “What are we getting for our expenditures?” This means that scientists must be increasingly cognizant of the relevance of their work to applied fields.

IMPEDIMENTS TO THE APPLICATION OF RESEARCH FINDINGS

What are some of the impediments to the application of behavioral treatment research? First, this problem must be addressed with the appropriate humility about what research can do for treatment practitioners and with an appropriate respect for what they are currently doing.

It must be recognized that most frontline treatment practitioners are not educated in the principles underlying behavioral treatment approaches or in the jargon of treatment research. Further, frontline treatment practitioners often deal with cases that would be excluded from research studies. How many research studies reject participation by those who are illiterate, have no fixed address, are polydrug abusers, or have other psychiatric or other medical complications?

In addition, those in the trenches of the “drug war” are underpaid, overworked, and often demoralized (Ball and Ross 1991; Gustafson 1991). with little time or energy to read about the latest treatment research findings in NIDA Notes, let alone apply them to their own clinical activities.

Furthermore, some of the frontline treatment providers in drug abuse clinics are recovering addicts who are emotionally tied to the approaches that they believe are responsible for their successful rehabilitation. It is a small wonder, therefore, that treatment practitioners are not using procedures that were described a few months ago in a professional journal! There are additional impediments to the acceptance of behavioral procedures that are unique to this treatment approach.

First, behavioral approaches, if not fully explained and understood, sound mechanistic and inhumane. To say, for example, the goal of treatment is to “control the behavior of clients” sounds to most like an Orwellian state with Big Brother watching.

In addition, behavioral approaches are met with skepticism by those who believe that addiction involves a disordered brain that can only be reordered by a medication. According to this view, behavioral interventions are inadequate because they only affect symptoms and do not address the underlying causes of drug abuse.

Further, behavioral treatment programs may be expensive to implement and require financial and staffing resources that are not available to the average drug abuse treatment clinic. For example, behavioral interventions often are evaluated in research clinics that have client-to-staff ratios that are considerably greater than those in the average clinic.

Finally, behavioral approaches can be complex and require a considerable amount of training to be properly applied. Given these impediments, it is obvious that, if researchers are interested in having new treatments applied, more must be done than simply publishing data in professional journals or giving lectures at professional conferences.

RESEARCH WITH THE GOAL OF WIDESPREAD APPLICATION

Ideally, research progresses in a stepwise fashion from the laboratory, in which basic principles are explored, to controlled studies, in which those laboratory-derived principles are applied in the form of new procedures to solve real problems, to widespread application under real-world conditions, in which the empirically derived principles and procedures are evaluated for their real-world utility.

Behavioral treatment interventions can readily follow this progression. Behavioral approaches are firmly rooted in an extensive body of laboratory research that has shown that drug self-administration in animals and humans can be diminished by systematic manipulations of the environment (Goldberg 1976; Griffiths et al. 1980; Johanson and Schuster 1981; Pickens et al. 1978).

The principles and procedures that have proven effective in modulating drug-taking behavior in the laboratory have served as the basis for the behavioral drug abuse interventions that currently are being applied and evaluated in controlled clinical research settings.

This powerful tradition will no doubt continue; behavioral researchers will continue to adapt laboratory-derived principles and procedures to develop new and effective behavioral treatments. At this point in the development of behavioral approaches to drug abuse treatment, it is essential to focus special attention on the final goal of widespread application.

This focus may help shape the development of new behavioral approaches in ways that may facilitate their subsequent application.

In recent years, behavioral drug abuse treatments have been developed and evaluated under relatively controlled circumstances in the context of small-scale research programs funded largely by the National Institute on Drug Abuse (NIDA).

Many of these programs have proven effective in reducing drug abuse (Childress et al. 1985; Stitzer et al. 1985, 1989), and some programs have produced effects that have not been equaled by other pharmacological or nonpharmacological approaches (e.g., Higgins et al. 1991, in press).

Although considerable advances have been made by researchers developing and evaluating behavioral interventions for drug abuse, this effort could benefit considerably by a systematic and coordinated research program similar to the NIDA Medications Development Program.

A program of this type could help focus the behavioral treatment research by developing specific goals, including goals that might facilitate subsequent largescale application of behavioral treatments across the United States.

In fact, a NIDA Behavioral Therapies Development Program already has been suggested by Dr. Snyder (personal communication), and NIDA has formed a Workgroup to develop and implement the program. The NIDA Behavioral Therapies Development Program could facilitate the large-scale application of behavioral treatments by outlining a number of specific objectives.

First, it could encourage the development of low-cost interventions that would use available resources and that could be applied with minimal training of counselors and other clinic staff professionals. Contingency management programs in methadone maintenance clinics that provide take-home methadone doses contingent on drug abstinence (as verified by urinalysis) are good examples of low-cost, easily implemented interventions of proven efficacy (Stitzer et al. 1984).

These programs are being refined and ultimately could be studied on a large-scale basis in methadone clinics across the country to determine their general utility. Experience suggests that these low-cost programs will likely have limitations.

Contingency management programs, for example, have been effective in reducing drug use as long as they are in effect, but they have not had long-term effects.

In addition, powerful reinforcers like methadone may not be readily available to treatment providers outside of methadone clinics, further limiting their general applicability.

Also, outside of research settings, the Federal methadone regulations do not allow total flexibility for contingent take-home methadone doses. Even if improved, these contingency management programs probably will have to be considered as important elements in comprehensive treatment programs designed to develop client behaviors (lifestyles) that support drug abstinence and that are incompatible with drug use.

Those comprehensive programs are likely to be costly and complex and to require extensive staff training to implement. Research on this type of program is clearly necessary, and the NIDA Behavioral Therapies Development Program could encourage it.

In addition, with a focus on eventual large-scale application, the NIDA Behavioral Therapies Development Program could encourage several other important activities.

First, researchers could be encouraged to create manuals and training procedures so that the behavioral interventions could be taught to the staff in nonresearch clinics.

Second, studies analogous to labeling studies for pharmacological treatments could be funded to examine whether the behavioral interventions can be properly administered by staff in nonresearch clinics, given the materials and training procedures prescribed by the originators of the treatment.

Third, efforts to replicate the results of successful behavioral treatments could be encouraged.

Finally, researchers could be encouraged to conduct economic analyses to determine if the treatments are cost-effective, considering not only the actual costs of the treatment but also the savings to society in terms of reductions in crime, the spread of human immunodeficiency virus infection, etc.

This type of analysis is essential to be able to get funding sources to increase the amount of money available for each treatment slot. Effective drug abuse treatment interventions that can be packaged and accurately and reliably taught to nonresearch treatment staff should be evaluated in large-scale demonstration projects that involve a number of nonresearch treatment clinics, preferably in more than one geographical area.

This research should evaluate process variables to determine if the treatment approach is implemented adequately and outcome variables to determine if the treatment is effective in reducing drug abuse.

The Center for Substance Abuse Treatment (CSAT), a part of the Substance Abuse and Mental Health Services Administration (SAMHSA), might fund such large-scale demonstration projects and in this way support an important step in a focused effort to disseminate new and effective behavioral treatments.

By providing special funding opportunities for research that is focused on ultimate large-scale evaluation and application, the Behavioral Therapies Development Program within NIDA, along with SAMHSA’s CSAT, could facilitate the development of effective behavioral treatments for drug abuse that have widespread applicability.

NIDA ENDORSEMENT OF EFFECTIVE AND EXPORTABLE PROGRAMS

Interpretation of research is a time-consuming and complex matter. Even if behavioral treatment approaches are thoroughly evaluated from the laboratory to large-scale demonstration projects, it may be difficult or impossible for frontline treatment providers to wade through all of the relevant publications to identify the most suitable program for their needs.

To aid in the identification of effective and applicable behavioral drug abuse treatment approaches, NIDA could establish an independent committee or consensus group in which experts would periodically review the current research and recommend treatment approaches for adoption by the treatment community. This committee could establish criteria and procedures for evaluating behavioral treatment approaches similar to the criteria and procedures developed by the Federal Drug Administration to evaluate new treatment medications, but without the regulatory authority.

Behavioral treatment approaches that are recognized as effective and appropriate for largescale application could be announced to treatment providers in marketing campaigns along with information about whom to contact for aid in the implementation of the newly endorsed programs.