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.
REINFORCEMENT CONTINGENCIES FOR PROVIDING EFFECTIVE TREATMENT
A fundamental tenet of behavior analysis is that behavior is, to a large degree, controlled by its consequences. This suggests that the problem of application of research findings can be analyzed by identifying the consequences of maintaining the behavior of researchers and practitioners and employing these consequences to maximize the effective utilization of research findings by practitioners.
It is clear that there are some natural reinforcers for the behavior of both researchers and practitioners that support effective utilization of research findings. There is no question that effectively preventing drug abuse in the target population of adolescents or successfully treating a drug-abusing client is highly rewarding to practitioners.
In postinterviews, attendees at a recent NIDA Technology Transfer Conference expressed a need for training in the use of prevention and treatment evaluation methods (Backer 1991).
Similarly, researchers at this conference who could see that the products of their work might be successfully applied to prevention or treatment were gratified and indicated their willingness to participate in future conferences where practitioners and researchers could get together. However, as discussed above, there are major impediments to the operation of these natural reinforcement contingencies in shaping and maintaining the behaviors of researchers and practitioners over the long term.
It may be necessary, therefore, to supplement these natural reinforcers with systems that provide other reinforcers to maintain the behavior of researchers and practitioners. Some of the suggestions described above involve arranging reinforcement contingencies for the behavior of researchers to develop programs that are suitable for large-scale application.
The funding opportunities that will be offered by the NIDA Behavioral Therapies Development Program for the development and evaluation of behavioral treatment programs that are designed and suitable for largescale application may help shape and maintain research activities that are focused on large-scale application. The opportunity to conduct large-scale demonstration projects with funding by SAMHSA’s CSAT might have two effects.
First, it might encourage NIDA-funded researchers to develop programs that appear suitable for widespread application so that those programs could be evaluated in large-scale demonstration projects funded by CSAT. Second, the funding opportunities to conduct large-scale demonstration projects should generate a substantial amount of behavior.
Finally, recognition of the efficacy and general utility of a particular treatment approach by a NIDA body of experts also might function as a reinforcer for the researchers who designed and evaluated the recognized treatment approach, particularly if that recognition is useful to those researchers in obtaining future NIDA grants and grants from CSAT.
One of two types of reinforcement contingencies could be arranged for the behavior of treatment practitioners. First, reinforcement contingencies could be arranged for adopting and utilizing treatment approaches that have been proven effective through research. Although this approach may have some appeal, it is probably impractical.
Treatment approaches can be implemented with varying degrees of skill and accuracy. The same treatment approach can be implemented by one clinic or one counselor properly and with great effectiveness while another clinic or counselor may implement the approach poorly, retaining its basic fonn while loosing much of its function.
Determining whether or not a clinic or a counselor is properly implementing the treatment approach so that the reinforcers can be applied would be very difficult in many situations. Alternatively, reinforcement contingencies could be arranged for providing effective drug abuse treatment.
Reinforcement contingencies of this type should function to increase the effectiveness of the treatment provided; in addition, those reinforcement contingencies might increase the likelihood that treatment programs and treatment practitioners would seek out and adopt new interventions that have been determined to be effective through research.
Unlike many types of treatment, the effectiveness of drug abuse treatment can be objectively and reliably determined through regular urinalysis. Using urine results, reinforcement contingencies could be arranged at the level of the treatment program as well as at the level of the individual treatment provider.
Currently, State and Federal funds to treatment programs are provided for those programs for complying with structural requirements. To increase treatment effectiveness and to increase the likelihood that treatment programs would adopt new and effective behavioral treatments, States and the Federal Government could make funding decisions based on the demonstrated effectiveness of treatment programs.
This could be accomplished by providing more funds to programs that are effective relative to other ongoing programs in retaining patients in treatment, reducing drug use, and producing long-term effects. Similar contingencies could be arranged for the individual treatment providers.
Counselors, for example, could receive benefits for retaining their patients in treatment, reducing drug use, and producing long-term effects in their patients (cf., McCaul and Svikis 1991).
The effectiveness of these contingencies should increase as a function of the magnitude of the reinforcement contingencies, suggesting that substantial monetary consequences will be most effective; however, given existing funding limitations, it may be necessary to provide consequences that are probably weaker but available to treatment programs such as flexible working hours, decreased caseloads, parking spaces, reduced paperwork requirements, and opportunities to attend conferences.
Reinforcement contingencies cannot be arranged for effective treatment unless adequate systems are in place to evaluate treatment effectiveness. Such systems necessarily will include regular urinalysis testing and regular monitoring of that testing by an independent agent.
No doubt, contingencies on effectiveness would have a number of effects, some of which may be undesirable (e.g., accepting into treatment only patients who are likely to succeed). Therefore, the precise delineation of the guidelines and controls for implementing reinforcement contingencies for treatment effectiveness will require careful planning.
Furthermore, although the recommendations to reinforce effective treatment by treatment programs and by individual treatment providers are reasonable and are based on an extensive body of literature on the effects of similar reinforcement contingencies on human behavior in other treatment situations (e.g., Iwata et al. 1976; Greene et al. 1978), reinforcement contingencies of this type have not been studied in the administration of drug abuse treatment and would be important subjects of future research.
TRAINING TREATMENT PRACTITIONERS
The majority of practitioners in the drug abuse field today are not skilled in behavioral treatment approaches, and some practitioners are philosophically opposed to such interventions, or at least are skilled in approaches that are antithetical to behavioral approaches.
It seems reasonable that new behavioral treatments will be most appealing and most easily taught to practitioners with prior training in behavioral approaches. Therefore, efforts must be made to increase the number of counselors, psychologists, and psychiatrists receiving training in behavioral approaches.
Currently, CSAT (through the Substance Abuse Counselor Training Program) provides training in drug abuse counseling to people entering the drug abuse treatment field. Advances in the application of effective behavioral treatments could be made if NIDA researchers who develop new and effective behavioral treatment interventions were encouraged to contribute to this training program.
Increasing the number of college and university programs for counselors, psychologists, and psychiatrists that provide training in behavioral approaches would further prepare the treatment community to accept and effectively utilize new behavioral interventions.
CONCLUSION
Five steps have been proposed to facilitate the widespread application of behavioral drug abuse treatment approaches:
(1) the funding by NIDA’s Behavioral Therapies Development Program of research efforts designed to facilitate widespread application of behavioral treatments,
(2) the funding of large-scale demonstration projects by SAMHSA’s CSAT to evaluate the widespread applicability of behavioral treatment approaches that have been found effective and reproducible in the smaller and more controlled NIDA-funded projects,
(3) the creation by NIDA of a committee or consensus conference of experts that periodically would review behavioral treatment research and endorse and market to treatment providers the approaches recognized as effective,
(4) the administration of State and Federal funds to treatment programs contingent on providing effective treatment relative to similar treatment programs and the arrangement of reinforcement contingencies for individual treatment practitioners for providing effective treatment, and
(5) an increased focus on providing training in behavioral approaches to drug abuse counselors in CSAT’s Substance Abuse Counselor Training Program as well as to counselors, psychologists, and psychiatrists in college and university programs.
The success of efforts to apply behavioral treatments will also depend on the reaction and cooperation of the communities in which the drug abusers live. Clearly, behavioral treatments, which often focus on the development of behaviors that compete with drug abuse, will be most likely to succeed in communities that support those efforts, for example, by providing jobs and recreational opportunities to people in drug abuse treatment.
Although some of this community involvement can be recruited by treatment practitioners, community support also can be encouraged through public education campaigns that prepare communities to accept the view that drug abuse can be treated by strategically molding and enriching the environments of drug abusers.
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Greene, B.F.; Willis, B.S.; Levy, R.; and Bailey, J.S. Measuring client gains from staff implemented programs. J Appl Behav Anal 11:395-412, 1978.
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Gustafson, J.S. Do more . . . and do it better: Staff-related issues in the drug treatment field that affect the quality and effectiveness of services. In: Pickens, R.W.; Leukefeld, C.G.; and Schuster, C.R., eds. Improving Drug Abuse Treatment. National Institute on Drug Abuse Research Monograph 106. DHHS Pub. No. (ADM)91-1754. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1991. pp. 53-62.
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Iwata, B.A.; Bailey, J.S.; Brown, K.M.; Foshee, T.J.; and Alpern, M. A performance-based lottery to improve residential care and training by institutional staff. J Appl Behav Anal 9:417-431, 1976. Johanson, C.E., and Schuster, C.R. Animal models of drug self-administration. In: Mello, N.K., ed. Advances in Substance Abuse: Behavioral and Biological Research. Vol. II. Greenwich, CT: JAI Press, 1981. pp. 219-297.
McCaul, M.E., and Svikis, D.S. Improving client compliance in outpatient treatment: Counselor-targeted interventions. In: Pickens, R.W.; Leukefeld, C.G.; and Schuster, C.R., eds. Improving Drug Abuse Treatment. National Institute on Drug Abuse Research Monograph 106. DHHS Pub. No. (ADM)91-1754. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1991. pp. 204-217.
Pickens, R.W.; Meisch, R.; and Thompson, T. Drug selfadministration: An analysis of the reinforcing effects of drugs. In: Iversen, L.L.; Iverson, S.D.; and Snyder, S.H., eds. Handbook of Psychopharmacology. Vol. 12. New York: Plenum, 1978. pp. 1-37. Stitzer, M.L.; Bigelow, G.E.; and Gross, J. Behavioral treatments of drug abuse. In: Karasu, T.B., ed. Treatments of Psychiatric Disorders: A Task Force Report of the American Psychiatric Association. Vol 2. Washington, DC: American Psychiatric Association, 1989. pp. 1430-1448.
Stitzer, M.L.; Bigelow, G.E.; Liebson, I.A.; and McCaul, M.E. Contingency management of supplemental drug use during methadone maintenance. In: Grabowski, J.; Stitzer, M.L.; and Henningfield, J.E., eds. Behavioral Intervention Techniques in Drug Abuse Treatment. National Institute on Drug Abuse Research Monograph 46. DHHS Pub. No (ADM)84-1282. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1984. pp. 84-103.
Stitzer, M.L.; Bigelow, G.E.; and McCaul, M.E. Behavior therapy and drug abuse treatment: Review and evaluation. In: Ashery, R.S., ed. Progress in the Development of Cost-Effective Treatment for Drug Abusers. National Institute on Drug Abuse Research Monograph 58. DHHS Pub. No. (ADM)88-1401. Washington, DC: Supt. of Docs., U.S. Govt. Print. Off., 1985. pp. 31-50. 16
AUTHORS
Charles R. Schuster, Ph.D. Senior Scientist
Kenneth Silverman, Ph.D. Staff Fellow Addiction Research Center National Institute on Drug Abuse 4940 Eastern Avenue Baltimore, MD 21224
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From NIDA Research Monograph 137 Behavioral Treatments for Drug Abuse and Dependence [pdf with multiple chapters, diagrams]