By William R. Miller
INTRODUCTION
There are striking parallels in the nature, etiology, and course of addictive behaviors. Alcohol, tobacco, and other drug problems overlap substantially in epidemiology, are all influenced by a combination of biomedical and psychosocial factors, involve impaired personal control, and are characterized by high rates of relapse (Brownell et al. 1986; Miller 1980).
These similarities extend to a broader range of compulsive behaviors (Heather et al. 1991; Orford 1985; Peele 1985). Yet, both treatment programs and research for alcohol versus other drug problems have developed with an astonishing degree of isolation.
Although clients of the Center on Alcoholism, Substance Abuse, and Addictions are increasingly difficult to classify as alcohol versus other drug abusers and there is increasing public recognition that alcohol is a drug, there remain separate treatment systems and staffs, research institutes, and self-help organizations.
Markedly different emphases have evolved for both treatment and prevention strategies. The reasons for this partition arise from historical and political events rather than from compelling differences inherent in the problems and clients. In considering how to advance behavioral treatment for drug abuse and dependence, it may be informative to consider the state of research knowledge in treatment related to one particular drug: alcohol.
Treatment research is well developed in the alcohol field; currently, more than 250 controlled trials have been published. Behavioral treatments in particular are well studied, comprising more than half of the trials to date. For several behavioral strategies, dismantling research has been conducted to examine theoretical and practical foundations of efficacy. Alcohol treatment assessment technology has advanced substantially during the past two decades, permitting better quantification of outcomes.
Further, important gains have been made in knowledge on the interaction of client and treatment characteristics (“treatment matching”), and a multisite collaborative trial on this subject is underway at the National Institute on Alcohol Abuse and Alcoholism (NIAAA). This chapter will summarize this broad literature on alcohol treatment outcome, emphasizing behavioral treatments. It also will highlight issues that have emerged along the way, which may be informative for research and practice in the behavioral treatment of drug problems more generally.
TREATMENT OUTCOME REVIEWS
Reviews of the alcohol treatment outcome literature have progressed through several stages. The first-generation reviews were narrative summaries of findings with some commentary on methodology (e.g., Baekeland 1977; Bowman and Jellinek 1941; Voegtlin and Lemere 1941).
As studies accumulated, a second wave of reviewers attempted to derive average outcome statistics for treatment in general or for particular modalities, but these reviews remained largely narrative (Costello et al. 1977; Emrick 1974, 1975; Miller and Hester 1980).
In an attempt to discern more reliable patterns, Miller and Hester (1986a) provided a narrative review restricted to controlled trials-comparisons of two or more groups that were equated before treatment by randomization or matching.
This review concluded that only six treatment methods were “currently supported by controlled outcome research”: aversion therapies, behavioral self-control training, the community reinforcement approach, behavioral marital therapy, social skills training, and stress management.
It is noteworthy that all six of these are behavior therapies. This list was contrasted with “treatment methods currently employed as standard practice in alcoholism programs”: the 12-step method, alcoholism education, confrontation, disulfiram, group therapy, and individual counseling-none of which, it was concluded, were then adequately supported as effective treatment modalities by controlled research (Miller and Hester 1986a, p. 162).
A subsequent review by Holder and colleagues (1991) added two dimensions. First, controlled studies pertaining to each treatment modality were classified as positive or negative trials, and a weighted evidence index (WEIn) was compiled for each modality as a kind of box score of efficacy.
Second, through the polling of clinical experts, the optimal number and type of units of service required to deliver each modality were determined, and these units were costed to estimate the average cost (not price) of delivery for each modality.
This permitted the construction of a grid in which treatment modalities were located in two-dimensional space according to cost category and evidence for efficacy (WEIn).
The 10 modalities judged to have good or fair evidence of effectiveness included all six previously identified by Miller and Hester (1986a), as well as behavior contracting, brief motivational counseling, antidepressant medication, and disulfiram.
A striking finding was a significant negative correlation (r = -.385, p < .05) between the cost and effectiveness of modalities. Like the National Academy of Sciences (1990), Holder and colleagues (1991) concluded that it is wrong to ask: “Is alcoholism treatment (cost-) effective?”
Treatment modalities appear to differ dramatically in both cost and effectiveness, and no blanket endorsement can be given for “treatment.” They recommended instead focusing on the question, “Which alcoholism treatment modalities are most effective for the least cost?” (Holder et al. 1991, p. 533)
None of these reviews took into account the methodologic quality of studies in other than a narrative way. Thus, in the Holder and colleagues (1991) analysis, a poorly designed and conducted study was given the same weight in a modality’s WEIn score as a study with exemplary design and performance.
Two reviews are currently underway to take this next step: one at The University of New Mexico (UNM) and one at the National Drug and Alcohol Research Centre (NDARC) in Sydney, Australia. Using different approaches, each group is classifying studies on a variety of methodologic dimensions, with plans to use these ratings to improve the interpretation of study outcomes.
The plan at UNM is to calculate cross-products of methodologic strength scores and a treatment outcome classification. A sum of these cross-products, interpreted in relation to the total volume of research conducted, will provide a more refined index of research evidence for the efficacy of each modality.
The NDARC group, under the direction of Dr. Richard Mattick, is adding another important dimension to its review: the calculation of effect sizes. This will be the first comprehensive review of outcome literature in this area to include effect sizes. Furthermore, the reviews encompass treatments for alcohol, tobacco, and other drugs.
PROMISING BEHAVIORAL STRATEGIES
From these reviews, what behavioral approaches appear to be most promising? Supported modalities can be grouped subjectively into two general strategies:
1. Treatments designed to suppress use: Antidipsotropic medication with compliance contracting, Aversion therapies (covert sensitization), Behavior contracting, Behavioral self-control training, and Brief motivational counseling.
2. Methods to teach skills for successful sober living: Behavioral marital therapy, Community reinforcement approach, Social skills training, and Stress management training.
All five modalities designed to suppress use are readily applicable to other drug problems. Pharmacologic parallels to disulfiram are drug antagonists or agonist/antagonist combinations.
The principal problem in the use of medications such as disulfiram and naltrexone is compliance. Various procedures have been used to increase disulfiram compliance, including behavior contracting, spouse monitoring and encouragement, more frequent clinic visits with monitoring, and implantation (Fuller 1989).
Behavior contracting more generally has been found helpful in maintaining sobriety, and it is a familiar approach in treating drug abuse. Aversion therapies have a long and controversial history.
Holder and colleagues (1991) found adequate experimental support for covert sensitization, the only form of aversion therapy that involves no physical unconditioned stimulus but is conducted in imagination.
It clearly is possible to induce a conditioned aversion reaction through covert sensitization, and the establishment of conditioning has been found to be predictive of favorable outcome (Elkins 1980; Miller and Dougher 1989).
More broadly, conditioning-based procedures (e.g., cue exposure) have been explored as relevant processes in treatment for alcohol and other drug problems (Greeley and Westbrook 1991).
Behavioral self-control training (BSCT) involves teaching learningbased procedures to clients to assist them in altering their own behavior. In the Holder and colleagues (1991) review, BSCT had the largest number of trials (17) and the second highest WEIn score (after social skills training) of any modality.
BSCT has most often been applied with a goal of moderation of alcohol use (Hester and Miller 1989) or other drug use (Wilkinson and LeBreton 1986), but it also has been applied with a goal of abstinence (e.g., Sanchez-Craig et al. 1984).
Typically, BSCT includes a combination of strategies designed to modulate use (e.g., specific goal-setting, self-monitoring, alteration of the topography of use, stimulus control, self-reinforcement, and refusal training) and methods for altering the probability of future use (e.g., functional analysis and coping skill training).
Applications to other drug use are straightforward. The success of brief counseling in altering problem drinking has been documented consistently. In a recently completed review, Bien and colleagues (in press) identified 32 controlled trials with strikingly consistent results.
The methodology of these studies compares favorably with that for the alcohol field in general (mean of 13 on a composite methodologic quality scale of 0-17). Brief counseling (typically one to three sessions) has been found consistently superior to untreated controls and in 11 of 13 randomized trials has had comparable impact to that of more extensive treatments.
These brief interventions have included virtually no behavioral skill training, medication, or contracting. Their content is more cognitivemotivational (Miller and Rollnick 1991).
Six elements, summarized in the acronym FRAMES, have been described as common components of effective brief interventions (Miller and Sanchez, in press): FEEDBACK of personal assessment results, Emphasis on personal RESPONSIBILITY for change, ADVICE to change use, Description of a MENU of options for change, Therapeutic EMPATHY as a predominant counseling style, and Support for client SELF-EFFICACY and optimism.
In the Holder and colleagues (1991) grid, brief motivational counseling was the only entry in the box with highest evidence of efficacy and lowest cost. Researchers at UNM have developed and tested a “Drinker’s Check-up” to manifest the FRAMES elements (Miller and Sovereign 1989; Miller et al., in press) and are exploring the extension of this model to a brief intervention for other drug use.
All four effective behavioral methods that support a sober lifestyle are also readily applicable in the treatment of drug problems in general. Behavioral marital therapy teaches skills for more effective communication and positive reinforcement within intimate relationships (O’Farrell and Cowles 1989).
Social skills training focuses more generally on communication skills such as assertiveness for effective social relations (Monti et al. 1986).
Studies of stress management procedures in alcohol treatment have focused primarily on relaxation training and systematic desensitization, although a broader array of technologies can be applied (Stockwell and Town 1989).
Azrin’s community reinforcement approach, which has yielded some of the largest treatment effects in the literature, combines many of the wellsupported components described above, including monitored disulfiram, behavior contracting, motivational counseling, behavioral marital therapy, social skills training, and mood management (Sisson and Azrin 1989).
As with other behavioral strategies, the community reinforcement approach can be applied directly in the treatment of other drug problems (e.g., Higgins et al. 1991).
Investigators at UNM currently are conducting three clinical trials of this approach with 172 alcoholics (R0l-AA07564), heroin addicts (R18-DA06953), and dually diagnosed homeless individuals (R0l-AA08331).
CONTRAST WITH STANDARD PRACTICE
The presence of a large body of treatment outcome research in general, and of behavioral treatment studies in particular, has had little apparent impact on standard practice.
Alcoholism treatment programs continue to rely on a reasonably standard (if unspecified) melange of counseling strategies loosely derived from psychodynamic and disease model conceptions that have changed surprisingly little in 50 years (Miller, in press-a).
Group therapy is a common program component, often emphasizing confrontation of denial, group processes, and general exploration and expression of emotions (e.g., “inner child” work)– themes frequently pursued in individual counseling as well.
Educational lectures and films are likewise normative, typically teaching an attributional model that emphasizes a unitary disease that is biologically based and involves irreversible loss of control (Miller, in press-b).
Attendance at Alcoholics Anonymous meetings is usually advocated and sometimes mandated. Various forms of relapse prevention counseling commonly are practiced (e.g., Gorski and Miller 1982). None of these components has been shown in controlled trials to contribute significantly to the improvement of treatment outcomes.
Aggressive confrontational counseling tactics, in fact, appear to be associated with poorer outcomes (e.g., Miller and Rollnick 1991; Miller et al., in press) and may be particularly detrimental for individuals with low self-esteem (Annis and Chan 1983).
Counselor Behaviors
There appear to be large differences in effectiveness among counselors delivering allegedly similar treatments (e.g., McLellan et al. 1988; Miller et al. 1980). In all studies to date evaluating counselor style, a reflective, empathic, listening approach has been predictive of more favorable alcohol treatment outcomes (e.g., Miller et al. 1980, in press; Valle 1981).
It is conceivable that characteristics of counselor style account for more variance in treatment retention, compliance, and outcome than declared therapeutic approach. In studying the effectiveness of behavioral treatments for drug abuse, therefore, the influence of therapist characteristics and behavior should not be overlooked.
Client Characteristics
Client characteristics represent another determinant of treatment outcome (Moos et al. 1990). Reviewers have had little success in identifying universal prognostic characteristics of individuals in treatment for alcohol problems (e.g., Gibbs and Flanagan 1977).
It is conceivable, however, that profiles of optimal responder characteristics could be identified for specific treatment modalities (Miller and Hester 1986b). If such responder profiles are consistent across studies, criteria can be derived for a priori matching of clients to treatment approaches.
Kadden and colleagues (1989) found that behavioral skills training was more effective than interactional therapy with alcoholics higher in psychopathology in general and sociopathy in particular.
Project MATCH, an NIAAA multisite collaborative trial, is comparing 12-step, cognitive-behavioral, and motivational strategies in seeking differential predictors of response. It is likely that behavioral treatments are not optimally effective for all drug abusers, but they may be for definable subgroups. Different approaches may be more effective for clients with other characteristics.
RECOMMENDATIONS FOR RESEARCH
The accumulated research on treatment for alcohol problems suggests several general recommendations for future research on treatment (including behavioral treatment) for drug abuse more generally. Treatment researchers may be able to avoid some of the same pitfalls and blind alleys by considering this large existing literature.
1. It would be sensible to adapt and replicate for treatment of other drug problems those therapeutic modalities (primarily behavioral) that have been shown to be most effective in treating alcohol problems. A half century of outcome research points to specific treatment methods that are more (and less) promising, and this knowledge can be used to guide future research and practice.
2. Paralleling the recommendations of the National Academy of Sciences (1990) with regard to alcohol problems, drug use and problems can be understood as lying along a continuum of severity. Different intervention strategies are likely to be effective at various points along that continuum. Brief cognitivemotivational interventions may be particularly cost-effective in addressing the large population of individuals with less severe drug problems and dependence.
3. The impact of treatment settings should be separated from therapeutic modalities. The alcoholism literature suggests that there is little or no overall difference in effectiveness (but substantial difference in cost) between residential/inpatient programs and outpatient/community approaches (Miller and Hester 1986c; U.S. Congress 1983). It remains to be determined whether particular treatment modalities are differentially effective in alternative treatment settings.
4. Clinical trials and other treatment studies should include measures of therapist behavior and treatment processes. Attrition from and effectiveness of treatment in general, and of behavioral modalities in particular, appear to be impacted substantially by the characteristics of those who deliver the therapies.
5. Relevant client characteristics also should be assessed so pretreatment markers of therapeutic response can be identified. In trials comparing different treatments, tests for interaction effects with client characteristics should be routinely explored.
6. Studies of behavioral and other treatments will advance knowledge more effectively when designed to detect the mechanisms of therapeutic effect. Theory-grounded treatments are hypothesized to work for particular reasons, and it is worthwhile to test whether observed relationships between independent and dependent variables are consistent with these accounts.
7. Treatment research should include procedures to measure the cost of delivering the services under study. Treatment policy can be guided by knowledge not only of the relative effectiveness of alternative strategies, but also of relative cost.
8. Given the substantial overlap between alcohol and other drug abuse in clinical populations, it would be advantageous for clinical trials in both NIDA and NIAAA to include state-of-the-art outcome measures for drug use (including alcohol use) in general Alcohol treatment research to date has been plagued by a lack of consistency in outcome measures. It would be particularly beneficial to develop consensual prototypic assessment procedures to permit comparison of outcomes across studies.
SUMMARY
Behavioral approaches have a strong track record in the treatment of alcohol problems. They are generally cost-effective (Holder et al. 1991), can be readily combined with and enhance the effectiveness of pharmacologic interventions (e.g., Azrin et al. 1982), and have been found to be applicable all along the continuum of problem severity.
Cognitive-behavioral strategies appear to be particularly helpful in addressing common problems of treatment motivation, retention, and compliance. There is no reason to expect substantially different findings when behavioral strategies are applied in the treatment of other drug problems.
REFERENCES
Annis, H.M., and Chan, D. The differential treatment model: Empirical evidence from a personality typology of adult offenders. Crim Justice Behav 10:159-173, 1983.
Azrin, N.H.; Sisson, R.W.; Meyers, R.; and Godley, M. Alcoholism treatment by disulfiram and community reinforcement therapy. Behav Res Ther 14:339-348, 1982.
Baekeland, F. Evaluation of treatment methods in chronic alcoholism. In: Kissin, B., and Begleiter, H., eds. The Biology of Alcoholism. Vol. 5. New York: Plenum Press, 1977.
Bien, T.H.; Miller, W.R.; and Tonigan, J.S. Brief interventions for alcohol problems: A review. Brit J Addict, in press.
Bowman, K.M., and Jellinek, E.M. Alcohol addiction and its treatment. Q J Stud Alcohol 2:98-176, 1941.
Brownell, K.D.; Marlatt, G.A.; Lichtenstein, E.; and Wilson, G.T. Understanding and preventing relapse. Am Psychol 41:765-782, 1986.
Costello, R.M.; Biever, P.; and Baillargeon, J.G. Alcoholism treatment programming: Historical trends and modern approaches. Alcohol Clin Exp Res 1:311-318, 1977.
Elkins, R.L. Covert sensitization treatment of alcoholism: Contributions of successful conditioning to subsequent abstinence maintenance. Addict Behav 5:67-89, 1980.
Emrick, C.D. A review of psychologically oriented treatment of alcoholism: I. The use and interrelationships of outcome criteria and drinking behavior following treatment. Q J Stud Alcohol 35:523- 549, 1974.
Emrick, C.D. A review of psychologically oriented treatment of alcoholism: II. The relative effectiveness of different treatment approaches and the effectiveness of treatment versus no treatment. J Stud Alcohol 36:88-108, 1975.
Fuller, R.K. Antidipsotropic medications. In: Hester, R.K., and Miller, W.R., eds. Handbook of Alcoholism Treatment Approaches: Effective Alternatives. New York: Pergamon Press, 1989. pp. 117-127.
Gibbs, L., and Flanagan, J. Prognostic indicators of alcoholism treatment outcome. Int J Addict 12:1097-1141, 1977.
Gorski, T.F., and Miller, M. Counseling for Relapse Prevention. Independence, MO: Herald House-Independence Press, 1982.
Greeley, J., and Westbrook, F. Associative learning, drug use and addictive behaviour. In: Heather, N.; Miller, W.R.; and Greeley, J., eds. Self-Control and the Addictive Behaviours. Sydney: Maxwell Macmillan Publishing Australia, 1991. pp. 127-150.
Heather, N.; Miller, W.R.; and Greeley, J., eds. Self-Control and the Addictive Behaviours. Sydney: Maxwell Macmillan Publishing Australia, 1991.
Hester, R.K., and Miller, W.R. Self-control training. In: Hester, R.K., and Miller, W.R., eds. Handbook of Alcoholism Treatment Approaches: Effective Alternatives. New York: Pergamon Press, 1989. pp. 141-149.
Higgins, S.T.; Delaney, D.D.; Budney, A.J.; Bickel, W.K.; Hughes, J.R.; Foerg, F.; and Fenwick, J.W. A behavioral approach to achieving initial cocaine abstinence. Am J Psychiatry 148:1218-1224, 1991. 177
Holder, H.; Longabaugh, R.; Miller, W.R.; and Rubonis, A.V. The cost effectiveness of treatment for alcoholism: A first approximation. J Stud Alcohol 52:517-540, 1991.
Kadden, R.M.; Cooney, N.L.; Getter, H.; and Litt, M.D. Matching alcoholics to coping skills or interactional therapies: Posttreatment results. J Consult Clin Psychol 57:698-704, 1989.
McLellan, A.T.; Woody, G.E.; Luborsky, L; and Goehl, L. Is the counselor an “active ingredient” in substance abuse rehabilitation? An examination of treatment success among four counselors. J Nerv Ment Dis 176:423-430, 1988.
Miller, W.R., ed. The Addictive Behaviors: Treatment of Alcoholism, Drug Abuse, Smoking, and Obesity. Elmsford, NY: Pergamon Press, 1980.
Miller, W.R. Alcoholism: Toward a better disease model. Psychol Addict Behav, in press-b.
Miller, W.R. The evolution of treatment for alcohol problems: From the 1940’s to the 1980’s. In: 40th Anniversary Lecture Series. Toronto: Addiction Research Foundation, in press-a.
Miller, W.R.; Benefield, R.G.; and Tonigan, J.S. Enhancing motivation for change in problem drinking: A controlled comparison of two therapist styles. J Consult Clin Psychol in press.
Miller, W.R., and Dougher, M.J. Covert sensitization: Alternative treatment procedures for alcoholism. Behav Psychother 17:203-220, 1989.
Miller, W.R., and Hester, R.K. Treating the problem drinker: Modem approaches. In: Miller, W.R., ed. The Addictive Behaviors: Treatment of Alcoholism, Drug Abuse, Smoking, and Obesity. Elmsford, NY: Pergamon Press, 1980. pp. 11-141.
Miller, W.R., and Hester, R.K. The effectiveness of alcoholism treatment methods: What research reveals. In: Miller, W.R., and Heather, N., eds. Treating Addictive Behaviors: Processes of Change. New York: Plenum Press, 1986a. pp. 121-174.
Miller, W.R., and Hester, R.K. Inpatient alcoholism treatment: Who benefits? Am Psychol 41:794-805, 1986c .
Miller, W.R., and Hester, R.K. Matching problem drinkers with optimal treatments. In: Miller, W.R., and Heather, N., eds. Treating Addictive Behaviors: Processes of Change. New York: Plenum Press, 1986b. pp. 175-203.
Miller, W.R., and Rollnick, S. Motivational Interviewing: Preparing People To Change Addictive Behavior. New York: Guilford Press, 1991. Miller, W.R., and Sanchez, V.C. Motivating young adults for treatment and lifestyle change. In: Howard, G., ed. Issues in Alcohol Use and Misuse by Young Adults, Notre Dame, IN: University of Notre Dame Press, in press.
Miller, W.R., and Sovereign, R.G. The check-up: A model for early intervention in addictive behaviors. In: Addictive Behaviors: Prevention and Early Intervention. Amsterdam: Swets and Zeitlinger, 1989. pp. 219-231.
Miller, W.R.; Taylor, C.A.; and West, J.C. Focused versus broad spectrum behavior therapy for problem drinkers. J Consult Clin Psychol 48:590-601, 1980.
Monti, P.M.; Abrams, D.B.; Binkoff, J.A.; and Zwick, W.R. Social skills training and substance abuse. In: Hollin, C.R., and Trower, P., eds. Handbook of Social Skills Training. Vol. 2. New York: Pergamon Press, 1986. pp. 111-142.
Moos, R.H.; Finney, J.W.; and Cronkite, R.C. Alcoholism Treatment: Context, Process, and Outcome. New York: Oxford University Press, 1990. National Academy of Sciences, Institute of Medicine. Broadening the Base of Treatment for Alcohol Problems. Washington, DC: National Academy Press, 1990.
O’Farrell, T.J., and Cowles, K.S. Marital and family therapy. In: Hester, R.K., and Miller, W.R., eds. Handbook of Alcoholism Treatment Approaches: Effective Alternatives. New York: Pergamon Press, 1989. pp. 117-127.
Orford, J. Excessive Appetites: A Psychological View of Addictions. New York: John Wiley, 1985.
Peele, S. The Meaning of Addiction: Compulsive Experience and Its Interpretation. Lexington, MA: Lexington Books, 1985.
Sanchez-Craig, M.; Annis, H.M.; Bomet, A.R.; and MacDonald, K.R. Random assignment to abstinence and controlled drinking: Evaluation of a cognitive-behavioural program for problem drinkers. J Consult Clin Psychol 52:390-403, 1984.
Sisson, R.W., and Azrin, N.H. The community reinforcement approach. In: Hester, R.K., and Miller, W.R., eds. Handbook of Alcoholism Treatment Approaches: Effective Alternatives. New York: Pergamon Press, 1989. pp. 242-258.
Stockwell, T., and Town, C. Anxiety and stress management. In: Hester, R.K., and Miller, W.R., eds. Handbook of Alcoholism Treatment Approaches: Effective Alternatives. New York: Pergamon Press, 1989. pp. 222-230.
U.S. Congress, Office of Technology Assessment. The Effectiveness and Costs of Alcoholism Treatment. Washington, DC: U.S. Govt. Print. Off., 1983.
Valle, S.K. Interpersonal functioning of alcoholism counselors and treatment outcome. J Stud Alcohol 42:783-790, 1981.
Voegtlin, W.L., and Lemere, F. The treatment of alcohol addiction: A review. Q J Stud Alcohol 2:717-803, 1941.
Wilkinson, D.A., and LeBreton, S. Early indications of treatment outcome in multiple drug users. In: Miller, W.R., and Heather, N., eds. Treating Addictive Behaviors: Processes of Change. New York: Plenum Press, 1986. pp. 239-261.
ACKNOWLEDGMENT
Preparation of this chapter was supported in part by grant number K05-AA09051 from the National Institute on Alcohol Abuse and Alcoholism.
AUTHOR
William R. Miller, Ph.D. Professor of Psychology and Psychiatry Department of Psychology and Director Research Division Center on Alcoholism, Substance Abuse, and Addictions (CASAA) The University of New Mexico Albuquerque, NM 87131-1161
---------
From NIDA Research Monograph 137 Behavioral Treatments for Drug Abuse and Dependence [pdf with multiple chapters, diagrams]