Addiction Medicine: Closing the Gap between Science and Practice

Cognitive Behavioral Therapy (CBT).
Cognitive Behavioral Therapy (CBT) involves
training in social skills, self-control and stress
management through activities such as role
playing, behavioral modeling and feedback.^253 It
is designed to help patients identify, recognize
and avoid thought processes, behaviors and
situations that are associated with substance use;
manage cravings; refuse offers of tobacco,
alcohol or other drugs; and develop better
problem-solving and coping skills.^254

CBT generally is used as a short-term
intervention and can be tailored both to inpatient
and outpatient programs via group or individual
therapy.^255 The therapy has been proven
effective for adolescents and adults and for a
variety of manifestations of substance
addiction.^256 CBT has demonstrated efficacy for
specific populations such as women with
addiction and individuals with co-occurring
disorders.* 257

Community Reinforcement Approach (CRA).
The Community Reinforcement Approach
(CRA) is a multi-phase, intensive 24-week
outpatient treatment for addiction involving

• CBT may work as well for other populations and

other substances, but available data largely are
focused on the ones described here.

alcohol and drugs other than nicotine.^258

Counseling sessions focus on improving family

relations, learning skills to reduce substance use,

acquiring vocational skills and developing

recreational activities and social networks that

can help to minimize the drive to engage in

substance use.^259 CRA also assists patients in

developing communication, problem-solving

and drug refusal skills.^260 CRA is based on the

notion that patients must be taught life skills and

shown that living substance free can be more

rewarding than a life of addiction.^261

There is evidence of the effectiveness of CRA

for treating patients with addiction involving

alcohol and drugs other than nicotine.^262

Effectiveness is enhanced when coupled with

pharmaceutical interventions and abstinence-

based incentive programs, such as the provision

of vouchers exchangeable for retail items

contingent on negative urinalysis results.^263

Participation in a CRA intervention also has

shown positive supplementary effects, such as

increased employment rates and decreased

criminal involvement.^264

Contingency Management (CM).

Contingency Management (CM) is an

intervention that uses positive and negative

reinforcement to alter behavior, although

rewarding positive behavior has been

demonstrated to be more effective than

punishing negative behavior.^265 Most CM

interventions provide patients with vouchers and

incentives for meeting treatment-related goals

such as producing a drug-free urine test.

Incentives can include cash rewards, vouchers to

purchase desired items or treatment-related

privileges such as receiving multiple doses of

medication at one time to avoid having to make

numerous clinic visits.^266

The effectiveness of CM has been demonstrated

for addiction involving nicotine, alcohol,

marijuana, cocaine, methamphetamine and

opioids.^267 CM can improve program retention,†

increase abstinence and help prevent relapse. It

is most successful when used in conjunction

† Improved program retention is associated with other

positive treatment outcomes.

Motivational Interviewing

The MI therapist attempts to:

 Express empathy through reflective

listening;

 Recognize discrepancies between patients’

goals or values and their current substance

use;

 Provide normative feedback on the

discrepancy between patients’ substance

use and that of their peers;

 Adjust to patient resistance rather than

oppose it directly;

 Avoid arguments and direct

confrontations; and

 Support patients’ sense of self-efficacy to

change their behavior.^252