EvidenceBased Treatment

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Evidence-Based Treatment

• Community Reinforcement Approach (CRA)
• Robert J. Meyers, Ph.D.
• Jane Ellen Smith, Ph.D.
• University of New Mexico

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Early CRA Studies

• Hunt Azrin, 1973
• Azrin, 1976
• Azrin, Sisson, Meyers, Godley, 1982

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Hunt Azrin 1973

• inpatient alcoholics
• job finding counseling
• behavioral/marital tx
• social/leisure counseling
• reinforcer access counseling
• social club
• home visits
• total 50 hrs per client

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Results 6 month follow-up
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Azrin 1976 New Improved CRA

• inpatient alcoholics
• disulfiram w/compliance protocol
• problem prevention rehearsal
• buddy system

• early warning mood monitoring
• some group tx
• 70 as aftercare home visits
• Average 30 contact hrs

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CRA new improved Results
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1st CRA Outpatient Study (Azrin, Sisson, Meyers,
Godley, 1982)

• 43 outpatient alcoholics
• 3 groups
• traditional tx only
• traditional tx disulfiram compliance
• CRA only

• increased use of positive reinforcement
• sobriety sampling
• immed. disulfiram
• drink refusal training
• /- functional analysis
• job club
• phone contacts
• Average 5 tx sessions

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Results of 1982 study

• 6 month follow-up
• Disulfiram only group days abs 74
• CRA days abs 97
• Traditional group day abs 45

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CRA with Homeless Alcohol-Dependent Individuals

• PI Jane Ellen Smith
• Co-PI Robert J. Meyers
• Funded by NIAAA

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Primary Questions Addressed

• Is CRA gt a day shelters standard program for
  treating drinking problems among homeless
  individuals?
• What are the effects of the 2 treatments on the
  non-drinking variables (employment, housing)?

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CRA Group

• Group Sessions
• Problem-Solving
• Communication Skills
• Drink-Refusal
• Independent Living Skills
• Goal Setting/Community Meeting
• Social Club
• Disulfiram Compliance
• Individual Sessions
• Job Finding
• Case Management
• Couples Therapy

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Standard Treatment Group

• Day Shelter Program
• Project Share
• Alcoholics Anonymous Meetings
• 12-Step Counselor
• Job Service Program
• VA Benefits Advisor
• Project CARE

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Grant-Provided Housing

• All participants were housed
• Normal stay 3 months
• Extended stays if job and saved
• Random breathalyzer tests

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Drinks Per Week By Condition
--- Standard --- CRA
Median SECs
2 Month 4 Mont 6
Month 9 Month 12
Month
Follow-Up Period
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Percent Homeless By Condition
CRA Standard
Percent
2 Month 4 Month 6 Month
9 Month 12 Month
Follow-up Periods
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Percent Employed By Condition
CRA Standard
Percent
Intake 2 Month 4 Month 6
Month 9 Month 12 Month
Follow-up Period
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Limitations of the Study

• Not comparable doses of treatment
• Some CRA participants still drinking heavily
• Only moderate improvement in employment
• Cost of housing

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CRA with Homeless Alcoholic Women

• Why women only?
• Treatments
• Case Management
• CRA
• CRA contingency-managed computer training

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Summaries of Adult Treatment Research for Alcohol
Use Disorders

• Meta-analyses and Reviews

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Evidence of Effectiveness Meta-analyses

• Holder et al., 91 Miller et al., 95
• Social skills training Brief intervention
• Self-control training Social skills training
• Brief motivational tx MET
• Behavioral Marital tx CRA
• CRA Behavioral contract
• Stress management Aversion tx

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Evidence of Effectiveness (contd)

• Finney et al., 96 Miller et al., 03
• CRA Brief Intervention
• Social skills training Motivational Enhancement
• Behavioral Marital tx Acamprosate
• Disulfiram Implants CRA
• Other marital tx Self-Change (bibliotherapy)
• Stress Management Naltrexone

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CRA for Illicit Drugs Adult Studies

• Cocaine
• Higgins et al. (1991 1993 1994 1995 2000)
• Heroin
• Bickel et al. (1997)
• Abbott et al. (1998)

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Adolescent CRA
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Godley et al. (2002)

• Continuing care study (after residential
  treatment)
• UCC (usual continuing care) or ACRA case mgmt
• 114 adolescents
• 90 marijuana dependent at intake
• 57 alcohol dependent
• 82 involved w/ juvenile justice system

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Results 3 months

• ACRA significantly gt UCC in terms of
• abstinence from marijuana
• reduced alcohol use

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Cannabis Youth Treatment (CYT) Study (Dennis et
al., 2004)

• Outpatient treatment for marijuana
• Trial 1MET/CBT5 MET/CBT12 FSN
• Trial 2 MET/CBT5 ACRA MDFT
• 600 adolescents
• Hi rate of illegal activities

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Results 12 months

• Measures
• (1) days of abstinence (from drugs alcohol)
• (2) in recovery living in community (not
  jail)
• no use no past month substance problems
• General Findings All treatments significantly
  improved pre-post no significant tx comparison
  differences

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• Best overall in recovery rates ACRA (34
  next best MET/CBT5 at 27)
• Best of abstinent days for Trial 2 ACRA (73
  of days during the year best for Trial 1
  MET/CBT5 at 74)
• Most cost-effective? ACRA

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UNM CASAAs Street Youth Program Project STAR
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Percent days of substance use
Significant interaction between time (pre to 6
months) and group using number of treatment
sessions as covariate (F (1, 81) 9.10, p lt .01).
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Percentage of days off the street
Trend toward interaction between time (pre to 6
months) and group using number of treatment
sessions as covariate (F (1, 81) 3.09, p . 08).
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What does not work!

• Educational films and lectures
• General alcoholism counseling
• Psychotherapy
• Confrontational counseling
• Antipsychotic medication
• Psychotherapy, group process
• Insight therapy

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Why Isnt CRA Used More?

• Disease Model
• Limited accessibility
• Its hard to teach an old dog new tricks
• We already do that
• CRA isnt sexy