Assessment and Treatment of Addictive Behaviors Carl W. Lejuez, PhD

1
Assessment and Treatment of Addictive
BehaviorsCarl W. Lejuez, PhD

• Lecture 7
• Drugs, Alcohol, and Smoking Treatment

2
Drug Treatment Cost Effective?

• Yes!
• Less expensive than alternatives, such as not
  treating addicts or simply incarcerating addicts
• 1 year of methadone maintenance is about 4,700
  per patient
• 1 full year of imprisonment costs about 18,400
  per person
• Every 1 invested in addiction treatment programs
  yields a return of between 4 and 7 in reduced
  drug-related crime, criminal justice costs, and
  theft alone
• Costs reduced due to drops in health care
  expenses, interpersonal conflicts, improvements
  in workplace productivity, and reductions in
  drug-related accidents

3
Initial Considerations

• Due to heterogeneity of drug problems, detailed
  initial assessment is crucial
• Should assess how they made it to treatment are
  they self-referred or by the will of others
  including court mandate
• Multidimensional Outcomes
• Abstinence doesnt guarantee improvement in
  social, occupational, etc functioning
• Relapse often a part of long-term success
• Relapse rate on 1st attempt seeking treatment lt
  25
• Common treatments often have little empirical
  support

4
Basics of Treatment

• In addition to stopping drug use, the goal of
  treatment is to return the individual to
  productive functioning in the family, workplace,
  and community
• Measures of effectiveness
• criminal behavior
• family functioning
• Employability
• medical condition
• Overall, treatment of addiction is as successful
  as treatment of other chronic diseases, such as
  diabetes, hypertension, and asthma

5
Basics of Treatment

• Treatment reduces drug use by 40 60
  significantly decreases criminal activity during
  after treatment
• For example, a study of therapeutic community
  treatment for drug offenders demonstrated that
  arrests for violent and nonviolent criminal acts
  were reduced by 40 percent or more
• Methadone treatment has been shown to decrease
  criminal behavior by as much as 50 percent.
• Research shows that drug addiction treatment
  reduces the risk of HIV infection and that
  interventions to prevent HIV are much less costly
  than treating HIV-related illnesses.

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Basics of Treatment

• Important Considerations
• No single treatment is appropriate for all
  individuals
• An individual's treatment and services plan must
  be assessed continually and modified as necessary
  to ensure that the plan meets the person's
  changing needs
• Counseling and other behavioral therapies are
  critical components of effective treatment for
  addiction
• Medications are an important element of treatment
  for many patients
• Medical detoxification is an important first step
  to most drug addiction treatments

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Basics of Treatment

• Medical Detoxification
• Detoxification alone is rarely sufficient to help
  addicts achieve long-term abstinence
• Medical detoxification safely manages the acute
  physical symptoms of withdrawal associated with
  stopping drug use.
• Strongly indicated precursor to effective drug
  addiction treatment

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Types of Treatment

• Pharmacological Treatment
• Medication can be used to accomplish a number of
  goals
• Prevention of overdose
• Suppression of withdrawal
• Reduction of cravings
• Reduction of psychiatric symptoms
• Heroin Methadone, LAAM, Naltrexone,
  Buprenorphine
• Alcohol Disulfiram (Antabuse), Benzodiazepines
• No FDA approved medications for treatment for the
  following
• Cocaine
• LSD
• PCP
• Marijuana
• Methamphetamine and other stimulants
• Inhalants
• Anabolic steroids

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Types of Treatment

• Behavioral Treatment
• Assumption Drug Taking is a special case of
  operant behavior maintained by the reinforcing
  effects of the drugs.
• EvidenceHuman and animal self-administration
  studies repeatedly demonstrate that various
  psychoactive drugs serve as positive
  reinforcers.Variables that control other
  operant behaviorssuch as reinforcer magnitude,
  response requirement, and the availability of
  alternative reinforcersalso control drug
  taking.Numerous treatment studies have
  demonstrated that contingency management
  procedures can effectively reduce drug use
• Examples
• Contingency Management Interventions
• Behavioral Activation

10
Types of Treatment

• Multisystemic and Social Support Treatments
• These treatment programs attend to abstinence as
  well as other aspects of the individuals needs
  based on the theory that sobriety can not be
  maintained in a vacuum
• Areas Addressed include medical attention,
  occupational training, educational training
  (GED), housing, family relationships, exposure to
  community resources, social support, etc.
• Examples
• Out-patient treatment Programs
• Residential Programs
• Therapeutic Communities
• NA/AA/Narconon

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Types of Treatment

• Psychotherapy
• Useful for providing patients with individualized
  therapy
• Provides more privacy than group setting
• Enables patient to address problems that may be
  only peripherally related to drug use
• Enables patient to address other mental health
  issues
• Examples
• Individualized Drug Counseling
• Motivational Enhancement Therapy
• Relapse Prevention

12
Treatment Duration

• Individuals progress through drug addiction
  treatment at various speeds, but Good outcomes
  are contingent on adequate lengths of treatment.
• residential or outpatient treatment,
  participation for less than 90 days is of limited
  or no effectiveness, and treatments lasting
  significantly longer often are indicated.
• For methadone maintenance, 12 months of treatment
  is the minimum, and some opiate-addicted
  individuals will continue to benefit from
  methadone maintenance treatment over a period of
  years.
• Successful outcomes may require multiple
  treatment experience. Many addicted individuals
  have multiple episodes of treatment, often with a
  cumulative impact.

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Pharmacological Treatments
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Agonist Maintenance Treatment

• For opiate addicts usually is conducted in
  outpatient settings, often called methadone
  treatment programs
• These programs use a long-acting orally
  administered synthetic opiate medication
• usually methadone or LAAM
• sustained period at a dosage sufficient to
  prevent opiate withdrawal, block the effects of
  illicit opiate use, and decrease opiate craving
• Patients stabilized on opiate agonists can engage
  more readily in counseling and other behavioral
  interventions
• Most effective opiate agonist maintenance
  programs include individual and/or group
  counseling, as well as provision/referral to
  other needed medical, psychological, social
  services.

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Agonist Maintenance Treatment

• As used in maintenance treatment, methadone and
  LAAM are not heroin substitutes
• Pharmacological effects are markedly different
  from those of heroin.
• Far more gradual onsets of action than heroin
• No rush
• Wears off much more slowly than heroin
• No sudden crash
• Euphoric effects of heroin are significantly
  blocked
• No marked fluctuations experienced by brain and
  body
• Reduced craving for heroin

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Narcotic Antagonist Treatment Using Naltrexone

• For opiate addicts, usually conducted in
  outpatient settings although initiation of the
  medication often begins after medical
  detoxification in a residential setting
• Naltrexone is a long-acting synthetic opiate
  antagonist with few side effects that is taken
  orally either daily or three times a week for a
  sustained period of time
• Individuals must be medically detoxified and
  opiate-free for several days before naltrexone
  can be taken to prevent precipitating an opiate
  abstinence syndrome. When used this way, all the
  effects of self-administered opiates, including
  euphoria, are completely blocked.

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Narcotic Antagonist Treatment Using Naltrexone

• Theory repeated lack of the desired opiate
  effects, as well as the perceived futility of
  using the opiate, will gradually result in
  breaking the habit of opiate addiction
• Naltrexone itself has no subjective effects or
  potential for abuse and is not addicting.
• Patient noncompliance is a common problem.
• Most useful for highly motivated, recently
  detoxified patients who desire total abstinence
  because of external circumstances, including
  impaired professionals, parolees, probationers,
  and work-release prisoners

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Other Medications for Heroin Dependence

• Buprenorphine has recently been approved for
  maintenance treatment.
• Does not require daily administration, an
  advantage over methadone.
• Like methadone and LAAM, Buprenorphine suppress
  withdrawal, reduce cravings, and prevent users
  from getting high from heroin
• Another potential answer prescription Heroin
• Why prescribe heroin?
• Methadone does not work for everyone
• Might bring more people into treatment
• Reduce some of the harm associated with heroin
• Undermine the black market

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Cocaine Vaccine

• TA-CD is a combination of the cocaine molecule
  and a large protein
• Triggers the generation of antibodies.
• If cocaine is taken
• Antibodies combine with cocaine molecules to form
  a complex that is too big to cross the
  blood-brain barrier.
• Initial trails have indicated TA-CD is safe and
  effective in reducing cocaine intake in rats
• A single human study has shown that the drug was
  well tolerated (low side effects) and safe in
  humans.
• Awaiting FDA approval for use as a treatment of
  cocaine dependence

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Behavioral Treatment
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Contingency Management Programs

• Based on idea that in any particular instance,
  benefits of drug use often are immediate
  certain, whereas negatives often are delayed
  often uncertain
• Also focuses on fact that benefits for nonuse
  often are delayed and uncertain
• Basic Procedures
• Drug use and abstinence are readily detected
• Drug abstinence is readily reinforced
• Drug use results in a loss of reinforcement
• Reinforcement derived from non-drug sources is
  increased to compete with the reinforcing effects
  of drug use(Higgins et al., 1991)

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Voucher-Based Reinforcement Therapy in Methadone
Maintenance Treatment

• Provision of a voucher for each drug-free urine
  sample
• Voucher has monetary value and can be exchanged
  for goods and services consistent with treatment
  goals
• Initially, voucher values are low, but value
  increases with the number of consecutive
  drug-free urine specimens
• Cocaine- or heroin-positive urine specimens reset
  the value
• Escalating contingency to reinforce sustained
  drug abstinence.
• Patients receiving vouchers for drug-free urine
  achieved significantly longer abstinence than
  patients who were given vouchers independent of
  urinalysis results.

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Community Reinforcement Approach (CRA) Plus
Vouchers

• Intensive 24-week outpatient therapy for
  treatment of cocaine
• To achieve cocaine abstinence long enough for
  patients to learn new life skills that will help
  sustain abstinence
• To reduce alcohol consumption for patients whose
  drinking is associated with cocaine use.
• Patients attend one or two individual counseling
  sessions per week, where they focus on improving
  family relations, learning a variety of skills to
  minimize drug use, receiving vocational
  counseling, and developing new recreational
  activities and social networks.

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CRA Plus Vouchers

• Those who also abuse alcohol receive
  clinic-monitored disulfiram (Antabuse) therapy
• Patients submit urine samples two or three times
  each week receive vouchers for cocaine-negative
  samples
• The value of the vouchers increases with
  consecutive clean samples. Exchange vouchers for
  retail goods
• Facilitates patients' engagement in treatment and
  aids in gaining substantial periods of cocaine
  abstinence.
• Tested in urban and rural areas and used
  successfully in outpatient detoxification of
  opiate-addicted adults and with inner-city
  methadone maintenance patients who have high
  rates of intravenous cocaine abuse.

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Multisystemic and Social Support Treatments
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Outpatient Treatment

• Outpatient Drug-Free Treatment
• Varies in the types and intensity of services
  offered.
• Costs less than residential or inpatient
  treatment
• Most suitable for individuals who are employed or
  who have extensive social supports.
• Low-intensity programs focus is on drug
  education and admonition.
• Intensive day treatment comparable to
  residential programs in services and
  effectiveness
• Group counseling is emphasized
• Medical or mental health problems may also be
  treated

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Long-Term Residential

• Provides care 24 hours per day, generally in
  nonhospital settings
• The best-known residential treatment model is the
  therapeutic community (TC), but residential
  treatment may also employ other models, such as
  cognitive-behavioral therapy

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Therapeutic Communities

• Residential programs with planned stays of 6-12
  months
• TCs focus on the "resocialization" of the
  individual and use the program's entire
  "community,"
• including other residents, staff, and the social
  context, as active components of treatment
• Addiction is viewed in the context of an
  individual's social and psychological deficits
• treatment focuses on developing personal
  accountability and responsibility and socially
  productive lives.
• Highly structured and at times be confrontational
• activities designed to help residents examine
  damaging beliefs, self-concepts, and patterns of
  behavior and to adopt new, more harmonious and
  constructive ways to interact with others

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Therapeutic Communities

• Many TCs are quite comprehensive and can include
  employment training and other support services on
  site.
• Compared with patients in other forms of drug
  treatment, the typical TC resident has more
  severe problems, with more co-occurring mental
  health problems and more criminal involvement.
• Research shows that TCs can be modified to treat
  individuals with special needs, including
  adolescents, women, those with severe mental
  disorders, and individuals in the criminal
  justice system

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Narcotics Anonymous

• Begin in 1953, based on AA
• NA's earliest self-titled pamphlet, known among
  members as "the White Booklet," describes
  Narcotics Anonymous as
• "a nonprofit fellowship or society of men and
  women for whom drugs had become a major problem .
  . . who meet regularly to help each other stay
  clean We are not interested in what or how much
  you usedbut only in what you want to do about
  your problem and how we can help.
• Membership is open to any drug addict
• regardless of the particular drug or combination
  of drugs used.
• When adapting AA's First Step, the word
  "addiction" was substituted for "alcohol,
• Removed drug-specific language
• Continued focus on disease concept of addiction

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Demographics of NA

• Male/female ratio 58 male, 42 female
• Ages from 16 to 69 years, with an average of 37
  years
• Ethnicity 56 Caucasian, 28 African-American,
  4 Hispanic, 11 other
• Employment status 76 employed full-time, 9
  part-time, 5 homemakers, 4 disabled, 1
  retired, and 5 unemployed
• Continuous abstinence/recovery ranged from less
  than one year to 35 years, with a mean average of
  5.5 years

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Narconon

• The Narconon Treatment Residential Treatment
  Program
• The Narconon program is designed to get drug or
  alcohol abusers off drugs and back in control of
  their lives.
• Narconon was founded in the Arizona State Prison
  by an inmate and former heroin addict, William
  Benitez.
• The original group of ten inmates expanded to
  over one hundred within the first year
• In 1972 the program was made available to the
  public with the opening of the first street
  program in Los Angeles.
• Today there are Narconon centers throughout the
  Western world, in Canada, France, Germany, the
  Netherlands, Italy, Spain, Denmark, Sweden,
  Switzerland and Australia, as well as across the
  United States.

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Narconon

• PHASE I
• Drug-Free Withdrawal
• Narconon provides a safe, 24-hour care procedure
  for a drug free withdrawal. An individual in
  withdrawal is under the careful supervision of a
  Withdrawal Specialist 24 hours a day until the
  physical and mental discomfort associated with
  drug and alcohol withdrawal is no longer present.
• PHASE II
• Learning Improvement Course
• This course provides the student with the
  ability to study and retain knowledge along with
  the ability to recognize and overcome
  obstructions in the study and learning process.
• The Communications and Perception Course
• This course utilizes exact procedures, which
  focus the students attention onto the present,
  as opposed to being stuck in past experiences. It
  improves the students perception of his
  environment, and gets the student into better
  communication with others.

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Narconon

• PHASE III
• Ups and Downs in Life Course
• In this course, students learn the
  characteristics of social and anti-social
  personalities in order to evaluate objectively
  and choose those people in their lives who need
  to be avoided
• Personal Values and Integrity Course
• This course restores to the clients his basic
  sense of right and wrong, and the ability to live
  honestly again. Values and purposes are recovered
  and strengthened. Students often experience a
  strong feeling of relief, and a newfound feeling
  of freedom and self-respect because of this
  course.
• PHASE IV
• The Changing Conditions in Life Course
• This course gives the student the exact formulas
  to use to evaluate objectively and improve
  conditions having to do with himself, his family,
  the groups he belongs to, and other areas of
  life.
• The Way to Happiness Course
• This course introduces the student to a common
  sense moral code that he can use in living a new
  drug and alcohol-free life.

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Narconon

• Final Program Review
• A comprehensive review to ensure the student has
  thoroughly completed all phases of the program.
• Additional course work is assigned based on
  specific student needs to prepare the student to
  deal with life situations after graduation from
  the program.

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Narconon

• Follow-up Program
• A comprehensive long-term follow-up program is
  designed and implemented to assist the student
  through the first year of recovery. This is
  accomplished through regular contact with the
  student and family members.
• The entire Narconon program takes between 3-5
  months to complete. The difference in time
  depends on each individual and what is required
  for them.

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Psychotherapy Treatments
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Individualized Drug Counseling

• Focuses directly on reducing or stopping the
  addict's illicit drug use
• Addresses related areas of impaired
  functioningsuch as employment status, illegal
  activity, family/social relations
• Emphasis on short-term behavioral goals
• Development and application of coping strategies
  and tools for maintaining abstinence
• The addiction counselor
• Encourages 12-step participation
• Makes referrals for needed supplemental medical,
  psychiatric, employment, and other services
• Individuals are encouraged to attend sessions one
  or two times per week

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Motivational Enhancement Therapy

• Client-centered counseling approach for
  initiating behavior change by helping clients to
  resolve ambivalence about engaging in treatment
  and stopping drug use.
• Employs strategies to evoke rapid and internally
  motivated change in the client, rather than
  guiding the client stepwise through the recovery
  process.
• Consists of an initial assessment battery
  session, followed by two to four individual
  treatment sessions with a therapist.
• The first treatment session provides feedback
  generated from assessment battery to stimulate
  discussion regarding personal substance use and
  to elicit self-motivational statements.
• Motivational interviewing principles are used to
  strengthen motivation and build a plan for
  change.
• Coping strategies for high-risk situations are
  suggested and discussed with the client.
• This approach has been used successfully with
  alcoholics and with marijuana-dependent
  individuals.

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Confrontation vs. Motivation Enhancement
Counseling Strategy Confrontational Motivation Enhancement
Labeling Y N
Locus of control Provider Patient
Evidence for change Presented and interpreted by provider Presented provider Interpreted patient
Problem solving provider Driven by patient with help from provider
Interpret resistance Denial by patient Need new provider strategy
Treatment goals Set by provider Negotiated
Change strategies Set by provider Negotiated
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Other Techniques

• Application of Marlatts Relapse Prevention for
  alcohol
• Cue Exposure
• Extinction

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• Alcohol Treatment

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Factors that affect treatment success

• Current level of dependence
• Medical Problems
• Treatment History
• Previous Quit Attempts
• Social Support Systems
• Personal resources
• Other psychological problems
• Attitudes about treatment

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Detoxification

• Sx begin 5-12 hrs after drinking stopped and may
  last up to 72 hrs
• 4 detox alternatives
• Inpatient medical
• Partial hospital medical
• Inpatient nonmedical
• Outpatient medical

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Treatment Modalities

• Self-help groups
• Individual treatment
• Group therapy
• Couples therapy
• Family therapy
• In most cases, can occur as inpatient or
  outpatient

46
Treatment Approaches
47
Marlatts Relapse Prevention Model

• Coping Skills Training
• Drinking conceptualized in terms of deficits in
  interpersonal and coping skills
• Condition more adaptive responses to drinking
  cues
• Focus on new coping skills
• Functional analysis, relapse prevention, cue
  exposure, refusal skills

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Relapse Prevention

• Cognitive-behavioral therapy
• Developed for the treatment of problem drinking
  by Marlatt
• Adapted for cocaine and other drugs more recently
• Based on the theory that learning processes play
  a critical role in the development of maladaptive
  behavioral patterns
• Individuals learn to identify and correct
  problematic behaviors
• Includes several cognitive-behavioral strategies
  that facilitate abstinence and provide help for
  people who experience relapse
• Techniques include
• Exploring the positive and negative consequences
  of continued drinking
• Self-monitoring to recognize cravings early on
  and to identify high-risk situations for use
• Avoiding high-risk situations
• Developing strategies for coping with avoidable
  high-risk situations

49
Community Reinforcement Approach

• Based in Cognitive/Behavioral theory
• Sobriety through use of support systems
• Examine interaction of environment drinking
• Uses skills training
• Functional analysis
• Mood monitoring
• Vocational counseling
• Drink refusal training
• Compliance monitoring
• Buddy systems
• Can be limited by high cost of implementation,
  including time, , and participation of others

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Motivational Enhancement

• Developed by Miller
• Brief intervention tradition
• Nonconfrontational
• Client-centered
• Focus on motivation/readiness to change
• Techniques include
• Feedback of risk/impairment
• Responsibility for change
• Advice to change
• Menu of alternative change options
• Therapist empathy
• Facilitation of client self-efficacy

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Cue Exposure

• Based in classical conditioning
• Expose individual to alcohol-related stimuli such
  as people, places and things that they have
  experienced with alcohol in the past and that now
  cue alcohol urges
• Do not let the individual consume alcohol in the
  presence of the cue to begin to break down the
  association of the cue and alcohol consumption ?
  should reduce power of cue to produce urge over
  time
• Patients often taught drink refusal and other
  coping skills in the presence of the cue to help
  them deal with exposure to the cue in the future

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Pharmacological (1)

• Disulfiram/Antabuse
• In pill form by prescription only
• Inhibits adelhyde dehydrogenase (ALDH)
• Body cant break down alcohol
• When in system (lasts up to 3 days), alcohol use
  produces strong aversive physical reaction
• Must be taken daily
• Compliance is major drawback

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Pharmacological (2)

• Naltrexone
• In pill form by prescription only
• Blocks opioid receptors in the brain
• 2 main effects
• Decreases rewarding experience of alcohol
• Reduces craving
• Must be taken daily
• Compliane is major drawback

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12 Step Groups AA, NA, GA etc

• Most common form of tx across addictions
• AA established 1935
• Alcoholics Anonymous is a fellowship of men and
  women who share their experience, strength and
  hope with each other that they may solve their
  common problem and help others to recover from
  alcoholism. The only requirement for membership
  is a desire to stop drinking. There are no dues
  or fees for A.A. membership we are
  self-supporting through our own contributions.
  A.A. is not allied with any sect, denomination,
  politics, organization or institution does not
  wish to engage in any controversy neither
  endorses nor opposes any causes. Our primary
  purpose is to stay sober and help other
  alcoholics to achieve sobriety. All available
  medical testimony indicates that alcoholism is a
  progressive illness, that it cannot be cured in
  the ordinary sense of the term, but that it can
  be arrested through total abstinence from alcohol
  in any form.

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Alcoholics Anonymous

• Estimated A.A. Membership and Group
  InformationGroups in U.S. 51,735
  Members in U.S. 1,162,112 Groups in Canada
  5,104 Members in Canada
  98,816 Groups Overseas 41,423 Members
  Overseas 832,994 Internationalists
  106 Groups in Correctional
  Facilities (U.S./Canada) 2,504 Lone
  Members 313 Total 2,160,013
  Members 100,766 Groups
• Estimates provided by the A.A. General Office,
  January 1, 2001

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12 Step Groups Keys to success

• Acceptance of powerlessness vs. addiction
• Recovery cant occur alone
• External motivation (from god?)
• Recognition of own character defects
• Fellowship in a group
• Completion of steps
• 90 meetings in 90 days

57
12 Steps of AA

1. We admitted we were powerless over alcohol - that
   our lives had become unmanageable.
2. Came to believe that a Power greater than
   ourselves could restore us to sanity.
3. Made a decision to turn our will and our lives
   over to the care of God as we understood Him.
4. Made a searching and fearless moral inventory of
   ourselves.
5. Admitted to God, to ourselves and to another
   human being the exact nature of our wrongs.
6. Were entirely ready to have God remove all these
   defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed, and
   became willing to make amends to them all.
9. Made direct amends to such people wherever
   possible, except when to do so would injure them
   or others.
10. Continued to take personal inventory and when we
    were wrong promptly admitted it.

58
Success rates of AA

• Why are success rates unclear?
• Only minimal amount of empirical evidence to
  support claims of high success rates
• A.A. and 2-step treatment are associated with
  significant reductions in substance abuse and
  psychiatric problems.
• Also associated with reduced health care costs
  over time in naturalistic, quasi-experimental,
  and experimental studies.
• Humphreys, 2003

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Rational Recovery 1

• Differs from AA
• Greater emphasis on rational thought, viewing
  drinking problems as problems in living for which
  people need to learn cognitive/behavior skills
• Grounded in Rational Emotive Therapy (RET Ellis)
• Views use of psychoactive substances as
  irrational choice.
• Believes that persons can learn to use their
  rational mind, rather than spirituality, to
  empower themselves not to drink.
• RR suggests abstinence as the safest route but
  emphasizes rational decision making, and
  acknowledges that some members may make a
  rational decision to drink moderately rather than
  to abstain.

60
Rational Recovery 2

• All groups have a professional therapist as an
  advisor.
• Attend meetings for 6-12 months, then move on
  with life
• Not a lifelong program of recovery requiring
  regular attendance at meetings.
• One study analyzed the Big Book and the Little
  Book (of RR) and found that the Big Book 8th-
  9th grade reading level was required, for RR
  book, needed college educ for adequate
  comprehension.
• VERY FEW STUDIES (MAYBE ONLY 1 2) OF RR.
  THEREFORE, EFFICACY IS UNKNOWN.

61
Rational Recovery 13 ideas

• I have considerable voluntary control over my
  extremities and facial muscles.
• I accept that, in order to get better, I had
  better refrain from any use of alcohol or drugs,
  because any use will very likely lead to more,
  and then a return to my previous addiction.
• I accept that I will likely benefit from
  residential care, because I have been
  unsuccessful in previous attempts to resist my
  desire to drink or use drugs.
• Although I may have serious personal problems, I
  still have the capacity to learn about myself,
  about new ideas, and how to achieve a satisfying,
  rational sobriety.
• The idea that I must depend on something greater
  than myself in order to stay sober is only
  another dependency idea, and dependency is my
  original problem.
• I am willing to reject ideas of perfection for
  myself and for others, and my first goal is to
  learn to accept myself as I am a fallible, yet
  worthwhile, human being.
• I place high value on principles of rationality,
  learning, objectivity, self-forgiveness, my own
  self interest
• I recognize that, even though I am chemically
  dependent, I am responsible for my
  emotions/behavior.
• Over time, I may learn that refraining from
  mind-altering drugs is easier than trying to
  control them
• I will eventually complete my recovery and live a
  normal life.

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What works across approaches

• Address Motivational/reinforcing effects
• Use a nonconfrontational approach
• Teach specific skills
• Promote active coping and goal setting
• Target social/environmental factors
• Decrease cues for drinking
• Support for not drinking
• Relationship change
• Increase access to social support

63
Nonspecific factors that affect treatment

• Therapist empathy
• Therapist active interest
• Patient adherence

64

• Nicotine treatment

65
"All Truth passes through Three Stages First, it
is Ridiculed...Second, it is Violently
Opposed...Third, it is Accepted as being
Self-Evident." - Arthur Schopenhauer (1778-1860)
66
Treatment Success

• About 25 of Americans currently smoke
• 42 in 1960 with annual reduction of about .5 up
  until 25 in 1990s currently leveling off
• About equal number of men and women
• Due to increase in females smokers from about
  1960
• 1/3 of smokers attempt to quit each year
• Between 1 and 5 are successful
• Most attempt to quit on their own
• Smoking cessation NOT associated with worse
  outcomes for abstinence from other substances

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Nicotine Withdrawal

• Physical Up to 2 weeks of the following
• Depressed mood
• Insomnia
• Irritability/frustration/anger
• Anxiety
• Difficulty concentrating
• Restlessness
• Decreased heart rate
• Increased appetite
• Psychological the possibilities are limitless!

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Pharmacotherapy

• Nicotine Replacement
• It may seem counter-intuitive to put nicotine in
  your body when trying to quit, but its somewhat
  effective
• Basic idea behind NRT is to slowly taper smoker
  off the nicotine in cigarettes by replacing it
  with another, controlled source
• Patch (often fewest problems with compliance, low
  side-effects)
• Gum (control dosing)
• Inhaler (some behavioral components of smoking,
  due to puffing)
• May be used for longer time(3 months) because it
  may address psychological factors as well as
  physical
• Limitation used for 15-20 at a time
• Nasal Spray (fastest acting, control dosing, high
  side-effects)
• May be best for highly dependent smokers who miss
  rush from smoking
• Lozenge

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The patch

• Never use while smoking (max of 5 per day across
  several days)
• Use highest dose (about 22mg for 24-hr and 16mg
  for 16hr) from quit unless smoking less than
  10/day or weigh under 100
• Continue for 4 weeks
• Reduce dose for weeks 5-6 and reduce again for
  weeks 7-8
• Benefits are minor after 8 weeks

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Zyban

• Chemical name is Buproprion
• Renamed version of the low level anti-depressant
  Wellbutrin
• Prescription-only medication to help reduce
  smoking urges and withdrawal symptoms
• Exact course of action unknown, but the drug has
  anti-depressant qualities
• Evidence suggests that it can be effective
• especially when used with psychosocial treatment

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Zyban

• Begin taking about 2 weeks prior to quit attempt
• unlike NRT, can be used while still smoking
• Taken for about 10 weeks
• Doses 8 hours apart
• Helps limit the following withdrawal symptoms
  from smoking
• Mood changes, anxiety, irritability, decreased
  concentration, restlessness, unusual hunger,
  trouble sleeping, constipation
• Side-effects of Zyban
• Dry mouth, sleeplessness, shakiness,
  constipation, nausea, headache, appetite loss,
  blurred vision, heart palpations

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Standard TreatmentBased on Marlatts Relapse
Prevention Model

• Triggers identification management
• Relaxation
• Why quit smoking personalize pros and cons
• Social support for not smoking
• Non smoking game plan
• Lifestyle change
• Coping w/ high risk situations
• Feeling badly if you slip
• Preparing for the quit
• fading

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Triggers

• People, places, things etc
• Identify cigarettes that would be most difficult
  to give up
• Use wrap sheets to identify triggers

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Relaxation Breathing

• Benson 1975
• Getting ready
• Choose quite undisturbed time and space, in a
  comfortable position and relax
• Relaxing
• Sit quietly in comfortable position
• Close eyes
• Relax muscles full and deep
• Become aware of breathing, with each breath out
  repeat word or phrase associated with relaxation
• 10-20 minutes and cool down before standing

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Relaxation Muscle Relaxation

• Similar to breathing, but
• Start with one muscle group
• Tense for 5 sec and then relax
• Work way through muscle groups, tensing new group
  and keeping old group relaxed
• Relax, but do not fall asleep must learn to
  associate relaxation with wakeful activivty

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Coping with high risk situations

• Based in Marlatts relapse prevention theory
• Identify behavior chain associated with smoking
  and use functional analysis
• Emotion vs. problem focused coping
• Use cognitive restructuring and behavioral
  experiments

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Fading

• Brand fading
• Movement to cigarettes with less nicotine
• Week 1 30 reduction
• similar reductions until 90 less nicotine
• Makes smoking less preferable
• Rate fading
• Reduce number of cigarettes gradually
• Not a good idea to go under 10 or so
• Might make few cigarettes seem really good
• One alternative is to smoke in unusual
  situations
• Both decrease future withdrawal
• Money in the bank

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Other Techniques

• Rapid Paced Aversive Smoking
• Create aversive reaction to smoking through
  overuse
• Mixed evidence regarding effectiveness and safety
• Motivational Interviewing
• Cognitive-Behavioral Treatment
• Similar to standard treatmentbut
• Focus on addictive beliefs
• I need a cigarette
• I cant cope without a cigarette
• Smoking as a learned habit
• Hypnosis
• Some effects, but no better than other strategies
• Acupuncture

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Positives of Quitting

• 20 minutes
• Drop in BP and HR, Increase in temp
• 8 hours
• CO normal increase in blood oxygen levels
• 24 hours
• Chances of heart attach drop
• 48 hours
• Regain shaprness of taste and smell
• 2-3 weeks
• Circulation improves
• 1-9 months
• Breath easier, increased energy
• 1 year
• Risk of coronary heart disease cut in half
• 5-15 years and beyond
• Risk of stroke and cancer reduced significantly

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Web Site for Hypnosis

• Better described as Relaxology
• Safe/natural and is completely drug free and non
  addictive
• It is self induced assisted by the suggestions of
  the hypnotist
• It involves a  state of deep mental and physical
  relaxation and concentration, bringing with it, a
  state of heightened awareness.
• Here are some FACTS
• The client remains conscious at all times
• The client is not asleep.
• The client is unlikely to "feel" hypnotized
• The client remains in complete control at all
  times
• The client is not manipulated to do anything they
  do not wish to do
• The client cannot get "stuck" in hypnosis
• The client will suffer no unpleasant side effects
• Once is a state of Hypnosis, the conscious mind
  can be almost "shut-down" allowing positive
  ideas, strategies and concepts to accepted and
  acted upon by the sub-conscious
• At this same time the subconscious can be
  encouraged to release that pent up anxiety