The current issue of the American Journal of Psychiatry carries a meta-analysis of different psychosocial interventions for the treatment of substance abuse (Dutra L et al., Am J Psychiatry 2008 165: 179-187). While the article may not qualify as pleasure-reading, it is an important scientific contribution, because it shows that the effect sizes for certain therapeutic techniques for substance abusers are reasonably good, with an aggregated average effect size of 0.45, which is in the “moderate” range, an impressive effect in the world of psychiatric trials.

This review focuses specifically on techniques for treating abusers of cannabis, cocaine, and opiates. What works the best, and what techniques can you bring into your practice?

Of all the techniques examined, the most effective was “contingency management,” a fancy term for “paying patients to stay clean.” Typically, this is done in a clinic environment, in which patients come in for weekly urine drug screens, and get paid in cash, tokens, or prizes if the screen is negative.

“In some ways it is amazing that this technique works as well as it does,” said the senior author of the report, Michael Otto Ph.D. of Boston University, whom I interviewed by phone. “When you think of all the reasons people have to quit, from the threat of incarceration to financial catastrophe, it’s surprising that simply offering them a small tangible reward can be so effective.”

Of course, in a private practice situation, it’s not likely that many psychiatrists are going to be reaching into their own wallets to pay patients for clean drug screens, and it is unlikely that insurance companies will be footing this bill. In such cases, Otto recommends enlisting the patient’s spouse. For example, the spouse can reward the patient with a dinner out, or other favorite outing.

The other effective technique highlighted in the paper is relapse prevention. This is a common sense approach in which you help your patient come up with strategies to avoid their triggers to substance abuse.

“Sometimes the triggers are external, like being around somebody who is using,” says Otto. “But sometimes there are emotional triggers, such as feeling bored, frustrated, or envious.” He recommends both helping patient to avoid such triggers, and helping them to plan out specific alternative activities to help resist acting on momentary cravings in response to triggers. “These can be mundane activities, like walking the dog or going to the movies or bringing your spouse with you when you go to a friend’s house where you know people might be using. The key is to program something into patients’ routines that will allow them to avoid that moment of weakness leading to relapse.”

Otto emphasizes that underlying both contingency management and relapse prevention are standard, tried-and-true cognitive behavior therapy (CBT) techniques. “Don’t forget about classic cognitive restructuring. For example, patients often coach themselves into using more drugs with self-talk like ‘Oh I smoked half a joint, I might as well smoke a lot more.’” In basic CBT, you would encourage such patients to develop alternative thoughts in order to reinforce abstinence.

TCPR Verdict:

Manage contingencies, prevent relapse