EBP Treatment for Heroin/Opiate Addiction: Contingency Management Nicholas Perfetto

Contents Heroin and Opiates Treatment and Options What are they? How is the addiction developed? How prevalent is it? Treatment and Options Contingency Management What is it? How does it work? How well does it work? Short and long-term effects Models/Theories of Addiction Conclusions Heroin Image. Retrieved from: http://www.phoenixrecoverycenter.com/uncategorized/fentanyl-laced-heroin-rise-harford-county-maryland-treat/

What are Heroin and Opiates? Heroin and opiates are derivatives of the poppy plant Opiates include Oxycodone, Vicodin, Morphine, and other prescription drugs These drugs are commonly abused and can affect the brain in similar ways to heroin These can all be snorted, inhaled, smoked, or injected Heroin and opiates affect opioid receptors in the brain and also impact areas of the brain stem and body Users experience euphoria and a suppressant “downer” effect National Institute on Drug Abuse. Heroin Retrieved from http://www.drugabuse.gov/publications/drugfacts/heroin on July 6, 2015

How is the Addiction Developed? There are many theories of addiction (and comorbidity), which we will discuss later. However, we are combining heroin with other opiates because often prescription opiate drugs become an addiction after injury, surgery, etc. That addiction often serves as a gateway to heroin, as it is cheaper to obtain on the street than prescription opiates. Nearly half of people who inject heroin report abusing prescription opiates before switching to heroin (National Institute on Drug Abuse, 2015)

Prevalence of Heroin Use Based on the National Survey on Drug Use and Health of 2012, heroin use in the past year was reported by 669,000 people in the US. Daily use was reported by 335,000 people This is dramatically increased from the numbers 5 years prior, which showed 373,000 and 161,000, respectively. (Substance Abuse and Mental Health Services Administration, 2012)

First Steps to Treatment . First Steps to Treatment Detoxification Serious addicts will first need to detoxify. This can be done through supervised withdrawal, or with a replacement drug called methadone. The withdrawal process is not life-threatening for opiate addiction, but is extremely uncomfortable mentally and physically. This should be done at a controlled healthcare center. (Treating opiate addiction, part 1: Detoxification and maintenance, 2005)

Methadone and Drug Replacement Methadone is not only used for withdrawal. It is also used as a longer-term replacement for heroin. It is given at controlled facilities, and blocks the effects of heroin while eliminating the extreme highs and lows and medical risks of injecting heroin. Buprenoprhine, AKA Suboxone, is another promising drug replacement that has little risk of abuse and thus does not require a facility to distribute it. These pharmacological practices is often used in conjunction with other EBPs and behavioral interventions. (Treating opiate addiction, part 1: Detoxification and maintenance, 2005)

Treatment Options Contingency Management (CM) Pharmacological Only Cognitive-Behavioral Therapy (CBT) Holistic Harm Reduction Community Reinforcement Approach 12-Step Family Behavior Therapy (FBT) Others Contingency Management (CM)

What is Contingency Management? Contingency Management (CM) is a behavioral method of controlling addiction or maintaining abstinence. It utilizes tangible rewards for positive behaviors, such as abstinence. Can be used as part of psychosocial counseling or simple pharmacological (methadone) treatment programs. (National Institute on Drug Abuse, 2012) (Carrot Image. Retrieved From: http://www.apa.org/monitor/2011/11/money.aspx)

How Does CM Work? CM is surprisingly simple. It relies on the concept of operant conditioning to pair good behavior, such as a passed drug test or verified abstinence, to a reward. Behaviors associated with positive consequences are inherently more likely to be repeated, and vice versa. Drugs provide an immediate positive consequence in the form of a high, but the positive consequences of abstinence and living a healthy life are much less immediate. That is where CM can help to make the positive consequences more obvious and immediate, especially initially (Stanger & Budney, 2010). CM can be successfully paired with other types of treatment, such as the Community Reinforcement Approach. (Carroll & Onken, 2014)

Types of CM Voucher-Based Reinforcement (VBR): The rewards may be cash, vouchers redeemable for goods or services, or privileges, such as taking doses of methadone home from the clinic or treatment center. Prize Incentives CM: This uses similar principles, but involves chances to win prizes via drawings or a chance system involving points. Aversive CM: Also relying on operant conditioning, but involves negative consequences to a lack of positive behavior. Something positive may be taken away due to a failed drug-test, etc. (Carroll & Onken, 2014) (National Institute on Drug Abuse, 2012)

Efficacy of CM CM has been shown to be effective at increasing heroin and other drug abstinence by the addition of positive or threat of aversive consequences (Dolan, Black, Penk, Robinowitz, & DeFord, 1985 and Kidorf & Stitzer, 1997, and Silverman et al., 1996). CM has been effective with a variety of types of substance abuse, including alcohol, stimulants, marijuana, nicotine, and for our discussion, heroin/opiates (National Institute on Drug Abuse, 2012)

Short-Term Results Contingency management, both positive and aversive, was successful in increasing drug abstinence during a two-month treatment (Kidorf & Stitzer, 1997). Heroin Image. Retrieved from: http://www.phoenixrecoverycenter.com/uncategorized/fentanyl-laced-heroin-rise- harford-county-maryland-treat/

Long-Term Results Dolan, Black, Penk, Robinowitz, and DeFord (1985) showed that using contingency with methadone privileges led to better drug abuse abstinence over a 3-year study. Silverman et al. (1996) found that heroin addicts were more likely to abstain from opiate use after receiving a voucher- based reinforcement program, and those results maintained even after 8-weeks removed from the treatment. This suggests that providing the immediacy of a voucher may help the addicts to persevere through initial stages or even allow them to make long-term changes to their addiction.

Limitations of Contingency Management Can become quite costly to provide rewards consistently Varied implementation and lack of hard, standardized manual may make its effectiveness inconsistent Decreasing rewards may decrease effectiveness over time May not be sufficient without other EBPs such as CRA, CBT, or methadone maintenance

Models of Addiction and Comorbidity Common Neurobiological Dysfunction Model Impaired or excessive activity in the mesolimbic dopamine tracts Inability to regulate reward system Common factor leads to above, which may link psychotic symptoms and substance use disorders Common factor may be abnormalities in the hippocampus and frontal cortex VS Multiple-Risk-Factor Model Poor interpersonal skills, vocational/educational failure, poverty, disadvantaged social circumstances, or dysphoria could lead to increased substance use disorders.

Case Conceptualization: Heroin and the Common Neurobiological Dysfunction Model There is a common factor that may cause the comorbidity of psychiatric illness and the use of heroin. That factor is impairment in the reward system of the brain. Heroin and opiate addicts seek reward from the use of these drugs, as their brains have reduced inhibitory control regarding the use of heroin, and enhanced positive effects of the heroin reward. The use of heroin comes primarily from an internal cause. That internal reward system could be alleviated by CM’s ability to make the reward of abstinence more clear and immediate, particularly early on in treatment.

Case Conceptualization: Heroin and Multiple-Risk-Factor Model Heroin/opiate addicts are driven to use the drug by psychiatric illness or social conditions of their lives. For example, the poor may use it as an escape from pain or failure. This aligns well with the theory we mentioned earlier, involving the use of heroin springing from a cheaper way to manage accidental prescription drug addiction. The use of heroin comes from both internal and external cause(s). The ability of CM to praise addicts who may not have much else to be praised for or proud of, as well as the monetary reward system for those who may be in poverty, could alleviate some of the drive towards heroin.

Selected Models and Contingency Management While the multiple-risk-factor model almost certainly has merit based on the real-world research on heroin and opiate abuse, it aligns only somewhat with the principles of contingency management. The reward system of using the drug may be enhanced by poverty, psychiatric illness, or other poor psycho- social conditions, but this is more complex than the principles of CM. Contingency management is based on the ideas of behaviorism, operant conditioning, and the reward system. These concepts match up quite well with the common neurobiological dysfunction model of comorbidity. CM is best correlated with the common neurobiological dysfunction model of addiction and comorbidity.

Conclusions Heroin and opiate addiction is common, on the rise, destructive, and complex in nature. Contingency management is a useful and effective behavioral evidence-based practice for treating heroin addiction, among other substance use disorders. However, it is best paired with another modality of treatment, such as methadone maintenance, and it may be quite costly. It is best explained with the common neurobiological dysfunction model of addiction, as reward systems are primary in both theories.

References Carroll, K. M., & Onken, L. S. (2014). Behavioral therapies for drug abuse. American Journal of Psychiatry. Carrot Image. Retrieved From: http://www.apa.org/monitor/2011/11/money.aspx Dolan, M. P., Black, J. L., Penk, W. E., Robinowitz, R., & DeFord, H. A. (1985). Contracting for treatment termination to reduce illicit drug use among methadone maintenance treatment failures. Journal Of Consulting And Clinical Psychology, 53(4), 549-551. doi:10.1037/0022-006X.53.4.549 Heroin Image. Retrieved from: http://www.phoenixrecoverycenter.com/uncategorized/fentanyl-laced-heroin-rise-harford- county-maryland-treat/ Kidorf, M., & Stitzer, M. L. (1997). Contingent use of take-homes and split-dosing to reduce illicit drug use of methadone patients. Behavior Therapy, 27(1), 41-51. Mueser, K., Noordsy, D., Drake, R., & Fox, L. (2003). Integrated treatment for dual disorders: A guide to effective practice. The Guilford Press National Institute on Drug Abuse. Heroin Facts Retrieved from http://www.drugabuse.gov/publications/drugfacts/heroin on July 6, 2015

References (Continued) National Institute on Drug Abuse. Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition). Retrieved from: http://www.drugabuse.gov/publications/principles-drug-addiction-treatment-research-based-guide-third- edition/evidence-based- approaches-to-drug-addiction-treatment/behavioral-0 on July 6, 2015 Silverman K, Wong CJ, Higgins ST, Brooner RK, Montoya ID, Contoreggi C, Umbricht-Schneiter A, Schuster CR, Preston KL. (1996). Increasing opiate abstinence through voucher-based reinforcement therapy. Drug and Alcohol Dependence, 41, 157-165. Stanger, C. & Budney, A. J. (2010, July). Contingency management approaches for adolescent substance use disorders. Child and Adolescent Psychiatric Clinics of North America, 19(3), 547-562. doi: 10.1016/j.chc.2010.03.007 Substance Abuse and Mental Health Services Administration, Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. Treating opiate addiction, Part I: Detoxification and maintenance. (2005, April 1). Harvard Medical School. Retrieved July 8, 2015. Withdrawal Image. Retrieved From: https://www.discoveryplace.info/quit-heroin-comprehensive-guide-heroin-recovery