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Substance Abuse Treatment Modalities: Literature Review

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Cue Exposure

Cue exposure is a relatively new treatment technique that considers tolerance, withdrawal and cravings for drugs/alcohol as conditioned states that are amenable to change or extinction (Eliany, & Rush, 1992). The general approach is to expose drug or alcohol users to cues for using (e.g., expose a cocaine abuser to white powder or an alcohol abuser to a beer bottle) while concurrently addressing and attempting to lessen the desire to use. It has been argued that cue exposure has many advantages: (1) cue exposure in the absence of drug or alcohol use can reduce the desire to use that was caused by the cue; (2) cue exposure provides the opportunity to practice coping responses (e.g., relaxation) realistically; and (3) cue exposure can increase self-efficacy, which will increase the likelihood that the response will be utilized in future real-life cue exposures (Monti, et al., 1989). Cue exposure as a treatment technique recognizes that it is impossible to avoid drug/alcohol-related cues and it is better to prepare patients to handle these cues outside of treatment in real-life situations (Chiauzzi & Liljegren, 1993).

Rohsenow, et al. (1990-1991) have examined cue reactivity (i.e., powerful physiological reactions to drug- or alcohol-related cues) according to different types of substances. For alcoholics, the kinds of cues that have shown the greatest reactivity include ingestion of small amounts of alcohol, or the expectancy that alcohol either has been consumed or will shortly be available for consumption. There is also support for imagining a situation associated with relapse or one with negative mood and drinking which may be more powerful elicitors of reactivity. For opiate users, auditory, visual, or role-playing stimuli of drug sales or use appear to be powerful conditional stimuli. Mood states, alone or in combination with substance abuse stimuli, may also be significant in eliciting cue reactivity. These results are consistent for cocaine users although much less research has been conducted.

The rationale for cue exposure as a treatment approach stems from studies which have found that many patients retain cue reactivity after treatment (Chiauzzi & Liljegren, 1993). For example, Childress et al. (1988) found that individuals addicted to opiates who achieved abstinence in treatment still presented physiological arousal to drug cues 30 days after treatment completion. Similar results have been found with cocaine (Washton, 1989) and alcohol users (Cooney, et al., 1987). Given that cues augment relapse potential (Niaura et al., 1988), it has been argued that treatment can become an exercise in futility when the addicted person is re-exposed to relapse cues in his/her natural environment. Addressing the cues in treatment while reducing the desire to use may be the patient's best defence.

The effectiveness of cue exposure in reducing post-treatment substance use has been examined for both alcohol and drug abusers. Early studies of alcoholics involved individualized assessments of relevant drinking cues which were exposed to the individual whenever possible, either in vivo or through imaginal exposure. Examination of drinking outcome data showed that abstinence was maintained for most of the 6 to 9 month follow-ups (Blakely & Baker, 1980; Hodgson & Rankin, 1982) and that imaginal exposure was less effective that in vivo exposure (Rankin et al., 1983). The later was found to significantly decrease urges to drink, the difficulties in resisting the urges to drink, and the speed of drinking alcohol at post-test. A more recent examination of the outcome literature has pointed to a more conservative interpretation of effectiveness, suggesting only that current knowledge indicates the potential of cue exposure as a treatment technique for alcoholics (Drummond et al., 1990).

Treatment outcome studies examining the effectiveness of cue exposure for drug abusers have been conducted with opiate and cocaine users. For opiate users, two studies (Childress et al., 1986a; 1986b) examined cue exposure with a standard set of drug-related stimuli, starting with the clients' self-produced verbal imagery ("drug stories"), followed by audio tapes of drug-related conversations, colour slides of opiate preparation and injections, and handling drug injection stimuli, in that order. The results of the first study (Childress, 1986a) with a sample of methadone patients showed significant reductions in cravings across 35 sessions, although withdrawal symptoms persisted. Although promising, the findings were somewhat ambiguous as a result of drug use occurring outside of treatment. In order to address these problems, the study (Childress et al., 1986b) examined a sample of 30-day abstinent opiate users exposed to the above set of cues at a rate 6 or 7 times more than in the first study. The findings showed that cue exposure virtually eliminated both craving and withdrawal symptoms by the end of the inpatient phase. Although no data were available on the impact of actual use, results showed that cravings did not differ between the experimental and control groups, suggesting that the extinction to the cues used in treatment did not generalize well to other cues in the environment. Similar results have been found with more recent studies of cue exposure with opiate addicts, showing significant reductions in cue-elicited cravings, withdrawal responses and negative mood (Dawe et al., 1993; Powell et al., 1993).

The increase in the number of patients admitted to treatment for cocaine use has prompted the extension of cue exposure to cocaine users. Only one study has reported on cue exposure with detoxified cocaine users (Childress et al., 1988). The treatment involved 15 hour-long sessions of exposure to standardized stimuli during two weeks of inpatient treatment followed by once weekly exposure during eight weeks of outpatient treatment. Preliminary analyses showed significant reductions in the within-session ratings of the intensity of cravings and withdrawal symptoms, with the greatest reductions shown for craving ratings. However, most patients continued to report incidents of craving in response to stimuli outside of treatment, indicating that lack of complete generalization of the extinction to other cues is a problem.

In summary, the rationale for cue exposure as a treatment technique stems from results indicating that alcohol and drug abusers experience strong physiological reactions to cues for using (i.e., cue reactivity), thereby increasing the probability of relapse after treatment. Cues differ for different types of substance abusers, although results suggest that cues are most powerful to the user in the type of alcohol or drug most often used. Repeated exposure of the cue stimuli have found significant reductions in cravings and withdrawal responses for both alcohol and drug abusers. However, outcome results examining the direct impact of cue exposure on actual use are needed to fully understand its utility. Currently, cue exposure as an adjunctive to a more comprehensive treatment program may improve treatment outcome by addressing a factor that is commonly not treated (Rohsenow et al., 1990-1991).

References for Cue Exposure:

Blakely, R., & Baker, R. (1980), “An exposure approach to alcohol abuse”, Behaviour Research and Therapy, 18, 319-325.

Chiauzzi, E. J., & Liljegren, S. (1993), “Taboo topics in addiction treatment: An empirical review of clinical folklore”, Journal of Substance Abuse Treatment, 10, 303-316.

Childress, A. R., MC Lellan, A. T., & O'Brien, C. P. (1986a), “Role of conditioning factors in the development of drug dependence, Psychiatric Clinics of North America, 9, 413-425.

Childress, A. R., MC Lellan, A. T., & O'Brien, C. P. (1986b), “Abstinent opiate abusers exhibit conditioned craving, conditioned withdrawal, and reductions in both through extinction”, British Journal of Addiction, 81,

Childress, A. R., MC Lellan, A. T., Ehrman, R., & O'Brien, C. P. (1988), “Classically conditioned responses in opioid and cocaine dependence: A role in relapse?”, In B.A. Ray (Ed.), Learning factors in substance abuse (DHHS Publication No. 88-1576, pp. 25-43). Washington, DC: U.S. Government Printing Office.

Cooney, N. L., Gillespie, R. A., Baker, L. H., & Kaplan, R. F. (1987), “Cognitive changes after alcohol cue exposure”, Journal of Consulting and Clinical Psychology, 55(2), 150-155.

Dawe, S., Powell, J., Richards, D., Gossop, M., Marks, I., Strang, J., & Gray, J. (1993), “does post-withdrawal cue exposure improve outcome in opiate addiction: A controlled trial”, Addiction, 88, 1233-1245.

Drummond, D. C., Cooper, T., & Glautier, S. P. (1990), “Conditioned learning in alcohol dependence: implications for cue exposure treatment”,British Journal of Addiction, 85, 725-743.

Eliany, M., & Rush, B. (1992), The effectiveness of prevention and treatment programs for alcohol and other drug problems: A review of evaluation studies. (Unpublished report). Ottawa: Health and Welfare Canada.

Hodgson, R. J., & Rankin, H. J. (1982), “Cue exposure and relapse prevention”, In W. M. Hay & P. E. Nathan (Eds.), Clinical case studies in the behavioral treatment of alcoholism, (pp. 207-226). New York: Plenum.

Monti, P. M., Abrams, D. B., Kadden, R. M., & Cooney, N. L. (1989), Treating alcohol dependence, New York: Guilford Press.

Niaura, R. S., Rohsenow, D. J., Binkoff, J. A., Monti, P. M., Pedraza, M., & Abrams, D. B. (1988), “Relevance of cue reactivity to understanding alcohol and smoking relapse”, Journal of Abnormal Psychology, 97, 133-152.

Powell, J. H., Bradley, B., & Gray, J. A. (1993), “Subjective craving for opiates: evaluations of a cue exposure protocol for use with detoxified opiate addicts”, British Journal of Clinical Psychology, 32, 39-53.

Rankin, H., Hodgson, R., & Stockwell, T. (1983), “Cue exposure and response prevention with alcoholics: A controlled trial”, Behaviour Research and Therapy, 17, 389-396.

Rohsenow, D. J., Niaura, R. S., Childress, A. R., Abrams, D. B., & Monti, P. M. (1990-1991), “Cue reactivity in addictive behaviours: Theoretical and treatment implications”, The International Journal of the Addictions, 25 (7A & 8A), 957-993.

Washton, A. M. (1989), Cocaine addiction: Treatment, recovery, and relapse prevention, New York: Norton.