Substance Use Disorders and Pain Management: MATE Act Training _ _______________________________
The goal of these types of treatments is to modify drug-seeking and other behavioral aspects of drug dependency [19]. Psycho- social therapy and pharmacotherapy are not mutually exclusive; in fact, some drug therapies for substance abuse are considered useless without a psychosocial/behavioral component [18; 19]. Psychosocial therapies for substance use disorders can be divided into two broad categories. The first category consists of therapies that were originally developed for patients with anxiety and depression and modified for use with patients with substance use disorders. This group of therapeutic approaches includes cognitive-behavioral therapy (CBT), the behavioral therapies, and interpersonal therapy. The second group of psychosocial therapies was developed explicitly for patients with substance use disorders and includes motivational inter- viewing and motivation enhancement therapy [19; 20]. All psychotherapies are intended to be delivered in a supportive, empathic manner that minimizes confrontation.
engaging patients in abstinence, but relapse to drug use may occur following removal of the reinforcer. In contrast, natural- istic contingencies are more likely to maintain the initial gains made by the patient and to facilitate the sustained change of behavior over time [22]. The goal of contingency management interventions is to increase the opportunity cost of substance use by arranging an environment where drug use results in the forfeiture of a predetermined item or privilege, referred to as an alternate reinforcer [23]. Treatment with a contingency management component was first used with cocaine-abusing methadone patients, a highly suitable population for two reasons: cocaine abuse is prevalent among patients with opioid use disorder receiving methadone maintenance, and methadone patients are required to report to the clinic daily to receive their medi- cation under staff supervision. Daily clinic appointments are often considered a significant constraint on employment, travel, and other activities. Patients who are able to abstain from drugs of abuse, as measured by a urine drug screen, may be allowed several days of take-home methadone doses, which can act as a behavioral contingent [24]. Several studies have shown that this contingent condition has led to greater treatment retention and reductions in cocaine use than those found in comparison treatment conditions, although this effect dissipates with longer-term follow-up [22; 25; 26; 27]. Community Reinforcement Community reinforcement approaches are biopsychosocial interventions designed to engage and change the lifestyle of the drug abuser by addressing the role of environmental cues and alternative reinforcers in influencing behavior. The theo- retical basis of the community reinforcement approach is that substance abuse is maintained by substance-related reinforcers as well as by the absence of competing alternative reinforcers. The primary goal of the community reinforcement approach is to build and strengthen relationships, recognize appropri- ate leisure activities, and identify vocational interests of the patient to provide competing reinforcement with substance use and the drug-using lifestyle [28]. The community reinforce- ment approach aims to increase abstinence by increasing or highlighting the opportunity cost of relationships and social support the patient stands to lose through drug use [22]. In addition to integrating cognitive-behavioral and, in some cases, pharmacologic approaches, community reinforcement approaches may also include the use of vouchers, whereby tokens are given to the patient for producing substance-free urine samples, which are then used to purchase goods and services desired by the patient. A review of four studies utilizing a community reinforcement approach with patients with substance use disorder found evidence that a community reinforcement approach employ- ing abstinence-contingent incentives in the form of vouchers was more effective in promoting abstinence than community reinforcement approaches using noncontingent incentives and usual care. Patients assigned to community reinforcement
For patients with alcohol use disorder, the Department of Veterans Affairs Work Group recommends offering one or more of the following interventions, considering patient preference and provider training/ competence:
Drug counseling is a widely used therapy approach with patients with substance use disorders. It consists of a focus on abstinence, problem solving, and 12-step orientation and involvement. Drug counseling is usually provided by counselors who have a certificate in addiction counseling. A fair number of addiction counselors are themselves recovering from alcohol and/or substance use disorders [20]. Contingency Management There is considerable evidence that substance use is sensitive to the application of contingencies. Contingencies occur on a spectrum from contrived to naturalistic. Contingency manage- ment and vouchers are examples of contrived interventions, while 12-step programs are examples of naturalistic interven- tions [21]. Contrived contingencies may be effective in initially • Behavioral couples therapy for alcohol use disorder • Cognitive-behavioral therapy for substance use disorders • Community reinforcement approach • Motivational enhancement therapy • 12-step facilitation (https://www.healthquality.va.gov/guidelines/MH/sud/ VADoDSUDCPG.pdf. Last accessed April 27, 2023.) Strength of Recommendation : Strong
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