________________________________ Substance Use Disorders and Pain Management: MATE Act Training
incorporating abstinence-contingent incentives experienced a greater reduction in disease severity as measured by the Addic- tion Severity Index than comparison groups [28]. Despite early, promising reports of community reinforcement with patients with alcohol use disorder and evidence that patients receiv- ing community reinforcement approaches have demonstrated more favorable drug use outcomes than patients receiving standard outpatient counseling, a community reinforcement approach is seldom used because of the relatively high cost and labor intensity [19; 29]. Motivational Interventions Motivational interventions for substance use disorders stem from the theory that targeting and enhancing motivation to quit drugs will increase positive outcome; positive outcome is increased when motivation comes internally rather than when it is externally imposed. Specifically, motivational enhancement therapy is based on the Transtheoretical Stages of Change Theory, which postulates that patients pass through a series of stages of thought, planning, and action in the process of behavior change [30]. Motivational enhancement therapy is intended to enhance motivation and commitment to change, activate patient resources, and facilitate movement along the readiness-to-change spectrum [31]. Motivational enhancement therapy helps patients build internal motivation through the resolution of issues related to ambivalence. The therapeutic approach is characterized by nonconfrontive, nonjudgmental interviewing that helps the patient consider the pros and cons of change. Motivational enhancement therapy also strives to enhance patient self-efficacy [30]. Motivational enhancement therapy seems to be more effective in patients with low initial levels of motivation when used for patients with substance use disorder. It tends to result in less relapse to use and fewer total days of use [32]. Coping and Social Skill Training Coping and social skill training (CSST) evolved from social learning theory and is used to improve the inadequate coping skills found in many persons with substance use disorders, including deficits in regulation of emotion and in effectively coping with social situations. CSST addresses four primary areas [33]: • Interpersonal skills • Cognitive and affective regulation • Coping skills to manage stressful life events • Coping skills when substances or substance-related cues are encountered An added emphasis on drug-related cues is used when CSST is employed with patients with certain substance use disorders (e.g., cocaine, opioids) [33]. CSST has incorporated these findings into the treatment approach used with patients with substance use disorders. Preliminary results indicate some benefit of substance-specific CSST in reducing frequency of substance use and increasing
duration of abstinence, although these results have not been replicated in subsequent research [32; 33]. Drug Counseling CBT is among the most frequently evaluated approaches used to treat substance use disorders [34; 35]. CBTs have been shown to be effective in several clinical trials of substance users [36]. Characteristics of CBTs include: • Social learning and behavioral theories of drug abuse • An approach summarized as “recognize, avoid, and cope” • Organization built around a functional analysis of
substance use (i.e., understanding substance use with respect to its antecedents and consequences)
Skill training focused on strategies for coping with craving, fos- tering motivation to change, managing thoughts about drugs, developing problem-solving skills, planning for and managing high-risk situations, and cultivating drug refusal skills. Basic principles of CBTs are that [37; 38]: • Basic skills should be mastered before more complex ones are given. • Material presented by the therapist should be matched to patient needs. • Repetition fosters the development of skills. • Practice is needed for mastery of skills. • The patient is an active participant in treatment. • Skills taught are general enough to be applied to a variety of problem areas. Structured behavior therapy techniques can be effective compo- nents of substance use disorder treatment. Contingent incen- tive procedures are designed to enhance a patient’s motivation to meet treatment goals by offering concrete rewards for specific performance outcomes. Behavioral therapy techniques are often part of CBT. In this approach, substance use is believed to develop from changes in behavior and a reduction in opportunities for reinforcement of positive experience. The goal is to increase the person’s engage- ment in positive or socially reinforcing activities. Techniques such as having patients complete a schedule of weekly activi- ties, engaging in homework to learn new skills, role-playing, and behavior modification are used. Activity, exercise, and scheduling are major components of this approach based on the following: • Patients with substance use disorders require motivation and skills to succeed in stopping drug use. • Research has shown that drug abuse behavior can be reduced by offering contingent incentives for abstinence.
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MDNJ1525
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