Addiction Treatment

### **Chapter 5**

## Revisiting 12-Step Approaches: An Evidence-Based Perspective

*Dorothy Greene*

### **Abstract**

Alcoholics Anonymous (AA) is the longest-running mutual aid group for people with alcohol use disorders, and AA turned 85 years old in 2020. Though there has been much criticism regarding AA and other 12-step programs, there has been an equal amount of evidence to support their efficacy. This chapter explores the history of AA and other 12-step approaches, the foundational philosophy of the 12-steps, the key elements that support recovery, cultural considerations for special populations, and a review of the criticisms as well as strengths of 12-step approaches. The chapter concludes with recommendations for the integration of the approach into clinical practice.

**Keywords:** 12-steps, alcoholics anonymous, narcotics anonymous, substance use disorders, addiction, mutual aid groups, efficacy

### **1. Introduction**

In 2020, the most rigorous scientific study to date regarding the efficacy of Alcoholics Anonymous (AA) and other 12 step approaches were published [1]. Soon after, a sweeping review of scientific studies relative to Narcotics Anonymous (NA) was released [2]. Outcomes gleaned from these publications suggests substantial benefit to members of AA and NA both as an adjunct to professional treatment and as a stand-alone intervention for substance use disorder (SUD). Although valid criticisms exist regarding 12-step approaches, for those whom 12-step approaches work, they appear to work quite well. While alternatives to 12-step approaches are increasing, scientific information is limited. Thus, this chapter focuses primarily on 12 step-approaches.

The chapter begins with an introduction presenting demographic data, history of 12-step programs, and the fundamental philosophy of the 12-steps. Because AA and NA are the largest and most studied 12-step programs, most of this discussion is drawn from literature specific to these two programs. Additionally, there is a dearth of scientific literature pertaining to 12-step approaches and behavioral addictions. At present, there is only one behavioral disorder included in the DSM's classification of Substance-related and Addictive Disorders [3], gambling disorder, so the chapter's focus is 12-step approaches relative to substance use disorders. An introduction to the most common 12-step programs associated with behavioral addictions is also presented.

Substance use disorder mutual aid recovery has an intricate and complex history. Many mark the year 1935 as the birth of the mutual aid recovery movement as that is the year Alcoholics Anonymous was formed. According to White [4], the mutual aid recovery movement began centuries before in the late 1700s with Native American Recovery Circles. Section II presents a brief survey of the history of mutual aid groups, followed by a more pointed examination of the histories of AA and NA. A concise overview of common 12-step offshoots follows. The section concludes with a look at how 12-step approaches became integrated into professional addiction treatment services.

In section III, the philosophical underpinnings of the 12 steps and recoveryrelated activities associated with 12-step mutual aid recovery are described. According to research, those who participate in 12-step activities such as sponsorship, regular meeting attendance, and service have better outcomes regarding sustained abstinence [5–9].

Section IV presents the evidence surrounding 12-step mutual aid recovery. Beginning with an examination of several core elements that appear to support recovery, the section explores the efficacy and strengths of 12-step approaches as well as its criticisms and limitations.

The discussion continues in section V with a consideration of culture as it relates to 12-step approaches. One size does not fit all, and the spiritual or religious undertone of the 12 steps is likely the most cited barrier for those who prefer a secular approach to addiction recovery. In contrast, many are attracted to 12-step programs because of the emphasis on spirituality and a Higher Power. This and several additional cultural influences are explored.

Before the chapter concludes, recommendations are offered for integrating 12-step approaches into professional treatment services.

### **2. Demographics of 12-step membership**

In 2011, there were 54 different 12-step programs [10]. Alcoholics Anonymous and Narcotics Anonymous are by far the largest. A strength of 12-step programs is their wide availability across the globe. Estimated membership in Alcoholics Anonymous is 2,077,374 individual members and 125,557 groups as of 2019 [11].

A 2014 AA membership survey [12] reported the following demographic information. Sixty-two percent of membership identified as male and 38% identified as female. A large majority of membership identified as white, 89%, 4% black, 3% Hispanic, 1% Native American, 1% Asian, and 2% identified as other. The average age of AA members is estimated at 50 years.

Members are introduced to AA from a variety of sources. Thirty two percent of members are introduced to AA by an AA member, and another 32% are introduced by a treatment facility. Thirty percent of AA members report being self-motivated to attend, and 27% are referred by a family member. Other referrals come through the criminal justice system (14%), and medical and behavioral health professionals (17%). Less common referrals include Al-anon/Alateen member, AA literature, employer, or colleague, newspaper/magazine/radio/tv, clergy, and the internet. The survey reported the average length of sobriety is 10 years, with a range between less than one year (27%) and over 20 years (22%). On average, members attend 2.5 meetings per week, and 82% reported having a sponsor.

Narcotics Anonymous released a membership survey more recently [13]. They report 77,000 meetings weekly in 144 countries across the globe. Compared to AA, NA's membership is more diverse, with 70% identifying as White, 13% Black, 7% Hispanic, 4% multiracial, 2% Asian, 1% Indigenous, and 1% as other. In terms of gender, 58% identified as male and 42% as female. The average age of NA members *Revisiting 12-Step Approaches: An Evidence-Based Perspective DOI: http://dx.doi.org/10.5772/intechopen.95985*

is 46 years, with a range between less than 21 (1%) and over 60 (15%). The mean number of years clean is 8.32 years, with a range between less than 1 year (8%) and over 20 years (25%).

Most members are referred through other NA members (49%) and treatment of counseling services (45%). Other referral sources include family members, NA literature or an NA service effort, and AA members.

NA members reported using a variety of substances. Alcohol was the most common substance reported (73%), followed by cannabis (62%), cocaine (52%), opiates (38%), stimulants (38%), crack (31%), opioids (26%), tranquilizers (25%), hallucinogens (25%), prescribed medications (23%), ecstasy (17%), methadone or buprenorphine (14%), inhalants (11%), and other (14%).

It is important to note that these two surveys are *membership* surveys and not designed for research. The purpose is to provide a snapshot of current membership rather than the general population of people with SUDs. Nonetheless, there exists important challenges to researchers who seek to study recovery via 12-step mutual aid programs. This is explored further in section 8.

### **3. History of mutual aid groups and 12-step programs**

According to the addiction field's leading historian, William White, the history of abstinence-based mutual aid recovery groups begins with the Native American recovery circles [4]. Between 1737 and 1840, Indigenous leaders such as Handsome Lake, Wagomend, and Paounhan had transformational experiences leading to sobriety. These transformations led to cultural and religious reformations, which included the rejection of alcohol. Spawned by the temperance movement, the 1800s saw a variety of mutual aid societies begin and end. These included the Washingtonians, The Red Ribbon Reform Club, the Drunkard's Club, and several others. White further explicates that for those whose goal was moderation rather than abstinence, other groups formed such as Businessman's Moderation Society in 1879. European temperance societies formed in the 1800s as well. For example, in 1851 the Order of Good Templars formed, and in 1877 Switzerland founded the Blue Cross. White also states that European culture, like American culture, formed mutual aid groups founded on moderate drinking rather than abstinence such as the German Order of Temperance, French Temperance Society, and the Irish New Ross Temperance Society.

In the early 1900s, many American mutual aid and treatment organizations failed, and this was partly influenced by prohibition. According to White, the absence of mutual aid groups in the early decades of the 20th century is notable, but in 1935, an historic meeting occurred between two self-defined hopeless alcoholics that revolutionized the treatment for people with alcohol use disorders and a host of other addictive behaviors across the globe [14]. Today, AA is the largest and longest running mutual aid group for alcohol use disorders in the world. Such a profound impact has been made by AA, that its co-founder, Bill Wilson, was recognized by Time Magazine as one of the most influential people of the Millennium [15]. A brief history of AA is provided next.

### **3.1 AA's beginning**

From the book Alcoholics Anonymous [16], affectionately known as the *Big Book* because of its over 500 pages, and the Alcoholics Anonymous' website [17], Bill W.'s story follows.

In 1934, Bill W. sat alone drinking at his kitchen table when the telephone rang. He was greeted by an old high school friend and drinking buddy, named Ebby T., whom he had not spoken to in quite some time. He had heard his old friend was institutionalized due to chronic alcoholism. Ebby T. asked if he could visit Bill, and later that day the two men sat reminiscing about old times. Bill offered Ebby a drink, but he refused and told Bill that he *got religion*. Ebby shared his experience with spiritual principles and a process of change that required surrender to the alcoholic condition and acceptance of guidance from a Higher Power. Because Bill balked at the idea of organized religion and God, Ebby informed Bill that he could formulate his own conception of this power. The spiritual process described by Ebby also included a process of self-inventory, confession, and making amends to those whom he had harmed. Bill recognized a difference in his friend – something had changed. Though Bill did not stop drinking at this point, he opened his mind to the ideas presented by his friend for nothing else had helped him overcome the compulsion to drink.

According to Alcoholics Anonymous [16], the process described by Ebby T. was the foundation of the Oxford group. A mostly non-alcoholic, non-denominational, Christian group. Its fundamental principles and beliefs were later expanded and revised into what are now known as the 12-steps of Alcoholics Anonymous.

After that fateful meeting with Ebby T., Bill went on yet another drinking binge that eventually landed him in Towns Hospital in New York with delirium tremens. Remembering his friend's spiritual directions, he proceeded to take the steps as outlined by Ebby T. In Towns Hospital, 1934, Bill W. experienced his famous white light experience, never to drink again.

What happened in the following six months formalizes the beginning of AA. Upon release from Towns Hospital, Bill joined the Oxford Group. He and Ebby embarked on a mission to share this spiritual process with as many alcoholics as possible. A profound lesson was learned, which is the bedrock of AA.

After several month, Bill W. became very disheartened because although they had shared the message of recovery with with every alcoholic they met, none were able to maintain sobriety. Bill was ready to abandon their effort when Ebby emphasized that even though none of their recruits remained sober, he and Bill did. This is the crux of AA - *we can only keep what we have by giving it away*. Through helping other alcoholics, one could remain sober.

About six months after Bill's spiritual experience in Towns Hospital, he went on a business trip to Akron Ohio, alone for the first time in his newfound sobriety. Bill walked through the lobby of the hotel, immediately spotting the hotel lounge. The old memories of drink ensued, and the familiar craving took root. He went to the lobby phone booth and found a church directory where he began frantically calling churches to see if one knew of an alcoholic with whom he could speak. At the end of the church directory, he found a possibility. A meeting was arranged by the wife of an Akron surgeon to speak with her husband as he was dying of alcoholism. Dr. Bob Smith had been a member of the Oxford Group where he had sought help for his alcoholism, but to no avail.

On June 10th, 1935, Bill W. and Dr. Bob Smith met for the first time. Bill shared his experience with a chronic and seemingly hopeless alcoholic condition (what it used to be like), the spiritual process that transformed him (what happened), and how his life unfolded moving forward (what it's like now). The two men spoke for hours and agreed to work together to share their experience with other alcoholics who still suffered. From this point forward, Bill W. and Dr. Bob dedicated the rest of their lives to carrying the message of AA's 12-steps to other alcoholics. After 2 and a half years of sobriety, in 1937 Ebby T. relapsed. He did regain sobriety and died sober in 1966.

With the publication of AA's Big Book in 1939 and a flurry of articles published thereafter, AA's growth blossomed. A defining moment in AA's growth trajectory occurred in 1941 when Jack Alexander's article, *"Alcoholics Anonymous: Freed Slaves of Drink, Now They Free Others,"* was published in the Saturday Evening Post. The AA office received countless inquiries after its publication, and by 1950 AA's membership had reached over 100,000. The tireless dedication of Bill W. and Dr. Bob has resulted in millions of people helped worldwide, revolutionizing the way people with substance use disorders are treated.

### **3.2 Narcotics Anonymous**

Because the only requirement for membership in AA is a desire to stop drinking, and drug addicts were often shunned by AA, Narcotics Anonymous was formed. Unlike AA's beginnings, NA's first few decades were tumultuous, experiencing several starts and stops, and more than one version of the program [18].

Addicts Anonymous held its first meeting in 1947, but the Narcotics Anonymous we know today began in earnest in 1953, but nearly died in 1959 [18]. When this happened, Jimmy K. and two others started what became today's NA with the *mother group*, Architects of Adversity [18]. Though many members came and went, Jimmy K. was the mainstay in the early days of NA. Jimmy K's tireless effort to keep NA alive in those tenuous times is why he is credited as the founding member of NA [18].

In his historical presentation of NA, William White [4] describes Jimmy K.'s addiction as one that progressed from sneaking tastes of paregoric and alter wine as a child to binging on whiskey and pills in adulthood. According to White, Jimmy K.'s addiction "left him bankrupt physically, mentally, and spiritually, and an abject failure as a man, a husband, and a father" [4], p. 335. As a result, he began attending AA in 1950, introducing himself as an alcoholic and addict. He had a passion for helping those with multiple addictions. Jimmy befriended Dorothy S. in AA, who like Jimmy, had multiple addictions. Together, with the help from Danny C in New York, they worked to establish the NA we know today.

Narcotics Anonymous utilizes the same 12 steps and 12 traditions developed by AA, with several adaptations specific to *addiction* rather than *alcoholism*. For example, AA states: The only requirement for membership is the desire to stop drinking, and NA substitutes the word *using* for the word *drinking*. Additionally, AA's first step reads *We admitted we were powerless over alcohol—that our lives had become unmanageable*, whereas NA states *we were powerless over our addiction*.

Another point from which NA diverges from AA is that NA is a program of abstinence from all drugs [19], and NA does not differentiate between substances of misuse. Further, NA clearly considers alcohol a drug. Though for some, this may be a barrier to participation in NA. In nearly every NA meeting this section from the NA Basic Text is read:

*The only way to keep from returning to active addiction is not to take that first drug. If you are like us, you know that one is too many and a thousand never enough. We put great emphasis on this, for we know that when we use drugs in any form, or substitute one for another, we release our addiction all over again.*

*Thinking of alcohol as different from other drugs has caused a great many addicts to relapse. Before we came to NA, many of us viewed alcohol separately, but we cannot afford to be confused about this. Alcohol is a drug. We are people with the disease of addiction who must abstain from all drugs in order to recover. [19]*

Alcoholics Anonymous and Narcotics Anonymous also have offshoots for family members. Al-Anon, Alateen, and Nar-anon operate under the 12 steps and 12 traditions but are designed for those who love people with substance use disorders.

Though Alcoholics Anonymous and Narcotics Anonymous are by far the largest of the 12 step fellowships, numerous other groups have formed modeled after the AA prototype. The following section briefly introduces a few of its more common descendants.

### **4. Other 12-step programs**

Many twelve step programs have formed to treat both substance use disorders and behavioral addictions. In addition to AA and NA, several substance specific 12 step programs have followed: for example, Cocaine Anonymous, Heroin Anonymous, Marijuana Anonymous, and Nicotine Anonymous. Each AA derivative substitutes the word alcohol in the 12-step language for the substance or behavior the program addresses.

Although behavioral addiction is an unscientific term, many groups have formed to address a variety of compulsive behaviors. Gambling use disorder is the only exception and is classified in the DSM 5 as a Substance-Related or Other Addictive Disorder [3]. Gamblers Anonymous is one of the largest of the behavioral addiction 12 step programs. Gamblers Anonymous began in 1957 and "is a fellowship of men and women who share their experience, strength, and hope with each other that they may solve their common problem and help others to recovery from a gambling problem" [20].

Overeaters Anonymous formed to address a variety of compulsive eating behaviors. It is "a community of people who support each other in order to recover from compulsive eating and food behaviors. We welcome everyone who feels they have a problem with food" [21]. Overeaters Anonymous was founded in 1960 and currently has over 6500 groups in 75 countries, and an estimated 60,000 members worldwide.

Another well-known 12 step program is Codependents Anonymous program. "Codependents Anonymous (CoDA) is a 12 Step Fellowship for people seeking loving and healthy relationships" [22]. The concept of co-dependency has come under fire by feminist scholars. For example, Anderson [23] argued that the concept pathologizes and blames women. Yet, Melody Beattie's 1986 bestseller, *Co-dependent No More,* has sold more than 5 million copies [24].

### **5. 12-step integration into professional treatment**

The Minnesota Model, known as the fundamental philosophy of the well-known Hazelden Betty Ford Center, was born in 1949. It was one of the first facilities to provide therapeutic and human treatment for alcoholics and addicts [25]. Borrowing principles from Wilmar State Hospital and Alcoholics Anonymous, the model was replicated across the globe. So popular was the 12-step movement that by 1989, an estimated 90% of treatment facilities followed the Minnesota Model [26]. The core practices of the Minnesota Model included patient education on the 12 steps and the idea that addiction is a physical, mental, and spiritual disease [25]. Moreover, the model integrates the notion that alcoholics and addicts can stay sober best by helping one another as did Bill W. and Dr. Bob, the AA co-founders; thus, the beginnings of utilizing recovering alcoholics as lay counselors.

*Revisiting 12-Step Approaches: An Evidence-Based Perspective DOI: http://dx.doi.org/10.5772/intechopen.95985*

Before this section concludes, it is important to acknowledge one of the most utilized evidence-based models for addiction treatment, Twelve Step Facilitation Therapy or TSF. In the largest clinical trial of its kind, Project Match examined three of the most common evidence-based models for alcohol use disorder: cognitive behavioral therapy, motivational enhancement therapy, and TSF [27]. The purpose of the study was to learn if certain patients would have better outcomes with a specific therapeutic model compared to another. Overall, the study found that patient matching did not change outcomes and that all models were equally effective. Two exceptions should be noted. First, those with low levels of psychiatric comorbidities treated with TSF, experienced higher rates of days completely abstinent. Second, those who received TSF had higher rates of complete abstinence at year one. The next section will explore the 12-step philosophy, principles, and practices more fully.

### **6. 12 step philosophy**

When describing 12-step philosophy several core elements are emphasized: the 12-steps, 12 traditions, sponsorship, meeting attendance, service, and spirituality.

No discussion on the application of 12-step principles is complete without the perspective of those with lived experience. In addition to the author's voice, this section integrates the voices of those who identify as persons in recovery. The section begins with the 12-steps and 12 traditions of the program.

### **6.1 The 12 steps**


The program is described as "a set of principles written so simply that we can follow them in our daily lives" [19], p. 9. A simple translation of the 12-step process is provided by a woman who attends both AA and NA:

*For me, steps 1-3 are about developing a relationship with a power greater than myself, steps 4-7 are about healing the relationship with myself, and steps 8-12 are about healing and supporting my relationships with others. I don't do this by myself. My sponsor's main role is to guide and support me through working the steps. (Anonymous 12-step group member, personal communication, November 23, 2020).*

### **6.2 The 12 traditions**

Eddy G., a long-time member of NA, describes the purpose of the 12-traditions this way.

*If the 12-steps are how the program works, the 12-traditions are why the program works. The traditions keep the focus of the fellowship on helping each other. They teach us how to help each other while maintaining the integrity of the fellowship and the principles that drive it. (Eddy G., personal communication, December 30, 2020)*


### **6.3 Sponsorship**

Sponsorship and carrying the message to the person who still suffers (step 12) are fundamental practices in 12-step communities. Sponsorship is the tradition of a more experienced, sober member of the program supporting a newer member along their recovery journey. "The heart of NA beats when two addicts share their recovery" [29].

Though the following sponsorship guidelines are not required, they are suggested. In general, sponsors and sponsees should be same sexed as to avoid romantic distraction. A limitation here is the assumption that all members are heterosexual. There is not an established guideline for those who identify as LGBTQ. Additionally, the sponsor should have experience in working the steps and have attained stable recovery. There is not a written standard in terms of length of sobriety or how far along in the step process a sponsor should be.

Dekkers, Vos, and Vanderplasschen [30] discovered mutual understanding facilitates connection, and connection was identified as a key theme supporting recovery in their qualitative study of NA members. A large study of over 1800 veterans showed that having a sponsor was one element that helped mediate positive outcomes among participants of 12-step programs [7]. According to NA, "the two-way street of sponsorship is a loving, spiritual, and compassionate relationship that helps both the sponsor and sponsee" [29]. Sponsorship may be considered analogous to the therapeutic alliance [31]. Contact with a sponsor and a strong sponsorship relationship contribute to increased 12-step participation and abstinence.

### **6.4 Meeting attendance**

One often hears the maxim, *90 meetings in 90 days,* suggested to newcomers in the program. A substantial scholarly literature shows that regular 12-step meeting attendance supports positive substance use outcomes [5, 6, 8, 9, 29]. For example, results from a large National Institute of Drug Abuse funded project show that weekly or more frequent attendance at 12-step groups support alcohol and other drug (AOD) abstinence [32]. Similar findings are reported bey Greene and colleagues in a national sample of recovering addiction professionals [6]. Those attending meetings weekly had the lowest rates of relapse compared to those who attended less frequently.

The value of meeting attendance is best described by an anonymous member of AA and NA.

*The 12-step fellowship provides immediate access to a pro-recovery support system. All my friends were using buddies. I didn't have anyone in my life that didn't use drugs and alcohol, and I was young when I entered recovery. I needed a social network. I never would have been able to stay sober had I not attended so many meetings. (Anonymous 12-step member, personal communication, November 29, 2020)*

It is important to note that research also indicates 12-step meeting attendance alone may be insufficient for the maintenance of recovery. Participation in activities such as sponsorship, service work, working the steps, etc. appears to increase positive benefits compared to meeting attendance alone. In a study of 303 young adults, 12 step meeting attendance and *active* participation in the program lead to positive substance use outcomes [33]. Interestingly, for meeting attendance alone positive effects diminished over time, but positive effects increased over time with active involvement.

### **6.5 Service**

As noted in the previous section, positive recovery outcomes increase with the addition of other recovery activities to meeting attendance, and service is one of the foundational elements of 12-step programs.

One long-term NA member described service in NA as follows.

*Service in NA, in the beginning, is a way for me become accountable to a group of people that I've come to trust, and it allows me to build trust within the group. Later in recovery, it becomes a way to reverse self-centered fear because the opposite of self-centered fear is selfless service. It's pure volunteer. I don't get paid for any of it. Now that I've been given the gift of recovery, it's my responsibility to give it back. It's the 12th step. The only way I can keep the gift of recovery is to give it away. (NA member, personal communication, November 28, 2020)*

Service work in 12 step programs encompasses a variety of activities. The more common tasks, other than sponsorship, include, opening and closing the meeting; setting up and putting away chairs; making coffee; holding positions such as group chairperson, treasurer, or secretary. Service may also include activities such as taking meetings into facilities where clients are unable to attend in the community. Treatment centers, jail and prison facilities are the most common. Service commitments might extend all the way to the level of world service. In keeping with the fundamental tenets of the program, all service positions are unpaid. According to the traditions of the 12-step programs, there are no dues or fees for memberships, there are no leaders, groups are self-supporting and autonomous, and 12 step mutual aid groups do not accept outside contributions. So entrenched are these principles, that guests attending an NA group are often explicitly asked not to contribute when the donation basket is passed at the meeting.

Why is service such an important component of 12-step programs? Two theoretical ideas are proposed: the helper therapy principle and the wounded healer archetype [34]. These theories suggest that one's experience with addiction might be reduced through helping others. Further, by having addiction oneself, it may render the individual with special knowledge and insight that can be shared to help a person still struggling with addiction. This provides a logical segue into the final section of 12-step philosophy, spirituality.

### **7. Spirituality and 12-step programs**

While religion tends to be associated with an organized set of beliefs, practices, rules, and doctrines [35], 12-step programs' clearly state the program "should remain forever non-professional… ought never be organized" [19], pp. 69–70, and is "not connected with any sect, denomination, politics, organization or institution" [36]. Yet, 12-step programs are unapologetically spiritual in nature. A common axiom cited in AA and NA meetings asserts *there is no chemical solution to a spiritual problem.*

An entire chapter in AA Big Book is devoted to those who may struggle with organized religion and the concept of God – it is titled *We Agnostics* [16]. The fundamental premise is that spirituality is subjective and defined by each member individually. Written in 1952, a companion text to the original AA Big Book, *The Twelve Steps and Twelve Traditions*, says AA does not demand that you believe anything … I must quickly assure that AAs tread innumerable paths in their quest for faith … You can if you wish, make AA itself your 'higher power' … [37], pp. 25-27. The AA Big Book encourages readers to develop their own conception of God, and further states "don't let any prejudice you may have against spiritual terms deter you from asking yourself what they mean to you" [16], p. 47.

If 12 step programs are not religious but rather *spiritual* programs, what exactly is spirituality and how does it support recovery? Spirituality is described as a creative and universal part of the human experience. Subjective in nature, it is about one's connection to self, others, social groups, communities, and traditions. It can be experienced as an inner and/or transcendent personal relationship, which may exist beyond the self. Fundamental to this definition is the notion that spirituality is concerned with human values, truth, and experiences that provide meaning and purpose in life. Given the earlier discussion of 12-step philosophy's core elements, its fit within this definition of spirituality is undeniable [38].

No academic endeavor is complete, however, without a critical examination. The next section will do just that.

### **8. Strengths and limitations of 12-step programs**

While millions of people worldwide have found recovery from addiction through 12-step programs, millions more have found the program unhelpful. The science of addiction and recovery provides empirical evidence of the efficacy of 12-step approaches, but it equally shows there are multiple efficacious paths to recovery. One size does not fit all.

This section begins with the counterargument to the last section on spirituality. Likely the most frequently cited criticism to 12-step programs is its religious undertone. As noted in the history section of the chapter, AA and the 12-steps were birthed from a non-denominational Christian organization, the Oxford Group. Osten and Switzer argue that for those who identify as atheist, agnostic, or a non-Christian faith, 12-step programs might be challenging [39]. For example, multiple references to God, using the male pronoun, are found in the in 12-step literature. Step 3 of the 12-steps suggests *we turned our will and our lives over to the care of God as we understood Him.* Further, the recitation of the Lord's Prayer is common in many AA meetings, and many, if not most, 12-step meetings are held in churches.

Building on this criticism, feminist writers have named several barriers to accepting the 12-step path for women and people of color [40, 41]. Not the least of which is the reference to God using the male pronoun in steps 3, 7, and 11, and throughout the AA literature. For women, there is a long and painful history of patriarchy, oppression, and subjugation. Thus, the idea of turning one's life over to a male God may feel reminiscent of this history for some. Additionally, concepts of surrender, powerlessness, and turning one's life over are not only difficult for some women to accept but may also be challenging for ethnic minorities. For groups who have experienced the horrors of genocide and slavery, such as Native Americans and African Americans, these ideas may be particularly difficult.

One anonymous 12-step member, a middle-aged woman in long-term recovery, understands this criticism and has experienced discrimination and oppression in a male-dominated, patriarchal society, but states she has not experienced the 12-step community as such (Anonymous NA member, personal communication, December 1st, 2020). She shared that the terms *powerless* and *surrender* are not used in the same context as oppression and subjugation associated with slavery and a discriminatory and patriarchal culture. In fact, the 12-step process of recovery is experienced by many as an empowering process that leads to freedom from dependence on substances [42]. Alcoholics Anonymous asserts that through dependence upon a power greater than oneself, an individual becomes more personally independent [37]. Yet, it is important to acknowledge the era in which the original texts were written. Alcoholics Anonymous was founded by White, middle-class men in 1935, so the language of the time may create a barrier for many. Though the literature has been slightly updated, Alcoholics Anonymous has not conducted a major revision to the original literature for historical reasons. The biased language in AA's primary texts, written in 1939 and 1952, may impede AA's growth, particularly for women [43] and people of color.

Another criticism regarding language in AA and NA is related to stigma. Critics say that the tradition of introducing oneself in meetings as an "addict" or "alcoholic" places a negative label on the individual and perpetuates stigma and stereotypical views of people who have SUDs. Additionally, identifying oneself as their disorder is contradictory to strength-based and person-centered philosophies. A differing perspective is offered in Greene's article:

*In some marginalized groups, words that were historically pejorative have been reclaimed as a label of power, pride, and history—for example, the use of the term queer in some LGBTQ communities. Speaking for myself as a person in long-term recovery, the labels of "alcoholic" or "addict" serve, in a sense, as a badge of honor because I have survived a potentially fatal illness—and also thrive as a result. I feel a sense of pride and gratitude when I say, "Hi, my name is \_\_\_\_, and I'm an alcoholic." [44], p 11-12*

For those who have difficulty adapting to the language in AA's original literature, NA language may be more relevant to the present day, particularly newer NA publications and the latest edition of the NA Basic Text. However, the language of the 12-steps remains as originally written. Substitutes can be made in the language. For example, the male pronoun used in reference to God, may be substituted by a gender-neutral term. For example, dropping the male pronoun in the 11th step reads as follows: *We sought through prayer and meditation to improve our conscious contact with God as we understood God, praying only for knowledge of God's will for us and the power to carry that out*.

For those who do not identify as Christian, the word God may be substituted with Allah, Jehovah, Yahweh, the generic phrase Higher Power, or whatever is true for the individual. It is important to understand that 12-tep programs do not require a belief in God. In fact, many agnostic and atheist AA groups exist and are growing rapidly. In AA, one might hear GOD referred to as a Group Of Drunks, while a

*Revisiting 12-Step Approaches: An Evidence-Based Perspective DOI: http://dx.doi.org/10.5772/intechopen.95985*

group of sober alcoholics might be considered a higher power for whom to turn to for help. An interesting finding by Tonigan and colleagues found that belief in God is not necessary to experience benefit from AA, but those who identify as atheist or agnostic are less likely to attend meetings [45].

Another criticism should be highlighted. Some have found the language of the 12-steps reflects a tearing down rather than a building up process that emphasizes moral inventory and examination of one's character flaws. Steps 4 through 7 best show this critique. These steps recommend critical self-examination, admission to the exact nature of wrongs to God and another person, followed by a willingness to let go of, and have God remove, such character defects and shortcomings. When asked about these criticisms, an NA member had this to say.

*Well, I can certainly understand the criticisms because when you look at the steps as written without further guidance and instruction from a sponsor, it looks that way. It's important to understand a foundation is laid in steps 1-3, with the guidance of a sponsor, in preparation for working steps 4-7. Another important process to understand is that it's not only about wrongs committed, but also an inventory of assets and liabilities. We must self-examine in order to know what qualities and behaviors we want to nurture and what behavior patterns are unhealthy and need to be eliminated. If we don't change in a positive direction, we're likely to continue using. (NA member, personal communication, December 4, 2020)*

A major criticism is related to research. The tradition of anonymity in 12-step mutual aid recovery groups is an important aspect that attracts many to the program who otherwise may not attend. However, the lack of organization, anonymity, and the voluntary participation of members create methodological barriers to research. Additionally, survey research has inherent methodological flaws, particularly when studying members of 12-step programs. Self-selection bias is unavoidable, and this is particularly problematic as the voices of those who have not done well via 12-step mutual aid recovery may be missing and the voices of those doing well may be over-represented. Twelve-step attendees often come and go many times before they commit to sobriety or leave permanently. When evaluating the research literature, this criticism should not be overlooked.

Although 12-step meetings are more plentiful than alternative mutual aid recovery groups, availability is variable depending on geographic location. Meetings may be scant in rural areas and in some countries other than the U.S. Additionally, specialty meetings such as gender specific groups, LGBT groups, groups for adolescents, and groups for those who identify as atheist or agnostic are not available in all areas.

Depending upon which lens through which one views 12-step programs (member or researcher), the program's 12 traditions are both strengths and limitations. From a members' perspectives the traditions, as Eddy G. noted uphold the integrity of the program. But for researchers, anonymity, group autonomy, lack of professionalism and organizational structure, and their commitment to hold no opinion on outside issues, makes studying the program difficult. There is tremendous variability in how groups run and how one works the steps, for example.

This section ends with two additional strengths of 12-step programs – the first is cost. Membership in 12-step mutual aid programs is free. There are no membership dues or fees, no professionals, and the only requirement for membership is a desire to stop drinking or using [19]. The program is totally self-supported by its members' contributions collected at each meeting. A dollar or two is typical, but not required. Newcomers and those who do not identify as members are usually asked not to contribute. Finally, healthcare costs are substantially reduced for those who participate

in 12-step programs. In their systematic review, Kelley and colleagues demonstrated higher healthcare cost savings for individuals treated with AA or Twelve Step Facilitation (TSF) compared to those treated in an outpatient facility utilizing CBT, or no AA/TSF exposure [1]. Further, for those with a poor prognosis, AA/TSF had higher cost savings compared to Motivational Enhancement Therapy.

The final and maybe most important strength of the program discussed here concerns science. Several 12-step activities are supported by research. Though provision of a comprehensive review is not possible here, two empirically supported activities are highlighted. The first, helping others, is the primary purpose of the 12-step programs and is underscored in Tradition five, "Each group has but one primary purpose—to carry its message to the alcoholic who still suffers." Supported by a substantial scientific literature, personal well-being is enhanced by helping behaviors [46–49], and 12-step mutual aid recovery is founded on the principle of service. A common evidence-based practice for SUDs, contingency management [50], where rewards and incentives are provided to help reinforce abstinence and other health promoting behaviors, is exemplified in nearly every 12-step meeting. Through the chip system in AA or the key tag system often used in NA, members are recognized with a different colored chip or key tag for each marker of recovery, typically followed by a round of applause from the group. For example, if an NA member achieves 30 days of continued abstinence, they receive an orange key tag, 60 days is green, 90 days is red, blue is for 6-months, green for 9-months, and a glow in the dark key tag is awarded for one year clean. For members who attain multiple years of recovery, they often receive a special medallion.

### **9. Cultural considerations and the 12-steps**

Culture has been defined as "a community or society. It structures the way people view the world. It involves the particular set of beliefs, norms, and values concerning the nature of relationships, the way people live their lives, and the way people organize their environments" [51], p.11. Additionally, culture includes the many cultural identities one holds in terms of ethnicity, gender, sexual orientation, age, socioeconomic status, geographic region, etc. Narcotics Anonymous is one of the most culturally diverse mutual aid programs, and this seems to be generalizable across the globe [2]. An important question to consider is this: Are there cultural considerations relative to 12-step philosophy and who may, and may not, fare well with the approach?

### **9.1 Spirituality as a cultural element**

A key element of cultural beliefs, values, and norms is spirituality. In addition to examining spirituality as cultural element, this discussion provides a contradictory view of a primary criticism of 12-step programs, the religious and spiritual undertones. Abraham Maslow, noted psychologist and theorist, said "the spiritual life is part of the human essence. It is a defining characteristic of human nature, without which human nature is not fully human." In a large survey conducted by the Pew Research Center, nearly 90% of survey respondents reported belief in God or a Universal Spirit [52]. Spirituality and religion seem to be in the fabric of many cultures. Based on data from the Higher Power Project, Dossett suggests that helping professionals need not be wary of referring individuals and families to 12-step programs, and in fact may want to consider supporting individuals and families in seeking recovery through 12-step programs [53]. Participants in the

*Revisiting 12-Step Approaches: An Evidence-Based Perspective DOI: http://dx.doi.org/10.5772/intechopen.95985*

HHP consistently report the notion of "autonomous and personal construction of a Higher Power which works for them" [53], p. 380. Koenig [35] underscores the importance of allowing individuals to define spirituality for themselves. Findings consistently show that those who attend 12-step meetings regularly and actively participate in the program have better substance use and quality of life outcomes [53, 54].

While much of the criticism of 12-step programs surrounds language that may be interpreted as oppressive, a substantial literature exists that contradicts the criticisms. Though a comprehensive cultural review is not possible here, the following discussion highlights several population groups that have historically experienced oppression or may experience unique issues in terms of SUD recovery. The author would be remiss to fail to mention that culture is subjectively experienced, and there are substantial differences within groups as well as between groups. Maintaining cultural humility [55] is always recommended. The discussion that follows highlights several special population groups and associated findings relative to 12-step recovery: African Americans, Native Americans, women, adolescents, and LGBTQ populations.

### **9.2 African Americans and 12-step models**

In general, African American communities highly value spirituality and religion. Consequently, the topic of spirituality provides a smooth transition into the examination of the African American culture relative to 12-step programs. Peavy, Garret, Doyle, and Donovan compared outcomes of 12-step facilitation treatment between African American and Caucasian stimulant users and found treatment was equally effective for both groups [56]. One study found that African Americans were just as likely to attend and benefit from 12-step group attendance as their White counterparts and were slightly more likely to remain abstinent [57]. Another study explored spirituality among African American men attending a methadone maintenance program. The group of 25 men all reported a group focused on spirituality would be preferable to treatment as usual [58]. Given the spiritual foundation of 12-step programs, African American individuals with SUDs may derive great benefit from AA/NA.

### **9.3 Women and 12-step models**

While valid criticisms exist relative to women and 12-step programs, there is also substantial literature to support the efficacy of 12-step approaches for women. As highlighted in the introduction, women make up approximately 42% of NA membership and 38% of AA's membership. According to some authors, 12-step programs are equally effective for women and people of color compared to their European-Male counterparts. For example, Hillhouse and Fiorentine found that women were just as likely to attend 12-step groups and recover as their White male counterparts [57]. Data were analyzed from the Los Angeles Target Cities Evaluation Project (n = 356), inclusive of 26 outpatient programs. Participants were followed for 2-years. At each of three follow-up points in the study, over 50% of participants identified as female, and no statistically significant differences were found between men and women. Moreover, approximately 35% of women reported weekly attendance at a 12-step meeting, and 30% of men reported weekly attendance. Men and women were equally likely to be abstinent at the 2-year follow-up, but women were slightly more likely to be abstinent from alcohol than were men; however, this finding was not statistically significant. Further, women and men were equally likely

to dropout, 33.1% and 33.2% respectively. As a bridge into the next section, gender difference was compared among a sample of urban Native American individuals with SUDs as well, and none were found. Men and women in this sample experienced AA-related benefits equally, and 12-step meeting attendance helped to explain increased abstinence for both groups. For those who prefer gender specific 12-step meetings, there is availability in many areas.

### **9.4 Native Americans and 12-step models**

There are more than 566 recognized Native American tribes in the U.S., and as a cultural group, Native Americans have experienced significant historical trauma and harms relative substance use and addiction. Some of the highest rates of substance use disorders are found among this population group. For example, SAMHSA reports that American Indian/Native Alaskans have the highest rates of alcohol misuse compared to other cultural groups [51]. Because a frequently cited value of this community is spirituality, 12-step mutual aid groups may be effective for Native Americans with SUDs [26]. However, research is quite limited specific to the efficacy of 12-step programs among Indigenous populations.

Although there has been speculation that cultural factors may render 12-step programs less effective for Native Americans, some studies have contradicted that assumption. One study, longitudinal in design, compared 12-step group attendance, attrition, and abstinence outcomes between urban Native Americans and White Americans [59]. The authors found no significant differences between meeting attendance and abstinence outcomes at 3-, 6-, and 9-month follow-ups. Decreased drinking intensity and increased abstinence was associated with greater meeting attendance for both groups. Interestingly, Native American participants were less likely to decrease meeting attendance. A more recent study relative to benefits experienced by urban Native Americans who attended AA also found benefit for those who attended 12-step groups relative to positive drinking outcomes [60].

Before concluding this section, the Wellbriety Movement deserves mention. It is described as "a sustainable grassroots movement that provides culturally based healing for the next seven generations of Indigenous people" [61]. Though an oversimplification, Wellbriety is an integration of traditional 12-step philosophy and Native cultural practices, such as the Medicine Wheel. Currently, an estimated 175 Wellbriety meetings exist in the U.S.

### **9.5 Adolescents and 12-step models**

As a cultural group, adolescents with SUDs likely have the strongest need for social connection, and one benefit of 12-step program involvement is just that mutual aid group communities provide instant access to sober social support. Multiple studies show that adolescents benefit from 12-step program involvement [5, 33, 62–64]. Because teens are more susceptible to peer influence and identification, they appear to benefit more from youth-focused 12-step groups, and like adults, teens seem to have improved SUD outcomes with increased participation in 12-step-activities [64, 65]. There are several barriers for adolescents noted in the literature: lack of transportation, resistance to the 12-steps, and the idea of powerlessness [65]. Kingston, Knight, Williams, and Gordon build on ideas set forth by Nash: adolescents may not only reject the notion of powerlessness but also the idea of a Higher Power [66]. Overall, however, there is substantial research to support the consideration of 12-step models for treating adolescents with SUDs [1, 2, 65, 67].

### **9.6 LGBTQ populations**

Given the fact that as a cultural group, sexual minorities have high rates of substance misuse and SUDs, it is surprising that so little research exists specific to this population and 12 step recovery programs. In fact, SAMHSA suggests this cultural group has about a 30% prevalence rate of SUDs [68]. As a cultural group, sexual minorities tend to be highly stigmatized, which may contribute to higher rates of SUDs. For this reason, 12-step groups specific to the LGBTQ population are steadily increasing. For clients wishing to attend an LGBTQ specific AA group, Gay and Lesbian AA (GaL-AA) is an excellent resource and provides a meeting list for all LGBTQ AA meetings nationwide [69]. Narcotics Anonymous does not have an equivalent resource, but an internet search will locate LGBTQ NA meetings.

### **9.7 Co-occurring disorders and 12-step groups**

Nearly half of people with an SUD also have a co-morbid psychiatric condition [70]. According to SAMHSA, people with SUDs are twice as likely than the general population to experience mood and anxiety disorders, and anti-social and conduct disorders [71]. Further, about 50% of those diagnosed with schizophrenia will develop an SUD over their lifetime. So, how do those with co-occurring disorders fare in 12-step programs? According to Project Match, those with more psychiatric severity did less well in 12-step approaches compared to cognitive behavioral interventions [27].

Mutual aid groups utilizing the 12-step framework and specific to those with co-occurring SUDs and mental health disorders are becoming more common. One such group, Double Trouble in Recovery (DTR), seems to provide an extra layer of comfort and emotional safety for members when sharing about both conditions, SUD, and mental illness [72–74]. Dual Recovery Anonymous (DRA) is a similar program that also follows the 12-steps. There are meetings located in each of the United States as well as Australia, Canada, Iceland, India, and New Zealand [75]; yet there is an absence of scholarly literature relative to its efficacy. The factors that appear to support recovery via 12-step affiliation for those with co-morbid conditions are identification, emotional safety, social support, and increased abstinence [72–74]. Because this group tends to have higher rates of relapse [76], referral to these specialty groups in addition to traditional 12-step groups is suggested.

### **10. Recommendations for integrating 12-step mutual aid programs**

With such a strong literature supporting the efficacy of 12-step programs for individuals with SUDs, inclusion of 12-step approaches in the menu of therapeutic options for clients is warranted. From their comprehensive review on Narcotics Anonymous, White and colleagues underscore three salient findings [2]:


### **10.1 Eight recommendations for integrating 12-step approaches**


### **11. Conclusion**

As the chapter closes, it ends where it began, with the most rigorous scientific studies to date, and the main findings are presented here. Kelley and colleagues [1] examined 12-step mutual aid groups and professional therapeutic models based on 12-step philosophy, such as Twelve Step Facilitation (TSF), and their impact on SUD-related outcomes: "abstinence, reduced drinking intensity, reduced alcoholrelated consequences, alcohol addiction severity, and healthcare cost offset" [1], p. 1. Twenty-seven studies and 10,536 study participants are included in the review.

The main findings for manualized AA/TSF intervention groups follow. Compared to the clinical intervention groups (e.g., CBT), AA/TSF participants demonstrated higher rates of complete abstinence, and this effect held over time. Further, AA/TSF interventions performed equally to the clinical intervention relative to percentage of days abstinent, but at 24 months performed better. AA/TSF appears to be equally effective to comparison groups in terms of longest period of abstinence. Another equal comparison was shown regarding intensity of drinking and number of drinks per drinking day. For alcohol-related consequences, AA/TSF does just as well as comparison groups, and may also perform equally in terms of reducing alcohol use severity, with one study showing better outcomes for AA/TSF.

Findings for non-manualized 12-step interventions are just as good. At 3 to 9 months follow-up, AA/TSF appears to perform as well as comparison groups in terms of the proportion of individuals completely abstinent but may perform

### *Revisiting 12-Step Approaches: An Evidence-Based Perspective DOI: http://dx.doi.org/10.5772/intechopen.95985*

slightly better than the clinical intervention for percentage of days abstinent. Regarding drinking intensity and percentage of heavy drinking days, AA/TSF also performed as well as the clinical intervention.

The review conducted by White and colleagues asked, "what is known about Narcotics Anonymous from the standpoint of science?" [2], p. 3. Included in their review were 232 studies. Though the scientific literature on NA needs more rigorous and methodologically sound study, so far it appears to mirror the evidence of AA's efficacy. Researchers from this review concluded that participation in NA contributes to increased abstinence and decreased substance use. Physical, mental, and spiritual health is improved, and improvement in overall social functioning seems to occur for many members. Decreased healthcare costs, increased selfesteem, improved coping, increased pro-recovery social networks, and decreased depression and anxiety are also benefits experienced by some NA members. Additionally, participation in activities such as reading NA literature, working the steps, service, and sponsorship appear to extend the benefits. According to the review, diverse sub-groups of people with SUDs may also benefit from NA; in particular, people of color, women, adolescents, and those with co-occurring mental health conditions.

The evidence for the efficacy of 12-step interventions is compelling. Not only is the research compelling, but 12-step programs also have an interesting history. Millions of individuals have experienced addiction recovery through 12-step pathways and have intimately experienced its transformational power. Organizations are unsustainable without leaders, structure, organization, funding, profits, or grants. Yet, the 12 traditions include ideas such as these: the program should have no leaders, no initiation dues, or fees; the program should remain forever non-professional; and, the program ought never be organized. Even so, and for over 85 years, 12-step programs across the globe have helped millions of people achieve recovery. It is unfathomable the 12-step movement has thrived without a traditional organizational structure. The 12-step organizational structure is built on spiritual principles, 12-steps, and the fundamental idea of one addict/alcoholic helping another. The 12-step movement revolutionized professional treatment services and has been tested across numerous populations. Scientific literature consistently demonstrates 12-step interventions to be equal in efficacy compared to common evidence-based models, and sometimes they perform even better than the intervention for which they are compared. 12-step groups can serve as an adjunctive service to professional addiction treatment to extend treatment benefits; and for some, 12-step groups may be the primary mode of intervention. In addition to its demonstrated efficacy, 12-step meetings are abundant, making accessibility a minimal concern. Finally, because 12-step meetings are free, it is quite costeffective. In closing, clinicians should consider adding 12-step interventions to their clinical toolbox if they have not already done so. The science is out.

*Addictions - Diagnosis and Treatment*

### **Author details**

Dorothy Greene East Tennessee State University, Johnson City Tennessee, United States

\*Address all correspondence to: greeneds@etsu.edu

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Revisiting 12-Step Approaches: An Evidence-Based Perspective DOI: http://dx.doi.org/10.5772/intechopen.95985*

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### **Chapter 6**

## Assessment and Treatment of Addictions in Community Corrections

*Jacob D. Armstrong, Amy Bauman, Krystal J. Moroney and C. Brendan Clark*

### **Abstract**

This chapter discusses the treatment of substance use disorders within community corrections populations. The history of substance abuse treatment within correctional populations is outlined to provide context for the current diversion and rehabilitation models currently in use. Common systems where treatment is provided such as mental health court, drug court, and TASC are described. Common forms of therapy including Cognitive Behavioral Therapy, Mindfulness, social skills training, pharmacotherapy, and smoking cessation are discussed. This chapter focuses on their effectiveness as well as how these forms of therapy differ in community corrections as compared to other populations. Finally, recommendations and future directions for research are provided.

**Keywords:** Community Corrections, Criminal Justice, TASC, Drug Court, Mental Health Court

### **1. Introduction**

The United States (U.S.) incarcerates a higher proportion of its citizens than any other country in the world [1], approximately two-thirds of whom are supervised under community corrections [2]. In the substance abuse and mental health literatures, community corrections is a broadly inclusive term intended to categorize a variety of supervision models where individuals are subjected to legal supervision while being permitted to remain in the community. Both the BJS [3] and the National Institute of Justice [4] restrict definitions of community corrections to individuals under probation (i.e., being supervised in the community for a crime that does not warrant detainment in jail or prison) or parole (i.e., community supervision post detainment before one's sentence has expired). In the grey literature, this term is much more loosely defined, varies considerably across jurisdictions, and may be restricted to defining specific models that are not considered parole or probation. For the purposes of this chapter, community corrections will refer to any criminal offender being supervised in the community outside of jail or prison. Those supervised under community corrections tend to be low-risk offenders (i.e., drug offenders) and are often awaiting trial and sentencing. Individuals supervised under community corrections as well as the correctional population in general tend to have high rates of substance misuse [5], mental illness [6, 7],

traumatic brain injury [8], and suicidality [9]. These multiple comorbidities likely contribute to the high rates of recidivism (i.e., 45-65%) observed for correctional populations [10, 11]. Historically, the correctional system has not emphasized rehabilitation but has instead focused on longer and more severe sentencing in an effort to deter future crime. The increased incarceration rates and high recidivism rates are evidence that this approach has not worked. Over the past twenty years, the U.S. correctional system has shifted its focus toward a diversion rehabilitation model. The goals of this model are to identify the needs of low-risk offenders and provide treatment while diverting them from jail and prison into community supervision. Virtually all treatment models focus on addiction due to the high rates of substance misuse observed in these populations, but different treatment modalities also include psychotherapy, social skill training, vocational rehabilitation, and education, all of which have been shown to reduce crime and recidivism [12–14]. These efforts have been largely successful and have led to reductions in the recidivism rate for the first time in decades [2]. The goal of this chapter is to explain how treatment in corrections has evolved over time and what models and techniques are being used today. We will explain the more popular models of service delivery in community-based supervision (i.e., TASC, Drug Court, Mental Health Court) as well as different therapies utilized in community corrections which have been either popularly employed (Cognitive Behavioral Therapy, mindfulness, Social Skills training) or call for increased use (pharmacotherapy, smoking cessation).

### **2. History of substance abuse treatment in corrections**

Historically, the U.S. government's approach to reducing illicit substance abuse has been to impose harsher sentencing while offering minimal treatment opportunities to the incarcerated. Harsher and more severe sentencing was enacted to deter future crime. More prominent examples of such legislation include Nixon's "war on drugs," the zero tolerance policies of the 1980s, and the three strikes laws of the 1990s. Collectively, these and similar laws led to higher conviction rates as well as longer and mandatory sentencing requirements for substance offenders [15]. Starting in the early 1990s, crime, especially violent crime, began to decrease [16]; however, the arrest and conviction rates for drug offenses continued to increase. These rates remained high for years and propped up a continually increasing incarceration rate that remains high to this day [17]. These steadily increasing incarceration rates for substance-related offenses indicate that these policies were not effective at deterring future crime; however, lawmakers repeatedly doubled down on these efforts to impose harsher laws. Conversely, as sentencing was increased for substance related offenders, minimal funding was provided for treatment efforts aimed at rehabilitating these offenders. Early treatment efforts such as Transcendental Meditation showed promise, but these efforts were poorly funded. A prominent review was published in 1974 examining the effectiveness of different treatment modalities on incarcerated populations, and the author famously concluded that "nothing works" [18]. The article was credited with debunking the idea that criminals could be rehabilitated and had a tremendous impact not just on the scientific literature, but on policy makers and the correctional system itself for the next 25 years [19]. Thus, individuals abusing substances were being arrested at higher and higher rates, no genuine efforts were made to rehabilitate these offenders during most of the 20th century.

Today diversion and rehabilitation models, which divert individuals from jail and prison and provide a variety of therapies, are reducing recidivism for the first time in decades. The most influential and prominent of which is the

### *Assessment and Treatment of Addictions in Community Corrections DOI: http://dx.doi.org/10.5772/intechopen.96770*

Risk-Need-Responsivity (RNR) model [12]. The RNR model was developed in Canada, but due to its success it was quickly adapted across the U.S. and has become the dominant model used in community corrections to reduce recidivism. The RNR model has three main components: identifying individuals who could benefit from services, identifying the needs of the offender, and tailoring treatment to meet those needs. The model assesses eight factors, which have been strongly linked to criminal behavior and recidivism (i.e., antisocial behavior, antisocial personality patterns, procriminal condition, antisocial associates, substance abuse, family/ marital relationships, school/work, and lack of prosocial recreational activities), then diverts individuals to the appropriate level of community-based supervision and prescribes treatment recommendations based on these factors. The treatment recommendations provided by the model vary from program to program, but therapy tends to be far more comprehensive than typical psychotherapies due largely to the severity of symptoms and multiple comorbidities typically observed in criminal justice populations. These needs are assessed through the Level of Service Inventory–Revised (LSI-R; [20]), a standardized measure which provides specific recommendations. The RNR model has grown in popularity since its inception and remains the most popular and influential diversion rehabilitation model today.

### **3. Models of Treatment Delivery**

The TASC program, originally known as "Treatment alternatives to street crime," was developed in 1972 by the federal government to address the connection between drug abuse and criminal activity [21]. Today, the acronym represents a variety of different programs. The original goals of TASC were to decrease the possession, manufacturing, and distribution of illegal drugs and to derail the cycle of drug dependent individuals committing "street crimes" by diverting offenders with substance use issues to the appropriate community-based treatment programs [21]. Today TASC programs, known by several names including Treatment Accountability for Safer Communities and Treatment Alternatives for Safe Communities, represent a variety of diverse and tailored services based on the needs of client populations and surrounding communities, but each maintains the same overarching goals. TASC is not a direct treatment provider but instead acts as a link between the criminal justice system and community-based treatment programs. This separation of corrections and treatment maintains the confidentiality of the client and is a key component in promoting honesty, trust, and recovery. TASC's common objectives are to assess offenders' need for substance abuse treatment (regardless of their crime), direct qualifying individuals to the appropriate treatment programs and ancillary services, and to monitor offenders' progress throughout the program. In addition to substance abuse treatment, offenders in the TASC program may be referred to programs that aid in providing mental health treatment, medical treatment, housing assistance, education, and vocational skills training [22]. Federal funding for TASC programs was largely reduced in the 1980s due to the rising popularity of substances, such as cocaine, for which there were few treatment programs at the time [13]. Currently, most programs rely on local funds, grants, fees, and donations.

Evaluations of the TASC program have shown it to be a cost-effective alternative to incarceration [13] and largely successful in effectively identifying offenders in need of substance abuse treatment and making appropriate referrals. Offenders enrolled in TASC programs are more likely to complete substance abuse treatment compared to those with no legal involvement [23] and remain in the community longer without rearrest compared to offenders who drop out [22, 24]. Successful

completion of TASC may require completion of ancillary service programs unique to each offender (e.g., GED, vocational rehabilitation, mental health treatment) in addition to substance abuse treatment. TASC has been influential in the development of similar programs for offenders throughout the U.S. [23, 25], with numerous adapted programs, as well as distinct programs that provide comparable services, such as "Breaking the Cycle" (BTC), "Drug Treatment Alternatives to Prison" (DTAP), and California's "Proposition 36" [26].

Although TASC has been successful in linking offenders with appropriate interventions and overall reducing recidivism, there remain populations of offenders with substance abuse issues for which TASC has been less successful. Individuals who experience more instability in their living conditions and employment, as well as marital instability at the beginning of treatment tend to fail in TASC programs more rapidly, as do those who were arrested for non-drug related crimes [9]. Drug of choice is also impactful, in that offenders who abuse more addictive substances such as crack/cocaine and opioids tend to fail the TASC program more quickly, and those who do complete the program are quicker to be rearrested [9, 26]. Although TASC is available to offenders arrested for a variety of offenses, it might be most valuable for offenders arrested for drug crimes. Additionally, given that instability and preferred substances also impact the likelihood of success, TASC programs might consider implementing aftercare, which has shown to reduce the likelihood of substance use, relapse, and rearrest beyond treatment [27].

Drug court is a term typically used to refer to courtrooms dedicated solely to providing judicially-monitored and enforced drug treatment, testing, and services for non-violent drug offenders. The first drug court was established in 1989, in Miami, Florida, to address the high rates of substance abuse related recidivism observed by judges in Dade County. By 1997, there were approximately 275 jurisdictions across the country with operating drug courts [28]. By the late 1990's university and government researchers began publishing the first efficacy and effectiveness studies on the drug court model more broadly [29–32]. In one such critical review, Dr. Belenko summarized research on the model as follows:

*"The study found drug courts provide closer, more comprehensive supervision and much more frequent drug testing and monitoring during the program, than other forms of community supervision. More importantly, drug use and criminal behavior are substantially reduced while offenders are participating in drug court ([8], p. 2)."*

Drug offenders are selected for participation in a drug court program by prosecutors based upon their eligibility (i.e., severity and nature of their crime) and typically participate for between 12 and 18 months. The drug court model emphasizes collaboration between the varying components of the criminal justice system (i.e., judge, prosecutor, defense attorney, probation official, etc.) and the substance abuse treatment system (i.e., mental healthcare providers, medical providers, social services, etc.) in order to promote prosocial and treatment seeking behavior and reduce recidivism [33]. The successes of the first drug court program led to the proliferation of drug courts in the United States. In 1999, there were over 425 in operation across the country [34]. In 2020, the U.S. Department of Justice places the approximate number of drug courts in the United States at over 3000 (See [35]).

Like modern TASC programs, drug court programs are united by a key set of goals. There is a high degree of heterogeneity in drug court components and practices, as their operation is not only subject to differences in state laws and state funding, but also the preferences of the individual judges presiding over each drug

court. In 1997, a report on drug courts compiled by the U.S. General Accounting Office concluded that, in addition to the huge variability observed among bona fide drug courts, some programs were observed to be drug courts only by name, displaying no emphasis on judicial oversight of treatment delivery observed in the traditional drug courts described in this chapter. The variance in adherence to the drug court model represents a major limitation in the current drug court literature [36, 37].

In 1997, the Drug Court Standards Committee, part of the National Association of Drug Court Professionals, published a document detailing the ten key components of drug court. These key components concern early identification of eligible participants, referral to treatment and community services, ongoing participation in drug court status hearings, required completion of substance abuse treatment, regular random drug screening, positive reinforcement for continued compliance, rapid sanctions for noncompliance, and typically dismissal of charges upon completion of the program [38]. Due to differences in court structure, community context, and availability of local resources, drug courts differ in their adherence to these key components [39].

The literature has demonstrated drug courts to be significantly more effective at breaking the cycle of recidivism seen in substance abuse populations than traditional courts, with an average effect of reducing recidivism ranging from 50% to 38% [40, 41]. However, the literature has also demonstrated that not all drug courts exhibit the same levels of success. The results of studies examining the effectiveness of DWI courts and juvenile courts have been mixed, and structural components of drug court procedure, such as how participants are admitted to the court, have also shown to have an impact. There is also evidence suggesting the drug court model is more effective for participants with certain individual characteristics, such as being older and more educated [42]. Current research focuses on examining drug court outcomes utilizing disparate models in service of differing populations in order to identify which components of the drug court model are responsible for successful outcomes and how individual characteristics may impact successful completion of the program [39].

In addition to TASC programs and drug courts, mental health courts also serve as a system where offenders within community corrections with substance use issues may receive services. Popularized in the 1990s, mental health courts are part of the court system that intends to divert people with mental illness from prisons and jails by using a model that is problem-solving oriented as opposed to punishment oriented. Beginning in the 1960s, state hospitals began closing due to poor treatment within facilities. Government budget cuts of community-based mental health care resulted in numerous individuals with mental illness not receiving necessary treatment and instead being retained in prisons and jails. Mental health courts are, in part, a response to the overrepresentation of offenders with mental illness within correctional facilities. There is significant comorbidity between externalizing disorders (e.g., drug use disorders), internalizing disorders (e.g., bipolar disorder), and criminal behavior within community corrections populations. Offenders with comorbid substance use and internalizing disorders are also at higher risk of reoffending should they remain untreated, further indicating a need for treatment options within the community. The amount of mental health courts in the U.S. has grown rapidly in the past few decades. Currently, there are more than 300 mental health courts for both juvenile and adult offenders with various levels of enrollment size and approved target participants (e.g., severely mentally ill, misdemeanor) [43]. Mental health courts divert offenders with mental illness to various be behavioral health services based on individual needs including individual therapy, group therapy, psychopharmacology, and assessment [44].

Mental health courts vary in how they are structured, as there is not a national standardized protocol [45], and offenders are usually given the choice of whether to participate. Mental health courts consist of a collaborative team made up of a judge, prosecution and defense attorneys, and a mental health professional. These courts may have incentives, such as a decreased sentence for compliance (e.g., adhering to the recommended mental health and addiction treatment, not recidivating). Compliance is rewarded and noncompliance is punished with jail time, reprimand by the judge, or other sanctions [45]. Court participants are most often monitored within the community by probation officers and mental health professionals who confirm attendance of appointments, while maintaining confidentiality of topics discussed within the mental health setting [45]. The mental health court protocol, though variable based on location, allows for a collaborative effort between the court and mental health professionals to create a treatment plan for offenders.

Mental health courts have been moderately effective in reducing recidivism rates and sentence lengths for offenders [46, 47]. There is some evidence that the mental health treatment through the courts is successful in symptom reduction and improvement of quality of life [46, 48, 49]. Graduation from mental health courts (i.e., receiving the full intervention) leads to more successful results (i.e., lower recidivism) compared to individuals who drop out early [46]. Overall, mental health courts have been successful in reducing symptoms and reducing recidivism rates for offenders who participate.

Mental health courts can at times be ineffective dependent on various offender characteristics and choices. Failure to reduce symptoms, choosing not to participate, negative termination, and sanctions indicate non-fulfillment of the mental health court goals. History of drug crimes and racial minority status is associated with choosing not to participate in mental health courts [50]. Negative termination through failure to complete treatment is associated with multiple diagnoses and stealing crimes, while lack of negative termination is associated with offenders with drug crimes choosing to participate, as well as increased number of scheduled court appearances; however, some evidence suggests offenders with recent drug history or drug crimes are more likely to be sanctioned by mental health courts [50, 51]. Lack of successful treatment outcomes may also result from viewing the mental health courts as coercive in nature [52]. Overall, various factors impact the success of mental health courts including demographic factors, crimes committed, and how the court is viewed by offenders.

### **4. Therapeutic methods**

There are multiple evidence-based therapeutic methods utilized in treating individuals in corrections populations (whether incarcerated or in community corrections). Due to the high levels of variability between individual TASC programs, drug courts, and mental health courts, there is no single therapeutic method which is consistently implemented across all treatment delivery systems. Further, the difficulty in assessing community corrections populations (lack of control group availability, barriers to data collection, concerns regarding treatment fidelity, etc.) limits the body of evidence supporting the use of evidence-based treatments for use specifically in community corrections. For these reasons, this section will focus on evidence-based treatments which are commonly utilized in corrections populations more broadly, and which address presenting problems believed to be relevant to community corrections populations. These include cognitive behavioral therapies, mindfulness therapies, integrative therapies, social skills training, psychopharmacology, and smoking cessation treatments.

### **4.1 Cognitive behavioral therapies**

Cognitive Behavioral Therapy (CBT) is an umbrella term for diverse psychological treatments which share some common elements. CBT treatments have shown to be effective for treating a range of psychological disorders and presenting problems. At their core, treatments typically included under the term CBT operate under a theoretical model with roots in behaviorism (focusing on external behaviors), cognitive theory (emphasizing the importance of internal behaviors/thoughts), or both. Many CBT approaches acknowledge that thinking and behavior are interconnected and both play a role in the development of psychological problems. While there are various manualized treatments for different presenting problems, treatment packages rooted in CBT usually address learned patterns of maladaptive behavior as well as unhelpful or distorted thinking. Patients receiving CBT typically learn more adaptive ways of thinking and behaving, thereby improving their coping skills and resilience, which contributes to symptom reduction and improving the effectiveness of their behavior.

In settings where both criminological and psychological outcomes are targets of CBT treatment, this model has been adapted to address the patterns of thinking and behavior which are believed to contribute to criminal justice involvement. CBT treatments adapted for this purpose have shown to be highly effective in a variety of contexts. Barnes, Hyatt, and Sherman's [53] evaluation of a 14-week CBT intervention called "*Choosing to Think, Thinking to Choose*", designed specifically for individuals in community corrections settings at high risk of recidivism, demonstrated that participants with a history of nonviolent offending were significantly less likely to re-offend. A 16-week CBT program treating community corrections offenders with a repeated history of driving while intoxicated (DWI) was demonstrated to be significantly more effective than treatment-as-usual when recidivism was assessed during a three-year follow-up, thus providing evidence that CBT can be effective in reducing recidivism related to presenting problems which have historically been extremely challenging to treat [54].

A review of CBT's use in corrections populations, written by Milkman and Wanberg [55], identifies six treatments as being the most prominent for use with individuals in "correctional institutions, community corrections centers, and outpatient programs serving probation and parole clients" (p. xi): Aggression Replacement Training (ART), Criminal Conduct and Substance Abuse Treatment: Strategies for Self-Improvement and Change (SSC), Moral Reconation Therapy (MRT), Reasoning and Rehabilitation (R&R), Relapse Prevention Therapy (RPT), and Thinking for a Change (T4C). Milkman and Wanberg identify four primary goals that all of these therapies have in common: each attempts to assist individuals in (1) identifying the problems which contributed to their conflict with authorities, (2) identifying life goals, (3) identifying prosocial solutions to the problems conflicting with goals, and (4) putting these solutions into practice. **Table 1** provides a summary of these approaches:

CBT has accumulated significant empirical support for its effectiveness in criminal justice populations and is indicated for use with both juvenile and adult offenders. A meta-analysis of 69 research studies on the impact of CBT in a variety of criminal justice settings, including prison, jail, probation, and parole settings, from 1968 through 1996 found CBT treatment to be significantly more effective in reducing recidivism than solely behavioral treatments [61]. Another meta-analysis of 58 studies conducted between 1980 and 2004 found, on average, participants who received CBT treatment were over one and a half times as likely to remain rearrest and reincarceration free at 12-month follow-up than control participants [62]. Wilson, Bouffard, and MacKenzie [63] analyzed 20 studies conducted between


### **Table 1.**

*This table provides a summary of the most wildly used and emphatically supported Cognitive Behavioral Therapies used in corrections.*

1988 and 1999 and found that CBT treatment groups experienced significantly less recidivism than control groups, resulting in an overall decrease in recidivism by 8-16 percentage points. In addition to the broad support for the effectiveness of CBT treatments, meta-analyses have also provided support for the following claims: (1) CBT treatment appears to be more effective at reducing rearrest and reincarceration for moderate to high-risk offenders than for low risk offenders [62, 64]; (2) both CBT treatments emphasizing cognitive skills/cognitive restructuring and approaches emphasizing moral teachings and reasoning significantly decreased recidivism [63]; (3) CBT programming quality and dosage (measured in hours of treatment delivered rather than amount of time between first and last session) increase the effect size of treatment [62, 65].

*Assessment and Treatment of Addictions in Community Corrections DOI: http://dx.doi.org/10.5772/intechopen.96770*

Multiple studies have reinforced the importance of increased treatment dosage when utilizing CBT in criminal justice populations. A meta-analysis of 200 studies conducted between 1950 and 1995 with criminal justice samples found that a minimum of 100 hours of treatment was needed to reduce recidivism for juvenile offenders and suggested many programs may utilize effective treatments and technology but fail to reduce recidivism due to a lack of resources needed to provide necessary treatment dosages [66]. Based upon this earlier work, Sperber et al. [67] conducted a study of 689 adult male offenders successfully discharged from a Community-Based Correctional Facility to investigate the impact of dosage on recidivism. The results of this study further support the importance of providing a higher level of treatment dosage to high-risk offenders: the difference in recidivism for high-risk offenders was 24 percentage points between medium dosage (100-199 hours of treatment) and high dosage (200+ hours of treatment). In a replication of the Sperber [67] study, Markarios et al. [68] found the observed relationship between dosage and recidivism to be moderated by risk. This re-emphasized the importance of providing high doses of treatment to high-risk offenders, but also introduced the first evidence that high doses of treatment may increase rates of recidivism for low-risk offenders [68]. This suggests that limited resources may be allocated differently depending upon the risk level of the individual, possibly improving outcomes for both high-risk and low-risk offenders.

### **4.2 Mindfulness**

Although mindfulness has existed within religious and spiritual traditions which long predate the study of psychology, it is only relatively recently that mindfulness practices have been integrated into clinical psychological practice and subjected to empirical tests [69]. Cognitive behavioral therapies rooted in providing patients with psychoeducation and skills training related to contemplative practices (practices which broadly fall under the umbrella of mindfulness) have been growing in influence and popularity within clinical psychology since Jon Kabat-Zinn developed Mindfulness Based Stress Reduction (MBSR) in the late 1980s and early 1990s [70]. In 1990, Kabat-Zinn published *Full Catastrophe Living*, a book introducing his landmark approach to mindfulness-based treatment, in which he defined mindfulness as "Paying attention in a particular way: on purpose, in the present moment, nonjudgmentally" [71]. In the 30 years since, growing interest in mindfulness-based therapies led to the development of multiple therapies including Mindfulness-Based Cognitive Therapy (MBCT), Mindfulness-Based Relapse Prevention (MBRP), and Metacognitive Therapy (MCT). Further evidence-based treatments have emerged which, while not exclusively mindfulness-based, integrate mindfulness-based processes into the broader cognitive behavioral therapy model to promote positive behavioral changes. Two of the most well-known of these integrative approaches are Dialectical Behavior Therapy (DBT) and Acceptance and Commitment Therapy (ACT).

Within both mindfulness-based and integrative treatments, mindfulness is utilized as a teachable skill to improve an individual's awareness of the present moment. This increased awareness of the present is purported to increase the person's ability to recognize both the salient features of their environment and how they are reacting to that environment in the moment. Mindfulness as a component of therapeutic treatment has been demonstrated to improve behavioral regulation, decrease emotional reactivity as well as psychological symptoms, and lead to increases in subjective well-being [72]. In the context of relapse prevention or emotion regulation, mindfulness skills are meant to increase the likelihood that an

individual will notice and attend to internal stimuli (thoughts, emotions, cravings, physical sensations) and external stimuli (environments contributing to or worsening the problem), signaling the need to deploy behavioral regulation and coping strategies. This is a particularly salient skill for individuals in community corrections, as promoting increased self-regulation is an important component of treatment focused on rehabilitation [73].

Both mindfulness-based approaches and integrative approaches have a broad base of support for diverse presenting problems, the scope of which is beyond this chapter. However, there are specific uses for these treatments which have a more direct bearing on the treatment of presenting problems relevant to community corrections populations. Mindfulness-based treatments more broadly defined have modest evidence supporting their use in the treatment of mood disorders, chronic pain, and substance use disorders [74, 75]. MBRP in particular appears promising for the treatment of substance use disorders; early evidence comparing the outcomes of cognitively-based RPT to MBRP at 12-month follow-up suggests MBRP may be more effective in the long-term, showing reduced drug use and heavy drinking [76, 77].

Marsha Linehan [78] developed DBT, originally published under the title *Cognitive Behavioral Treatment of Borderline Personality Disorder*, as a treatment modality for chronically suicidal adults. Since its publication, DBT has accumulated strong research support for the treatment of Borderline Personality Disorder [79–81], and it is used in a variety of contexts to provide psychoeducation and skills training to address many of the same presenting problems as the CBT treatments discussed earlier; modules include mindfulness, interpersonal effectiveness training, distress tolerance, and emotion regulation [82].

In a review of transdiagnostic applications for DBT treatment, Ritschel et al. [82] describe the overall goals of DBT-based substance abuse treatment as:


There appears to be a gap in the literature specifically linking the use of DBT with community corrections populations. For example, a review of literature supporting the use of DBT in forensic settings found only 2 out of the 19 studies sampled forensic outpatient populations; of these, one was a feasibility study not reporting outcome data [83]. DBT's effectiveness, however, has been demonstrated for clients in forensic settings more generally and with mental health problems relevant to community corrections populations such as depression, substance use disorders, aggression, and violence [80, 83–85].

Although ACT was originally developed under the moniker Comprehensive Distancing, it emerged in its current form in the late 1990s [86]. ACT emphasizes identifying both a clients' values (what gives their life meaning, purpose, and vitality), as well as how their behavior is either bringing them closer to or farther from their values. As an integrative treatment, ACT also has marked similarities to the CBT treatments discussed earlier, with an emphasis on helping clients notice and identify their own thoughts and emotions, as well as promoting overall coping skills and the workability of chosen behaviors.

*Assessment and Treatment of Addictions in Community Corrections DOI: http://dx.doi.org/10.5772/intechopen.96770*

Since its publication, ACT has accumulated a significant body of evidence supporting its use in the treatment of a variety of disorders relevant to corrections settings. The use of ACT to improve willingness of drug and alcohol counselors to learn and apply evidence-based pharmacotherapy has been indicated; this is an important intervention given the stigmatization of pharmacotherapy in corrections settings despite its effectiveness in treating presenting problems such as substance use, stress, smoking cessation, chronic pain, and depression [87–89]. Similar to the literature surrounding the use of DBT, there is currently a gap in the literature surrounding ACT's use specifically with community corrections populations. However, an overview of the approach's applications in incarcerated populations is available in *ACT for the Incarcerated*, within the *Forensic CBT: A Handbook for Clinical Practice* [90].

### **4.3 Social skills training**

Social skills training is a form of behavioral training and is defined as improving social relationships by building both verbal and nonverbal interpersonal skills. Originally created in the 1970s, social skills training was designed to increase socially acceptable skills, improve interpersonal skills (e.g., cooperation, empathy), and decrease socially unacceptable and harmful behaviors (e.g., aggression, exploitation) [91]. Social skills training has been used for a wide variety of psychological disorders in the general population: it has been used with children, people with schizophrenia, people with social anxiety disorder, and people with autism (e.g., [91–94]). Overall, social skills training has been used widely to increase social competence across many populations. Presentation of this therapy does not differ substantially in correctional populations; however, in community corrections, the major targets of treatment include assertiveness training, active listening, and learning to read non-verbal communication cues. These skills are taught because deficits in these areas have been shown to be precursors to aggression and conflict in this population.

Due to the high rates of comorbidity in community corrections, social skills training is often used as a supplement to other therapies, such as cognitive-behavioral therapy, and is rarely used in isolation. Social skills training begins by identifying an individual's social skills deficits and working with the individual based on their personal goals and needs [95, 96]. After goals are set, people are given psychoeducation about the social skill that is being targeted, including why it is important to learn [95, 96]. The social skills are then modelled by the therapist and practiced though role-playing within sessions [95, 96]. Use and practice of the behavior is then reinforced and given corrective feedback by the therapist. Homework assignments are also used to help generalize the skills to the clients' other relationships. In summary, social skills training is a multi-step process to create effective social skills based off an individual's needs and is adjusted based off an individual's social growth.

Social skills training has been successfully used in corrections populations as a part of treatment protocols when working with offenders. Studies indicate there are deficiencies in offenders' social skills and competence, including a lack of empathy for others, poor interpretation of social cues, and deficits in interpersonal intimacy (particularly with sex offenders) [97–99]. These social skills deficits increase the likelihood of participation in antisocial behavior. Social skills training in offender populations often focuses on how to give positive feedback and negative feedback, as well as accepting negative feedback [100, 101]. Skills addressed also include social problem-solving, recognizing non-verbal cues in order to avoid misattribution of hostile intent, and improving one's ability to reject pressure from peers to use illicit drugs or commit crimes [100–102]. Overall, social skills training with offenders can have multiple learning goals dependent upon offender-specific needs.

Social skills deficits are especially notable in sex offenders, juvenile offenders, and offenders with severe mental illness or comorbid mental illnesses [97, 102]. These populations have been popular targets for social skills training due to empathetic deficits and low functioning upon re-entry from prison. It is important to target these low functioning offenders in order achieve adequate social support upon reentry into the community [102]. Targeting of these populations in research allows for therapists to understand what populations are most important to target with supplemental social skills training.

Research on the effectiveness of social skills training has provided mixed results for corrections populations. There are concerns as to whether social skills training, when presented in isolation, has any notable impact on recidivism levels and other criminogenic outcomes, with most studies finding social skills training to have similar recidivism levels to treatment as usual or control groups [61, 103]. Some findings indicate social skills training has been successful in improving self-esteem and social competence for both sex offenders and general population offenders [103, 104]. Participants in social skills training also indicate a self-reported reduction in social problems and improved responses on role playing measures [105, 106]. Overall, it appears social skills training alone has little impact upon criminogenic outcomes but likely creates personal successes for offenders.

### **4.4 Pharmacotherapy**

When substance abuse interventions are supplemented by pharmacotherapy, it is typically referred to in the literature as medication assisted treatment (MAT). Many of the studies conducted on the effectiveness and utilization of MAT in criminal justice populations have focused on the treatment of opioid and alcohol use disorders, given the high prevalence of these disorders in the U.S. corrections and community corrections populations [107]. Typical pharmacological treatment of alcohol use disorder involves the use of drugs disulfiram and naltrexone, while opioid use disorder involves use of methadone, buprenorphine, and naltrexone [108, 109].

Disulfiram has been FDA approved for the treatment of alcohol dependence for nearly 70 years, although clinical trials examining its effectiveness have shown mixed results. When taking disulfiram, patients typically experience strong negative physical reactions to consuming alcohol, reducing alcohol consumption and prolonging remission, but the drug is easily discontinued and difficulties in maintaining medication adherence have historically limited its effectiveness [110, 111]. In 1994, naltrexone, an opioid antagonist, was approved by the FDA for treating patients with alcohol dependency. A review of 50 randomized clinical trials found that naltrexone treatment's effect on heavy drinking was moderate, on average reducing treatment groups' risk of continued heavy drinking to 83% of the risk observed in placebo groups [112]. Overall, naltrexone has been found to be a safe and effective treatment for promoting controlled drinking behavior and reducing the risk of heavy drinking, but its effectiveness is also limited by low treatment adherence [113, 114]. Although treatment adherence is low with both of these medications, it appears the effectiveness of their treatment can be significantly increased by integrating patient monitoring strategies and compliance measurements into the treatment process, especially in combination with CBT [110, 115].

Pharmacotherapy for opioid use disorder is an effective adjunct treatment which reduces the likelihood of continued substance use, overdose, and recidivism in both incarcerated and community corrections participants [116, 117]. Naltrexone for opioid use is more commonly delivered in an injectable delayed release form, which has been demonstrated to significantly decrease opioid use, relapse, and overdose at

### *Assessment and Treatment of Addictions in Community Corrections DOI: http://dx.doi.org/10.5772/intechopen.96770*

6-month follow-up [118]. Methadone and buprenorphine maintenance treatments are both methods of treating opioid withdrawal and are used in MAT. Methadone appears to be more effective in MAT when introduced while incarcerated and continued on an outpatient basis in community corrections settings [119, 120]. Both medications appear to be roughly equally effective in their ability to significantly lower risk of continued use, relapse, re-arrest, or re-incarceration; however, buprenorphine patients were significantly less likely than methadone patients to voluntarily withdraw from treatment [121].

In spite of the evidence suggesting MAT's effectiveness in serving offenders with substance use disorders, it appears to be underutilized nationally. Robinson and Adinoff [122] point out that both patients and providers experience confusion surrounding the efficacy and effectiveness of pharmacotherapy for the treatment of people with substance use disorders. In the United States, in both adult and pediatric populations, it appears that misinformation and stigma contribute to underutilization by limiting the likelihood that providers will even prescribe pharmacotherapy for patients with substance use disorder [122–124]. A survey of 170 providers, working in diverse contexts, found that approximately 20% of providers never prescribed these medications [125].

A study reviewing policies and practices of 50 criminal justice agencies in the United States (across 14 states) found that 83% of prisons and jails surveyed reported offering MAT on a limited basis only (e.g., detoxification during withdrawal only, or for the maintenance of pregnant women experiencing withdrawal but not for offenders more broadly; [107]). A national survey of 103 drug courts found that approximately half of all drug courts responding to the survey had policies and procedures explicitly banning MAT [126]. Opposition to MAT (political, judicial, and administrative) for treating offenders with substance use disorders appears to play a significant role in the inconsistent use of MAT in corrections and community corrections settings, due to stigmatization and general lack of understanding [107, 127]. Traditional training has been found to be minimally effective in changing the attitudes of corrections staff and treatment providers opposed to MAT, and the development and deployment of targeted interventions addressing this issue is a recent focus of community corrections research [128, 129].

### **4.5 Smoking cessation**

Although tobacco is not an illicit substance and its use is not typically associated with committing serious or violent criminal offenses, there is substantial evidence suggesting smoking cessation treatment may positively impact treatment outcomes for other addictions by reducing overall substance use and increasing the likelihood of maintaining sobriety [130]. For example, individuals who quit smoking report reduced cravings for other stimulant drugs [131] and are less likely to experience future incidence of substance use disorders [132]. Further, smoking cessation treatment completed in conjunction with treatment for other addictions has shown to increase the likelihood of maintaining long-term abstinence from illicit drugs by 25% [133]. It has been hypothesized that successfully quitting smoking may facilitate changing other addiction-related habits. Unfortunately, despite widespread evidence of positive effects and virtually no reliable evidence of negative effects [130], smoking cessation treatment for substance addicted individuals has largely been neglected.

Over the past several decades, the proportion of cigarette smokers in the United States has steadily decreased to less than 16% [134]. However, smoking prevalence among individuals involved with the criminal justice system has remained consistently high (70-80%) constituting roughly 12% of all smokers in the U.S. [135].

Even individuals in the juvenile justice system smoke at a rate 40% greater than their peers in the general population [136]. Smoking remains a leading cause of preventable death and disability in the U.S., and individuals in the criminal justice system are at much greater risk for experiencing severe health conditions associated with smoking, including cardiovascular disease, cancer, circulatory and respiratory problems, kidney and liver problems, and diabetes, all of which may lead to premature death. Although the average age of individuals in the criminal justice system is in the mid-30's, many already report experiencing smoking-related illnesses and diseases. Further, individuals in community corrections are less likely to receive consistent medical attention to address such illnesses due to poverty and limited healthcare access encountered upon release.

The majority of prisons and jails across the country have banned smoking; however, almost all inmates released into community correctional supervision from smoke-free facilities resume smoking [137]. Widespread smoking bans in jails and prisons also limit the availability of smoking cessation treatment. Even when some forms of treatment are available, such as nicotine replacement, they are often priced so high that many inmates do not have access. Although smoking bans in correctional facilities may be a legitimate effort to aid in smoking cessation, being forced to stop smoking is not synonymous with quitting smoking, which may explain the high number of individuals released to community corrections who return to the habit.

Consequently, efforts to reduce smoking in criminal justice populations are primarily focused on community corrections, although the efforts have not been vast. Generally, smoking cessation treatment does not target criminal justice populations despite the high prevalence and associated health issues which are of great cost to the individuals and their communities. The few studies that have explored smoking cessation in criminal justice individuals have determined that more research is needed to understand the nuances associated with tailoring smoking cessation treatment to this population and its subgroups [135]. There is also an increased likelihood that those in the criminal justice system experience comorbid substance abuse issues, mental health issues, and poverty, all of which must be considered in determining the appropriateness and accessibility of treatment.

The interventions that have been studied in this population have, in some cases, been modified from traditional smoking cessation treatments, which vary widely. Some such interventions have shown to work well in certain subsets of the general population and poorly in others [138], which may further complicate the process of tailoring these treatments to individuals in community corrections. A common smoking cessation pharmacotherapy is Nicotine Replacement Therapy (NRT), which is intended to be used in place of tobacco products to relieve withdrawal symptoms and craving. When used in criminal justice populations, NRT has been successful in initiating smoking reduction even for individuals who were initially unmotivated to quit [139]. Varenicline is another leading pharmacological treatment that interferes with nicotine receptor stimulation and reduces craving. However, the cost is high and there is not presently a generic form, so it is likely not an easily accessible option for individuals in community corrections. Antidepressants such as nortriptyline and bupropion have also been utilized as smoking cessation pharmacotherapies and may be valuable for criminal justice involved individuals, as this population is at higher risk for experiencing mental illness, including mood disorders. Bupropion specifically has been shown to improve smoking cessation rates in community corrections individuals who take the medication reliably [140].

Some of the behavioral interventions utilized in smoking cessation treatment are adapted from broader therapies, such as Cognitive Behavioral Therapy (CBT),

### *Assessment and Treatment of Addictions in Community Corrections DOI: http://dx.doi.org/10.5772/intechopen.96770*

whereby individuals are taught to recognize specific circumstances that precede or trigger smoking and learn cognitive and behavioral strategies to effectively cope with those triggers. The WISE intervention (Working Inside for Smoking Elimination), which utilizes techniques from CBT and other empirically supported therapies, specifically targets inmates who are approaching discharge and has shown to reduce smoking relapse upon release from smoke-free prisons [141]. Mood Management (MM) Training was designed to prevent smoking relapse, and like CBT, it aims to identify triggers associated with smoking and to develop coping strategies. One study that adapted MM for a correctional population found it to be an effective smoking cessation treatment when combined with NRT [142]. One of the only known interventions that specifically targets smoking cessation in community corrections populations is DIMENSIONS: Tobacco Free Program, which was developed by Arkansas Community Correction (ACC) along with the University of Colorado's Behavioral Health & Wellness Program. The DIMENSIONS program is based on techniques and philosophy derived from tobacco cessation programs that target mental health populations and aims to provide holistic community-based support for individuals in community corrections. Results of the program are promising with the majority of individuals having exhibited decreased tobacco use after completing half the program, and those who completed the full program decreased tobacco use by at least 50% [143].

Along with a dearth of specifically targeted behavioral interventions, poverty and generally inadequate healthcare make even basic pharmacotherapies inaccessible for many individuals in community corrections. Unfortunately, lack of access to healthcare and negative attitudes about healthcare may contribute to exhibiting poor medication adherence, creating even more challenges in treatment. Medication adherence has shown to be the most powerful predictor of successful smoking cessation, and it is also a common issue in the community corrections population. However, individuals who have utilized pharmacological treatments in the past are more likely to succeed in subsequent cessation attempts [140]. Even short-term exposure to smoking cessation medication may be beneficial in increasing the likelihood of adherence in the future. Individuals who utilize smoking cessation medication in the presence of a treatment provider are also more likely to adhere to treatment even if the provider is minimally trained [144]. This is promising for individuals in community corrections, as they may not have consistent access to more highly trained professionals.

Smoking cessation treatment for individuals in community corrections is rife with challenges that impede success. Despite high rates of smoking in this population, as well as high interest in quitting, accessible interventions are sparse. Further research examining the effectiveness of certain interventions for individuals in community corrections, as well as methods of increasing accessibility, are certainly necessary. Future studies should also explore means of improving medication adherence to increase successful cessation. Regardless of differences in treatment effectiveness in certain subgroups, it is suspected that increasing adherence to medication will improve treatment effectiveness for the entire community corrections population.

### **5. Conclusions**

Historically, the treatment of substance use disorders in U.S. correctional populations has been slow to take hold. Traditional models of incarceration focused almost entirely on punitive sentencing with little afterthought devoted to rehabilitation efforts. These approaches failed to reduce recidivism. Diversion rehabilitation

models, particularly the Risk-Need-Responsivity model [12], which divert offenders from incarceration and provide tailored treatment in the community, have been shown to reduce recidivism rates both in research and practice. Popular implementations include TASC, Drug Court, and Mental Health Court, among others. Due to the high rates of substance abuse in these populations, most programs offer some form of substance abuse treatment. Different forms of Cognitive Behavioral Therapy (i.e., ART, SSC, MRT, R&R, RPT, and T4C) are the most commonly employed and likely have the most empirical support as well. Furthermore, substance abuse treatment in community corrections is typically complicated by high rates of comorbidity, as well as other factors such as poverty, unemployment, and inconsistent housing, which only serve to further complicate treatment [9]. As a result, these versions of therapy are often longer and more intensive than traditional forms of CBT. The cumulative product is an increased dosage and specificity of psychotherapy that had never been seen in U.S. corrections previously.

While increased substance abuse and mental health treatment are worthy of praise, especially considering the history of treatment in corrections, this same level of treatment would not be heralded as progress in a hospital or more controlled medical setting. There are multiple targets of treatment, such as traumatic brain injury and other organic issues that occur at a high base rate in both correctional and CC populations, and these diseases go almost wholly unaddressed [8, 145]. Furthermore, while the therapies employed in correction and CC specifically are comprehensive and span a multitude of presenting problems, there is a complete absence of dismantling studies to identify meaningful mechanisms of action. Furthermore, CBT based therapies are often supplemented by other forms of therapy, such as Mindfulness, social skills training, pharmacotherapy, or smoking cessation. The literature provides less support for using these other forms of therapy without some form of CBT. Therapies could likely be streamlined to focus more on the most meaningful components. Additionally, pharmacotherapy and smoking cessation can both have a positive impact on recovery but are highly underutilized in CC programs. The incorporation of treatment and therapy into the legal system has yielded very promising results, but these approaches are still in development and many have only come into existence over the past two decades. Future work needs to identify additional targets of treatment within this population, as well as streamline therapies to better emphasize the more important components.

A final component in need of change is continuity of care. The constitutional mandate to provide healthcare to prisoners does not extend to those supervised in the community. Transition from confinement back into the community is an extremely sensitive period with elevated homicide, relapse, and suicide rates [146, 147]. Furthermore, transitions from jail to CC and back to jail are often common for individuals who commit minor drug offenses, and this is especially true for individuals with limited criminal justice involvement. This period represents a window of opportunity for intervention, but coordination of treatment will require the cooperation of the treatment community and the legal system. Coordination at the national and/or state levels would likely be needed to standardize treatment and communication between jail and prison and CC providers as well as to provide consistent funding. This would likely come at considerable cost, yet the legal system in its current form was estimated to cost 182 billion in 2017 [148]. A more effective system better able to promote rehabilitation would certainly be better for offenders and may be more cost effective in the long run.

*Assessment and Treatment of Addictions in Community Corrections DOI: http://dx.doi.org/10.5772/intechopen.96770*

### **Author details**

Jacob D. Armstrong, Amy Bauman, Krystal J. Moroney and C. Brendan Clark\* Wichita State University, Wichita, United States

\*Address all correspondence to: c.brendan.clark@wichita.edu

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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[148] Equal Justice Initiative (2017). *Mass Incarceration Costs \$182 Billion Every Year, Without Adding Much to Public Safety*. Retrieved from: https://eji.org/news/massincarceration-costs-182-billionannually/

### **Chapter 7**

## Conceptualizing Drug Addiction and Chronic Pain through a Biopsychosocial Framework to Improve Therapeutic Strategies

*Zachary S. Harmon, Emily N. Welch and Christina L. Ruby*

### **Abstract**

The recent surge in opioid-related deaths has brought poor pain management practices to the forefront of our nation's collective consciousness. However, improving treatments for chronic pain, substance use disorders (SUD), and comorbid expression of both requires a better understanding of the pathophysiology involved in their development. In this chapter, the authors present the argument that chronic pain and SUD can be conceptualized similarly from a biopsychosocial perspective to inform a better approach to treatment. The authors describe the common neurobehavioral mechanisms of SUD and chronic pain, then discuss the efficacy of several psychotherapeutic methods employed to combat chronic pain, addiction, and related disorders. Such methods may contribute to positive health outcomes in managing chronic pain and curbing drug addiction by reducing the role of opioid analgesics for long-term pain management.

**Keywords:** addiction, substance use disorders, chronic pain, opioids, psychotherapy, cognitive behavioral therapy, mindfulness-based stress reduction, solution-focused brief psychotherapy, motivational interviewing

### **1. Introduction**

Over the past two decades, the rate of prescription drug misuse has been rapidly increasing worldwide, leading to a growing number of emergency department visits, hospitalizations, and overdose deaths. The National Safety Council reported that in 2017, it was more common to die of opioid overdose than in a car crash, and by 2018, drug overdose became the number 1 cause of unintentional death in the United States. The coronavirus pandemic has only exacerbated this situation [1]. Opioid analgesics have become the most commonly prescribed class of drugs in the United States [2] in part because approximately 100 million American adults suffer from chronic pain, more than those affected by heart disease, diabetes, and cancer combined [3]. The other major piece of this puzzle is that prescription opioids were misrepresented by pharmaceutical manufacturers as non-addictive, which led to widespread over-prescription of opioids for long-term chronic pain management. Although the addictive potential of oxycodone was recognized very early [4], very few studies have been conducted on this or other opioid painkillers. Recently, the

growing recognition that prescription opioids can be addictive has also led some doctors to over-correct the problem by not prescribing sufficient opioids to manage pain when it is appropriate, leaving patients to seek illegal sources or substances (e.g. heroin) to manage pain and physical withdrawal symptoms. These opposing but equally ill-informed prescription practices have culminated into a single outcome: an epidemic of opioid addiction and death in the United States.

From many different perspectives, chronic pain and substance use disorders (SUD) share a plethora of similarities and thus it is not surprising that they frequently occur in tandem, with either one preceding the other. Overall, the prevalence of chronic pain in individuals with SUD is estimated to be 27–87%, with individuals suffering from chronic pain 2-3X more likely to experience a SUD, and individuals that have a SUD 1.5 times more likely to experience chronic pain [5]. In people receiving an opioid prescription for long-term chronic pain treatment, 21–29% misuse the opioid medication and 8–12% develop an opioid use disorder (OUD) [6, 7], though some estimates are as high as 43%, with elevated risk for other substance-related disorders as well [5]. Some hypothesize that individuals self-medicate with drugs to manage the psychological aspects of pain [8, 9], while others suggest pre-existing physiological and psychological characteristics associated with OUD/SUD can be stimulated by a chronic pain condition [9, 10]. These hypotheses are not mutually exclusive, and draw attention to the fact that the relationship between chronic pain and SUD is difficult to disentangle, making it complicated to establish effective treatments.

As with many societal weaknesses exposed by the pandemic, SUD, particularly OUD, are flourishing and overdose deaths continue to rise [1]. This does not appear to be due solely to the disease itself, but rather the significant increase in life stress (e.g. job loss, social isolation, etc.) combined with lack of access to proper mental and physical health care. This illustrates well the central hypothesis we aim to present: that a biopsychosocial perspective of addiction and chronic pain, which incorporates factors from the societal to molecular levels, allows for a more thorough understanding of these disorders. We suggest that incorporating alternative therapeutic methods and reducing the role of opioid analgesics for long-term pain management may contribute to positive health outcomes in managing chronic pain, addiction, and comorbid expression of both.

### **2. Biopsychosocial approach to understanding health and disease**

As the name suggests, the biopsychosocial (BPS) model proposes that healthcare professionals use biological, psychological, behavioral, and social lenses to understand health and disease. Psychiatrist George Engel has been credited with the formulation, and call for action, that propelled the understanding of disease and illness past that of basic Renaissance philosophy and into an understanding not solely based in biological factors [11]. Engel introduced the BPS model as a contrast to the biomedical model of health and disease, which had long reigned supreme (and still predominates clinical practice in many fields). His model also contrasts with a purely environmental/ecological model, which holds a more holistic view of health, but may neglect the importance of biological influences. The BPS model incorporates the best of both worlds, recognizing that both nature and nurture are vitally important to health and disease. This new ideal formed the foundation for behavioral and psychological conceptualizations of health and medicine [12].

The BPS model has now become the leading one in conceptualizing many forms of illness, including chronic pain, although it continues to be underutilized in practice, particularly in acute medical and surgical fields of study that prioritize biomedical

### *Conceptualizing Drug Addiction and Chronic Pain through a Biopsychosocial Framework… DOI: http://dx.doi.org/10.5772/intechopen.95601*

views of disease and illness [13]. A large part of the problem in translating concept to practice is that the BPS model has minimal influence over provisional healthcare funding [13]. Critics of the BPS model claim that the diagnostic front would be marginalized by utilizing a threefold framework (although this had already been addressed by functional and practical analysis) [14, 15]. Biomedical model proponents suggest that the BPS model may promote a lack of focus, or that practitioners may misjudge other significant factors related to treatment, and therefore cause unintended harm to patients due to the complexity of the biopsychosocial approach and the negligence that may occur [14]. However, it is important to consider that harm can be associated with any models or frameworks, and that harm primarily results from misuse of models and failures to recognize limitations of those models [13].

The opioid epidemic is a profound and tragic illustration of the problems associated with the persistence of the biomedical model in many fields and countries (including the U.S.). This model has seen healthcare costs soar, while patient outcomes have fallen. A major cause of these failings is the lack of consideration of psychosocial factors in patients' lives, which can contribute greatly to overall health. Two recent Nature articles have drawn attention to the importance of social context - and the shortcomings of a biomedical-only approach - in relation to substance use. Hart (2017) argues that even conceptualizing addiction as a disease or disorder is not only inaccurate, but harmful, contributing to social injustice in the form of racism and socioeconomic marginalization [16]. He further takes issue with the exaggerated value placed upon neuroscientific evidence. Relatedly, Heilig et al. (2016) attributes the relative lack of addiction treatment advancements to the glaring omission of social context in neuroscience, and calls on the field to elucidate the impacts of social exclusion and marginalization on the development of drug-seeking and consumption [17]. Although these articles focus on addiction, the principles apply to chronic pain as well.

While solving the socioeconomic disparities that contribute to illness will be a formidable task that lies outside the scope of the current chapter, the authors argue that a biopsychosocial approach to addiction and chronic pain is superior to a strictly biomedical one, and that it has the potential to counteract the problems of a biomedical-only view. As noted above, the biomedical paradigm is struggling to confront rising healthcare costs and poor, patient-reported outcomes [13]. The BPS model, prided on person-centered care, can alleviate this financial and diagnostic burden, particularly as it relates to chronic pain, mental illness, and other functional disorders [13, 18]. The BPS model has the ability to yield more positive patient-reported outcomes of treatment, especially within the context of cognitive behavioral therapy, due to the person-centered approach and use of goal-setting, which has recognized utility in treating both chronic pain and SUD [19–21]. Family involvement in treatment can heavily reduce stigma related to SUD and chronic pain, and this social engagement is correlated with lasting, positive treatment outcomes [22]. If this model becomes more ingrained within the cultural sphere of Western clinical medicine and the general populace, it is predicted to drastically reduce societal stigma related to both chronic pain and SUD, thus altering perceived treatment outcomes and making non-pharmacological treatment more acceptable and accessible to those suffering [23]. Considerations of the social aspects of the BPS model would greatly advance future research, particularly that relating to psychological and behavioral functioning.

### **3. Neurobiological overlap between addiction and chronic pain**

Epidemiological and functional imaging studies suggest a bidirectional relationship between chronic pain and many psychiatric disorders, including SUD, and that significant neurological overlap exists between them [5, 24, 25]. As described below, these similarities in affect, cognition, and behavior between addiction and chronic pain are reflected by similar changes in neural circuitry. These conditions also share many genetic and epigenetic mechanisms, but a detailed discussion is outside the focus of this chapter.

### **3.1 Neurobiology of substance use disorders**

SUD are undeniably biopsychosocial in nature and expression, with hallmark features of impaired daily functioning in cognitive, physiological, psychological, and social domains as a result of substance use and continued use despite these negative consequences. Diagnostic criteria for SUD include impaired cognitive and behavioral control over drug use, social impairment, such as job or relationship loss, use of drugs in risky or inappropriate situations that pose physical or psychological harm, and pharmacological criteria such as tolerance and withdrawal [26]. Neuroscientists conceptualize the addicted brain in a framework that encompasses key elements of two theories of motivated behavior: incentive-sensitization theory, wherein the motivation to consume drugs is said to result from conditioned reinforcement and over-attribution of salience to drugs and drug cues [27], and opponent-processes theory [28], which holds that the motivation to consume drugs is initially driven by positive reinforcement (addition of pleasurable feelings or euphoria, e.g. reward/process A), but repeated drug use is driven by negative reinforcement (subtraction of aversive feelings or state associated with drug deprivation, e.g. antireward/process B). These theories have given rise to the concept of the addiction cycle, which is supported by abundant neuroscientific evidence (reviewed extensively in [29] and summarized below).

The addiction cycle is composed of three stages, each underlain by neuroplastic changes in the function of discrete brain circuits resulting from chronic drug exposure, with variability modulated by an individual's genetics, life experiences, and their drug(s) of choice. The binge/intoxication stage is characterized by drug-induced positive reinforcement and loss of control over the amount and duration of drug-taking. The main circuit involved in acute drug reinforcement is the dopaminergic projection from the ventral tegmental area (VTA) to the nucleus accumbens (NAc), supported by the central nucleus of the amygdala (CeA) and ventral pallidum (VP), while compulsivity in drug-taking involves the caudate/ putamen (CPu). Repeated drug use reduces baseline activity of these circuits, partly setting the stage for withdrawal/negative affect to drive drug-taking. The withdrawal/negative affect stage is marked by negative reinforcement (removal of unpleasant stimulus or emotional state) driven by the recruitment of the hypothalamic–pituitary–adrenal (HPA) stress axis and circuitry connecting the basolateral amygdala (BLA) and hippocampus to the extended amygdala, CeA, basal nucleus of the stria terminalis (BNST), and a subregion of the NAc shell, which in turn project to the VP and lateral hypothalamus (LH). Acute withdrawal from several drugs, including opioids, involves hyperactive corticotropin-releasing factor (CRF) and norepinephrine (NE) neurotransmitter systems, the endogenous antireward opioid dynorphin, substance P, neuropeptide Y, vasopressin, and nociceptin. The preoccupation/anticipation stage is marked by drug craving, key to the relapsing nature of the addiction cycle. The impetus of relapse determines the neurocircuitry involved, with drug-induced relapse regulated by glutamatergic projections from the medial PFC (mPFC) to the NAc and VP, cue-induced relapse regulated by BLA-PFC-NAc glutamate signaling and VTA-PFC dopamine signaling, and stress-induced relapse activating the extended amygdalar CRF and NE systems. Compromised cognition, memory, and inhibitory control involve the

hippocampus, mPFC and orbitofrontal cortex (OFC; [29]. As the authors discuss below, many of the structures, circuits, and neurochemical mediators that drive SUD are also involved in chronic pain.

### **3.2 Neurobiology of chronic pain**

Nociception is a physiological response to a noxious stimulus wherein normally silent sensory neurons called nociceptors deliver information to the brain to elicit protective actions [30]. When stimulated, nociceptors transduce signals along spinal cord primary afferent Aδ and C fibers and converge at the dorsal horn, where afferent neurons in laminae I and V provide input to the brain [31]. Pain results from the activation of a distributed group of brain structures within the brainstem reticular formation and the limbic system, collectively referred to as the pain neuromatrix [32], a three-tiered hierarchy of experiential pain processing [33]. First order processing occurs when the spinothalamic and spinoreticulothalamic tracts carry signals from the dorsal horn into the brainstem and posterior thalamus (pTHAL), which encodes localization of pain and identification of specialized pain characteristics [31, 33]. The second tier involves perceptive and attentional internalization of pain, including cognitive structuring and modulation, attenuation, and proposition of somatic reactions to the painful stimuli, and is regulated by the posterior parietal cortex (pPAR), anterior cingulate cortex (ACC), PFC, and insula [33]. The third tier is characterized by emotional reappraisal of the nociceptive stimuli, in which emotional context is applied to the experience to modulate its psychological and social consequences. The brain regions associated with this tier are the pPAR, OFC, and anterolateral PFC [33]. These cortical structures are responsible for determining the behavioral response to nociceptive stimulation [31, 34].

Chronic pain is defined as persisting past the normal time of healing, generally for six months or more [35]. Unlike acute pain, which is protective in nature, chronic pain has negative effects on psychological and social well-being. As with SUD, chronic pain is the result of the plastic nature of molecules and circuits within the nervous system [31]. When activated persistently, the pain neuromatrix and other regions of the brain and spinal cord involved in nociceptive and cognitiveevaluative processing undergo neuroplastic changes that amplify activity, called central sensitization [36–38]. These changes result in exaggerated responses to noxious stimuli (hyperalgesia) and pain responses being triggered by normally innocuous stimuli (allodynia). The transition from acute to chronic pain is underlain by greater engagement of emotional and motivational circuitry [39], paralleling the progression through the addiction cycle.

Not surprisingly, research suggests that there is significant overlap in the neurological mechanisms involved in chronic pain with those involved in drug addiction [29, 40, 41]. Neuroplastic changes in corticolimbic structures comparable to those seen in SUD also contribute to pain chronification [42]. Specifically, chronic pain, like SUD, involves neuroadaptations that dampen reward, recruit stress-related circuitry, and promote aberrant learning that converge to negatively affect physiology and behavior [39, 42–45]. Chronic pain can disrupt the reward/antireward balance through persistent sensitization of nociceptive circuitry within the NAc, and attenuation of behavioral inhibitory signaling from the habenula [46, 47] to produce an overall shift in reward level or hedonic tone [48]. NAc functional connectivity changes have also been associated with risk-taking behavior in chronic pain patients, with high gain sensitivity in sufferers of chronic back pain correlated to greater connectivity between NAc and subcortical areas, compared to controls with strong NAc-frontal cortex connectivity [49]. These changes can promote the use of alcohol and drugs, particularly opioids, for negative reinforcement

(alleviating physical and psychological pain) and ultimately predispose chronic pain sufferers to develop drug addiction [39, 43].

As discussed above, both repeated exposure to addictive drugs and chronic pain lead to changes in brain function that promote continued drug use. Conversely, recurring drug use can also promote the development of chronic pain, illustrating the logical fallacy in treating chronic pain with prescription opioids. As with other addictive drugs, repeated opioid administration can shift the balance between reward and antireward processes, affecting the ability to experience positive emotions from natural rewards over time [47]. This shift in balance is accompanied by amplification of the antireward state, effectively establishing a reward deficit state, which drives further opioid use to compensate [47, 50]. Allostatic changes from pain stimuli are amplified when opioids are misused [51–53], resulting in neural adaptations that promote hyperalgesia, drug tolerance, and difficulty regulating emotion, which can in turn amplify anhedonia, producing a downward spiral of chronic pain and further prescription opioid misuse [53].

### **4. Shared psychosocial factors in addiction and chronic pain**

As is evident from the sections above summarizing neural circuitry involved in addiction and chronic pain, the boundary between the neurobiological and psychological aspects of these conditions is somewhat arbitrary. Likewise, the boundary between the psychological and social components is poorly defined, reflecting the central concept of the BPS model, that health and disease involve biological, psychological, and social factors that influence one another in a reciprocal, highly dynamic manner [54]. Meints and Edwards (2018) divide psychosocial variables involved in chronic pain into two main categories. General psychosocial factors include affect, trauma, social/interpersonal disposition, sex- and race-related disparities, and pain-specific psychosocial factors include catastrophizing, coping, expectations, and self-efficacy [54]. Another way of conceptualizing the division is factors that predispose an individual to develop chronic pain and those that emerge as a consequence of pain. As discussed below, there is a high degree of overlap between the psychosocial aspects of chronic pain and addiction, and it is not always easy to make the distinction between cause and consequence in SUD.

Psychosocial factors influencing reward, stress, and motivation can contribute to a downward spiral of chronic pain and comorbid conditions [46]. It is wellknown that negative affect promotes drug use, while conversely, repeated drug use increases risk for depression and anxiety. Similarly, anhedonic depressive symptoms often exceed 50% comorbidity in individuals suffering from fibromyalgia, temporomandibular joint disorder, chronic spinal pain, and chronic abdominal pain [5]. Symptoms of depression and anxiety are prominent in both episodic and chronic cluster headaches, with those in the chronic subset being less likely to cognitively reframe their pain sensations and more likely to ruminate [55]. In contrast to the bidirectional nature of negative affect and SUD, depression and anxiety are strong predictors of pain and related disability, but neither pain nor related disability appear to be good predictors of depression and anxiety [54]. Affective factors are a strong predictors of opioid misuse, with mood disorders, anxiety disorders, and chronic pain conditions either preceding or overlapping with OUD [9, 56–60]. Furthermore, negative affect and cognitions increase risk of developing an OUD in surgical patients, as their pre-operative presence were major predictors of prolonged opioid cessation following the operation [61]. Childhood physical, psychological, and sexual abuse have been implicated in later-life development of several chronic pain conditions [54], as well as alcohol and drug abuse [62]. Post-traumatic

### *Conceptualizing Drug Addiction and Chronic Pain through a Biopsychosocial Framework… DOI: http://dx.doi.org/10.5772/intechopen.95601*

stress disorder (PTSD) in adult veterans (which can be related to combat exposure and/or injuries such as traumatic brain injury) and in victims of childhood abuse are highly associated with development of chronic pain [54] and substance use [63].

Deficits in executive function can contribute to and result from repeated drug use. Likewise, chronic pain is associated with impairments in memory, attention, and cognitive flexibility, although the relationship is a complex one, owing to a lack of standard tests and poor control of confounding variables such as sleep and medication in existing studies [64]. Working memory and emotional control were shown to be impaired in chronic pain patients, but neither the intensity nor the duration of pain itself predicted executive dysfunction [65]. As with negative affect, poor executive function may predispose the development of chronic pain, a notion supported by a recent study wherein poor cognitive performance before surgery on Trail-Making Test B and Rey-Osterrieth Complex Figure copy and recall predicted the persistence of pain up to 12 months after surgery [66]. Relatedly, while impulsivity is not generally prominent in chronic pain patients [67], this trait is quite pronounced in SUD [29] and may play a key role in determining the likelihood of opioid misuse in pain patients. Specifically, urgency and attentional impulsivity have been implicated in current and future misuse of opioids by chronic pain patients, while sensation-seeking seems to have little to no influence [67, 68]. High baseline impulsivity in rats was also correlated with high impulsivity in the variable delay-to-signal test after spared nerve injury [69]. Additionally, a recent study showed that decision-making in the Iowa Gambling Task by chronic pain patients was robustly modeled mathematically by over-valuation of gains and under-valuation of losses, typical of risk-taking [70]. Risky decision-making and lifestyle is also highly prevalent with long-term substance use [9], which may, in turn, increase risk for developing a chronic pain condition. For example, prescription opioid use was associated with a 47% increased risk of car crash initiation, and thus, injury [6]. Other drug-associated behavior, such as injecting and high-risk or illegal activity to obtain drugs could also contribute to chronic pain and vice versa.

Much research underscores the importance of social support in ameliorating pain and improving function in chronic pain [12, 54], as well as preventing relapse in SUD [71]. However, negative social interactions can have the opposite effect. For example, the "sick role" of individuals experiencing chronic pain is a social context accompanied by attention, pity, and permitted exemption from daily routines [40]. Although moderately pleasurable for the individual experiencing pain, socioemotional pain relief is stressful for family and friends, and may promote aversion and distaste of the individual that has assumed it. This can cause isolation, communication deficits, emotional setbacks, and may amplify the original chronic pain state without the presence of a nociceptive stimulus [72]. Similarly, psychosocial stressors such as aversion, isolation, and other emotional setbacks are also heavily apparent in addiction and other mood disorders [8, 10]. Relatedly, family members and peers attitudes and behaviors also influence individuals with chronic pain and SUD. Parental catastrophizing, spousal/partner depression or avoidant, anxious attachment styles, lack of social support at work, and negative interactions with co-workers and workmans compensation programs can all promote chronic pain and disability [54]. Similar interpersonal factors are at play with SUD [73], and they can be particularly important for adolescents, whose peers and parents exert heavy influences over substance use by affecting availability of drugs and the child's perception of approval/disapproval of drug use [74]. Therapies targeting positive behavioral change in the social context may be essential in combating both chronic pain and SUD.

In addition to interpersonal factors, gender and race are other aspects of the social milieu that can have profound positive or negative effects on physical and mental health. While there can clearly be biological influences in both cases, such as chromosomal and hormonal influences in gender, and genetic variability in race, it is worth considering the social features, which may be even more important in determining risk for mental health-related functioning (as appears to be the case for schizophrenia; [75]). Females have a higher prevalence of pain, decreased pain threshold, more severe, recurrent, and longer duration of pain compared to males, differences explained at least in part by social factors, such as gender roles and differences in coping strategies [54]. Compared to men, women also show greater propensity for addiction to many drugs, including opioids, but research seems to have focused primarily on potential biological explanations for such differences [76, 77]. The negative impacts of alcohol and drug use are greater on Black and Hispanic Americans, although consumption patterns between Blacks, Hispanics, and Whites do not explain this difference (at least in relation to alcohol; [78]). Data are lacking for many ethnic groups regarding chronic pain, but Blacks and Asian Americans report higher levels of pain and lower pain tolerance compared to Caucasians, differences which may stem from racism, socioeconomic strain, and ineffective pain coping strategies [54]. Other structural vulnerability factors such as poor access to health care are likely to contribute to the unequal impacts of SUD and chronic pain on minority groups [79]. Further research is needed to gain a better understanding of how complex social and structural factors shape risk for chronic pain and SUD. The field of epigenetics, which has begun to address the neurobiological effects of well-known social context-related risk factors for schizophrenia - early life adversity, growing up in an urban environment, minority group position, and cannabis use [75] - holds great promise in advancing science, therapeutics, and social change, and underscores the strengths of the biopsychosocial perspective.

### **5. Non-pharmacological treatments for addiction and chronic pain**

The focus of biomedical interventions to manage chronic pain is primarily pharmacological, using opioid analgesics or surgical procedures [80]. However, surgery inherently subjects patients to risks associated with the surgical procedures, including more pain [80]. Likewise, opioids do not show substantial evidence for beneficial long-term pain management [80–82] and as discussed above, may even exacerbate it. For example, in a study of 26,014 individuals experiencing chronic back pain, psychological distress (depression, anxiety, posttraumatic stress disorder, and SUD), unhealthy lifestyle (obesity and smoking), and health care utilization increased incrementally with duration of opioid use [83]. As chronic pain and long-term opioid use may cross-sensitize across multiple biopsychosocial domains, it is essential to identify alternative treatment options.

A large body of clinical evidence suggests that treatments such as cognitive behavioral therapy (CBT) and mindfulness-based stress reduction (MBSR) alleviate symptoms of depression, anxiety, SUD, and chronic pain [84] and that the core mesocorticolimbic structures impacted by SUD and chronic pain can be effectively targeted by innovative therapies [85]. The CDC has also recommended treatments like exercise therapy and CBT to reduce pain and improve function in patients with chronic pain [86]. These alternative treatments aim to directly dismantle the negative biofeedback created by drug- or pain-induced maladaptive changes within reward and stress circuitry. Although more research is needed, the authors suggest that a more integrated approach for managing chronic pain and addiction should include clinical mental health therapeutic techniques, discussed below.

*Conceptualizing Drug Addiction and Chronic Pain through a Biopsychosocial Framework… DOI: http://dx.doi.org/10.5772/intechopen.95601*

### **5.1 Cognitive behavioral therapy (CBT)**

The goal of cognitive behavioral therapy (CBT) is to educate the client in the realm of positive coping strategies utilizing cognitive, respondent, and behavioral techniques [87]. CBT is designed to manage individual patient characteristics through a collaborative reframing of negative prediction, selective abstraction, and depersonalization to help the patient assume responsibility for their cognitions and behaviors. Cognitive behavioral therapists highlight the direct link between negative emotional states, sedentary cognitions, and resulting behaviors and seek to alter them in a holistic fashion that allows patients to grow through therapeutic change. This patient-therapist collaboration shakes sedentary perspectives and faulty core beliefs surrounding their ailment and allows the patient to reframe their thoughts and learn from new experiences.

Many individuals with SUD present to treatment unwillingly and approximately 45–50% will continue to use one or more drugs while in treatment [88]. In one study, CBT-treated individuals with SUD showed a 31% rate of abstinence compared to 13% abstinence rate in controls [89]. Compared to other psychosocial treatments, such as insight-oriented therapies involving psychoeducation, CBT appears more durable [90]. In the context of OUD, studies have shown that CBT alone does not lead to consistent therapeutic outcomes in patients, although it does seem to enhance the effects of methadone maintenance treatments (MMT) [91–93]. Combined treatment outcomes include greater attendance and treatment adherence and an increase in abstinence as evidenced by urine toxicology [88, 94]. Although reductions in substance use are often modest, sleeper effects, the notion that positive responses to CBT will increase over time, have been historically documented [95]. Relatedly, compared to MMT-only groups, or MMT and another independent counseling strategy, CBT has been associated with latent positive effects on psychosocial functioning. For example, employment consistency was shown to increase in parallel to daily functioning, and stress was shown to decrease with increased cognitive coping skills, reduced opioid use, and less depressive symptomology [91, 92]. Contingency management utilized within the context of CBT has been found to increase the likelihood of abstinence, and therefore may further enhance effectiveness of SUD treatment [89, 96]. A study in rats also supports the use of contingency management to enhance the relative value of nondrug reinforcers (in this case, delayed food reward) versus immediate opioid delivery, suggesting that people may similarly develop delay-discounting (a behavioral component of impulsivity) because of contingencies in their environment [97]. Combining pharmacological treatment with CBT to increase coping skills appears to be a promising strategy for SUD and its effectiveness may lie in addressing the individual's biopsychosocial functioning rather than simply treating withdrawal symptoms.

Recent international guidelines prescribe psychological interventions, rather than strictly pharmacological interventions, for the treatment of chronic nociceptive pain [98]. In chronic pain, CBT aims to help the patient channel their painrelated negative affect pain into a new cognitive interpretation of their sensations to increase their quality of life. Evidence has shown that outcomes from CBT-based interventions for chronic pain are moderate and comparable in efficacy to those for SUD. While CBT does not have a direct impact on the disability causing chronic pain [99], it has positive effects on patients' cognitions and appears to increase quality of life. For example, participants were 3X as likely to report no pain interference after CBT techniques to target and reframe negative cognitive patterns associated with the perceptions of pain [100]. Likewise, unrelenting chronic pain from terminal illness can increase desire for hastened death, but CBT-based activities like education, targeting of negative appraisal states, and relaxation association have been shown

to allow management and attenuation of pain [101]. Experimental, graded *in vivo* exposure therapy, a broad-spectrum CBT technique, has been shown to have some success in targeting the fear-avoidance model of chronic pain. Here, exposure to fearful movements gradually reduces classically conditioned fear/anxiety to reduce avoidance of these movements over the long-term [102]. Although more research is necessary, CBT appears promising as an adjunctive treatment in chronic pain. It may also be effective in augmenting treatment for patients with comorbid chronic pain and OUD by targeting patients' ability to cope with pain- and stress-related opioid craving.

### **5.2 Mindfulness-based stress reduction (MBSR)**

Mindfulness is a novel treatment strategy with roots in Eastern religions and philosophies that aims to enhance the experience and understanding of positive emotions and dismantle aberrant learning underlying pathological thoughts and behaviors. At the core of mindful therapeutic practice is acceptance that the stressors that trigger drug use or exacerbate chronic pain cannot be eliminated from one's life, but that their responses to those stressors can be modified. Relatedly, MBSR teaches a non-judgmental approach to affective, cognitive, and behavioral states; whether a particular stimulus is positive or aversive makes no difference. Invocation of the present moment is also key, allowing the patient to moderate their awareness and attention by attending to themselves in the here-and-now. The idea is that this systematic awareness of the present state coupled with a non-judgmental, accepting attitude ameliorates stress by weakening the negative emotional states attached to stressors, and thereby interrupting the cycle of addiction/chronic pain and eliminating the need to self-medicate.

Mindfulness programs are particularly efficacious for SUD because they address aberrant learning related to distressing stimuli and promote an openness to experience that leads to a reduction in future distress from those stimuli [103], rather than promoting avoidance of stressors or triggers, which does not address the underlying pathology. Mindfulness strategies also lead to pro-adaptive changes in intrapersonal thought patterns and ingrained belief systems, such as cues and cravings [104], while momentary awareness enhances an individual's ability to accept and cope with negative experiences, such as relapse and risky behavior [105]. This momentary acceptance of unpleasant stimuli leads to neurobiological alterations related to new learning, and consequently protects against relapse [103]. MBSR has been found to alter neurostructural changes in the mesocorticolimbic system and reduce autonomic arousal, physiological correlates to individual perceptual shifts, value and priority clarification, increased self-awareness, urge and craving shifts, and the ability to "let go" [106]. This sensory- and perception-focused strategy system has also been found to positively impact hedonic processing in the context of chronic pain and opioid management that interferes with habit-forming behaviors associated with addiction [107].

MBSR and similar strategies that target aberrant learning have been shown to interrupt the progression of addiction to opioids [107]. Mindfulness trainings reduce the intense neural reactivity to drug-cues, reduce cravings, and uncouple negative affective states from the previously induced, self-medicated state [108]. Functional MRI studies have revealed that MBSR can enhance top-down limbicstriatal connections by strengthening associations between the PFC and the parietal regions of the brain [109, 110], suppressing the influences of craving and autonomic responses, and enhancing cognitive control and flexibility related to attention [109]. Furthermore, by promoting gratitude for positive experiences and acceptance of negative physical and affective states, MBSR has been shown to

### *Conceptualizing Drug Addiction and Chronic Pain through a Biopsychosocial Framework… DOI: http://dx.doi.org/10.5772/intechopen.95601*

reduce craving, downregulate sympathetic arousal, and heighten natural reward [111], essentially breaking the cycle of addiction. Compared to typical treatments for OUD that focus patient attention on suppression of craving, which can actually increase self-medication and relapse, mindfulness strategies that focus the attention of the patient on acceptance of substance use uncouples opioid craving and opioid use to promote long-term relapse prevention [109, 112, 113].

Utilizing mindfulness in the context of treating chronic pain is new to Western society. Eastern practices, such as Zen Buddhism and Hatha yoga, have been applied to a plethora of physical ailments for centuries, but now these are combined with traditional psychotherapies such as CBT and acceptance and commitment therapy [114]. As in addiction treatment, a non-judgmental stance is vitally important to MBSR-based treatment of chronic pain. The patient focuses their attention on uncomfortable physical sensations with no attempt to alter them, instead developing compassion toward both positive and aversive bodily experiences [114, 115]. Neuroimaging studies support the notion that MBSR strategies have allowed patients to adopt a new perception of their chronic pain. The chronic pain experience involves the interplay of nociceptive cues, cognitive distortions, and negative emotional appraisal. Compared to controls, subjects receiving mindfulness instruction showed reduced activity in the right amygdala, parahippocampus, and insula, and increased activation in the dorsomedial and other PFC subregions during the presentation of unpleasant visual stimuli, consistent with attenuated emotional activation [116]. Mindfulness training has also been shown to reduce pain severity and uncouple pain from opioid use by helping the patient attenuate negative appraisals, reduce fixation and hypervigilance from chronic pain, and reduce pain catastrophizing [86, 107, 117–120]. As in SUD, MBSR interventions help to disengage the cycle of maladaptive pain coping strategies and prevent related behaviors, such as opiate stockpiling and other habits [107]. Together, these lines of evidence suggest that mindfulness-based therapeutic interventions hold great promise for treating and preventing OUDs, chronic pain, and co-expression of both, and the authors hypothesize that the biopsychosocial nature of the approach is key to its effectiveness.

### **5.3 Solution-focused brief psychotherapy (SFBP)**

Solution-focused brief psychotherapy (SFBP) applies a postmodern constructivist approach to counseling, meaning that an individual's experience of their substance use acts as the "objective truth" [121]. In this way, the therapist will collaborate with the client in order to develop a working, clinical understanding of the client's problem situation in terms of experience, perception, and meaning related to ambiguous stimuli and events [122]. Like CBT and MBSR, SFBP hinges on the development of a personalized construction of the problem behaviors or experiences and reframing of meaning that perpetuates maladaptive cycles of thought and behavior. Some researchers believe that it is not the specific interventions, but the demeanor and actions of the therapist that promote the therapeutic effects of solution-focused therapy. The collaborative relationship extended by the therapist, use of core facilitative conditions of the counseling process, mindfulness of the stages of change, and a focus on solutions instead of problems provides moderate empirical backing [123–125]. SFBP practitioners believe that therapy relies on the therapist's ability to engage the client in examining their negative *status quo* and that they become aware of exceptions to problem situations so as to direct insight toward future change [126]. SFBP allows the client to determine their own goals related to recovery, which includes harm-reduction strategies, and does not rely upon all-ornothing measures such as complete abstinence from drugs.

Many reports support the notion that solution-focused brief psychotherapy (SFBP) has worked well for individuals with SUD, and more modern group-based SFBP approaches have continued to be successful [121, 122, 127]. Although research has stagnated somewhat, SFBP group therapy appears to be effective for treating SUD, sometimes outperforming traditional programs [127]. This success may lie in allowing patients to choose their own goal structures and giving them more responsibility, which generally increases the likelihood of a positive therapeutic alliance between clinician and patient and typically yields better treatment outcomes [127]. Because depression and anxiety, like chronic pain, are highly comorbid with SUD, clinicians have had more success in targeting these disorders in order to address the other habitual drug-seeking behaviors [122, 127] and solution-focused techniques have been found to outperform traditional therapies in this regard [127]. Specifically, interpersonal functioning, symptom severity, and social roles pre- and post- treatment, have shown improvements in those receiving solution-focused interventions [127–129]. Meta-analyses have also shown that 23% of systematic reviews have reported positive trends in depression-related outcomes [130, 131]. Applying a solution-focused mindset to other psychotherapies, including CBT and MBSR, has also led to positive outcomes in the treatment of SUD and depression [127, 132]. Another advantage of SFBP is its cost effectiveness, due to its brief duration yet surprisingly long-term positive outcomes for many. Although no studies to date have examined the efficacy of SFBP specifically for the treatment of OUD, application of this approach to OUD seems promising.

In the context of chronic pain, the emphasis of solution-searching in SFBP may be advantageous, as individuals living with chronic pain typically react passively to their pain sensations, or develop coping strategies that can be misguided or unhelpful [133]. The idea of a "preferred future," a concept at the core of SFBP wherein the therapist assists the patient in identifying exceptions to their painful *status quo*, has elicited unique responses from patients often lacking in hope [126, 133]. Research on the therapeutic effects of SFBP for chronic pain is quite limited. However, SFBP has been helpful when coupled with physical rehabilitative practices. Two studies have shown improvement of individuals undergoing orthopedic rehabilitation while on sick leave, with over 60% of participants returning to homeostatic daily functioning levels as a result of solution-focused practices, as opposed to a 13% return rate from the waitlisted control groups [134, 135]. A case study also supports the efficacy of combined biofeedback (galvanic skin response) and SFBP in order to manage chronic pain associated with gastro-esophageal reflux disease, with the patient showing a significant decrease in chest pain and increase in personal life satisfaction lasting two months post-treatment [136]. Further research on biopsychological interventions such as combining biofeedback with SFBP for chronic pain could be illuminating.

### **5.4 Motivational interviewing (MI)**

Originally developed by Dr. William Miller for alcohol use disorders in 1983, motivational interviewing (MI) can be described as a therapeutic conversation, held by the therapist and client, about aspects of change [137]. Therapists use specific communication strategies that allow the client to explore their arguments for why change is not possible, seeking to elicit "change talk" from the client by developing discrepancies in the way the client thinks and speaks about their issues. These discrepancies arise from a collaborative exploration of the client's story pertaining to how substance use, for example, has impacted their lives. The therapist's role is to highlight ambivalence that has arisen from the storytelling and provide space for the client to think about what changes they are capable of making [138]. Eventually,

### *Conceptualizing Drug Addiction and Chronic Pain through a Biopsychosocial Framework… DOI: http://dx.doi.org/10.5772/intechopen.95601*

by weighing personalized positive and negative aspects related to change outcomes, the client breaks down the lines of logic sustaining pathological behaviors [139, 140]. MI addresses four processes: engaging, focusing, evoking, and planning [141]. Engaging the client in a person-centered style develops the therapeutic bond that will facilitate change [141]. Focus revolves around the change target of the client, which is developed collaboratively to avoid negative power dynamics, polarization, or fractures to the therapeutic relationship [142]. Evocation involves intentional change talk wherein the client must identify their own personal reasons for change and therapist feedback aims to prevent potential losses in motivation related to these reasons. Planning involves collaboration and commitment as the primary method for enforcing the desired change. The ability for the client to elicit their own motivations for change rather than the therapist imposing their own advice is the driving force of this therapy.

MI has become one of the leading theoretical interventions for treating individuals with SUD. Some early explanations of its popularity are its cost effectiveness, theoretical fluidity, usefulness for non-treatment-seeking populations, and motivational enhancement of the client, which is highly important in addiction treatment [143, 144]. Although there have only been a handful of studies, MI has shown clinical efficacy in the treatment of a variety of SUD [143, 145]. For example, the ability to resolve ambivalence related to drug use and to reframe one's perspective of change ultimately reduced active drug use to a larger extent in an MI group compared to a more confrontational counseling style focused on the consequences of risky drug use [138, 139, 146]. Change talk has been shown to play a vital role in treatment outcomes and researchers have hypothesized that it promotes a neurocognitive shift negatively correlated with substance use [147, 148]. For example, an fMRI study showed that positive change talk inhibited activation of reward circuitry by alcohol-associated cues, suggesting that change talk can nullify reward activation under high-risk circumstances and thereby prevent cue-induced relapse [147, 149]. A single-blinded, randomly controlled trial found that bimonthly MI treatment significantly reduced the number of opioid overdose events and promoted a lower attrition rate amongst participants [150] compared to psychoeducation and tertiary prevention strategies [150, 151]. Educational programs did reduce other risk factors, such as viral infections as a result of needle misuse and enhanced protective factors including how to detect overdose, promotion of needle exchanges, and safe injection habits [151]. Future studies examining potential benefits of combined pharmacological and MI methods on treatment outcomes for patients with OUD will be important.

Although controlled studies have been limited by the fluidity of motivational strategies and their implementation, researchers have found that MI can augment treatment of chronic pain, and is moderately effective for lower-back pain, asthma, hypertension, cardiac and respiratory issues, and fibromyalgia [152]. In this context, the focus of MI is on resolving ambivalence through change talk and enhancing the ability to cope with chronic pain by incorporating mindfulness and cognitive restructuring techniques [153–155]. In addition, MI interventions used in conjunction with physiotherapy enhance the therapeutic relationship between the physician and patient, which correlates to more positive outcome expectancies of the patient that ultimately decrease subjective pain intensity and increase range in physical functioning [156]. Another study found that infusing a biopsychosocial assessment of chronic pain with MI also had more favorable outcomes, including marital satisfaction, reductions in pain intensity, stability in positive mood, lower ratings of personal distress, and higher ratings of empathy [155]. Future studies examining the efficacy of MI in treating comorbid SUD and chronic pain would be informative.

### **6. Conclusions**

Chronic pain and addiction are widespread, pervasive, and significant public health burdens that demonstrate a need for more effective management strategies. The known effectiveness of opioids for managing acute pain combined with the limited therapeutic alternatives for chronic pain, have led to an overreliance on opioids for long-term pain management and the current opioid crisis in the United States [2]. In this chapter, the authors have discussed conceptualizing chronic pain and SUD using a similar biopsychosocial framework and suggest that both can be more effectively managed by including clinical mental health therapeutic techniques as opposed to a purely biomedical approach. While psychotherapy has long been used in treating SUD, applying these techniques to chronic pain is fairly novel. Evidence of the effectiveness of these nonpharmacological treatments for chronic pain, particularly for long-term management, is still sparse [157]. However, the techniques highlighted in this review, CBT, MBSR, SFBP, and MI are promising in managing mental illnesses that are frequently comorbid with chronic pain, suggesting further research into their efficacy for chronic pain is warranted. Moreover, the biopsychosocial parallels between chronic pain and SUD represent potential areas of translational research to further improve these nonpharmacological pain management practices and foment social change. By addressing these areas of biopsychosocial overlap, nonpharmacological approaches may hold great promise in reducing the negative impacts of chronic pain and the opioid epidemic simultaneously.

### **Author details**

Zachary S. Harmon1 , Emily N. Welch<sup>2</sup> and Christina L. Ruby3 \*

1 Department of Counseling, Indiana University of Pennsylvania, Indiana, PA 15705, USA

2 Department of Biological Sciences, Kent State University, Kent, OH 44242, USA

3 Department of Biology, Indiana University of Pennsylvania, Indiana, PA 15705, USA

\*Address all correspondence to: cruby@iup.edu

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

*Conceptualizing Drug Addiction and Chronic Pain through a Biopsychosocial Framework… DOI: http://dx.doi.org/10.5772/intechopen.95601*

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### **Chapter 8**

## Supervision of Substance Abuse Therapeutics Emphasizing the Discrimination Model of Supervision and Motivational Interview Practices

*John A. Mills and Maren Krizner*

### **Abstract**

There is considerable pressure from varied sources to provide effective supervision to professionals who deliver therapeutic services to persons being treated for substance use disorders. The literature of supervision continues to evolve as the utility of supervision models and their applicability with substance abuse therapeutics are explored. Among the many models of supervision, Bernard's Discrimination Model of supervision is experiencing on-going development in the context of a variety of clinical services. The current chapter will describe how Bernard's model can be used effectively to enhance the supervision of substance abuse professionals as well as how further development of the model would enhance the approach. The Discrimination Model will be combined with existing literature of Motivational Interviewing approaches to describe key elements of effective clinical supervision with professionals delivering services in a complex and challenging industry.

**Keywords:** Discrimination model, motivational interviewing, supervision of substance use therapeutics

### **1. Introduction**

Clinical supervision is indispensable to the professional development and well-being of therapists in all areas of mental health intervention.1 Supervision is unavoidably a process that involves at least three participants: a Supervisor, a therapist, and at least one client. In most supervision cases, the supervisory activity attends to the work of the therapist with more than one client and each client then becomes part of this relationship triad (one triad for each client). Therapists must contend with challenges associated with patient difficulties and possess a great range of skills and knowledge to be successful. Besides the extensive array of personal and professional attributes necessary to promote therapeutic effectiveness in general, therapists must understand particular and unique patient concerns in the context in

<sup>1</sup> "Therapist" will be used interchangeably with comparable professional titles such as "counselor" and "service provider." No substantive difference is intended or implied.

which the therapist works. Intervention with patients with substance use disorder (SUD) requires a uniquely broad and complex body of knowledge as well as the ability to thrive under an emotionally charged set of stressors that are intrinsic to the treatment industry [1]. SUDs are serious and commonly long-term disorders that requires systematic and vigorous interdisciplinary intervention, education, and support [2]. As a result, successful work as a therapist with clients with SUDs requires skills associated with all types of psychological intervention as well as issues that are uniquely relevant to intervention with SUD patients [2].

In addition to the challenges of work with persons with SUDs, the treatment setting is further complicated by the fact that the professional background of SUD treatment providers is quite heterogeneous. While it may not be obvious to people outside the industry, SUD treatment professionals function in their roles on the basis of many different specific forms of professional training [2–5]. In fact, SUD treatment programs are unique within the spectrum of mental health services in that professionals within these programs are qualified to provide services even if they do not have a master's degree (e.g. [6]). While many jurisdictions have established certifications for SUD professionals, the variety of therapist backgrounds and characteristics is a reality that heightens the need for effective and persistent mentorship. Tatarsky [7] described the main components of intervention with SUDs. The author asserted that any supervision of SUD intervention must include how the therapist works with the therapeutic alliance, fosters corrective emotional experiences with the client, and how to teach of self-regulation. These challenges are considerable.

There are more than sufficient rational arguments for attending to the nature and quality of the supervision of SUD therapists. First, there is great variability in therapist training, so initial preparation to provide SUD treatment is critical. The range of issues that are essential to even beginning SUD treatment include skill with addiction processes, diagnostic concepts and practices, and methods of intervention. Next, these aforementioned basics that may be considered internal to treatment can be made more complicated by political realities. For example, there have been widely shifting attitudes in both public and professional circles about the status of persons with SUDs ("junkies," "addicts") throughout history [7]. The ethical and effective clinician will be sensitive to the varieties of client backgrounds and will use supervision as a part of on-going efforts to be expand these sensibilities. Such a clinician will refrain from a narrow view of patients and strive to build a therapeutic alliance in the context of the client's cultural context. These forces have real consequences for persons with SUDs that may become a focus in treatment. In addition to the initial considerations training, SUD therapists have considerable on-going training needs as they continue working in the field. For example, legal and ethical issues are persistent challenges that must be resolved. Adding to the demands already noted, the stress of continued work in the field places real demands on therapists, rendering continued emotional support essential. One can readily see how supervision may be essential to the well-being of clinicians and the utility of treatment efforts.

As already established, therapists and supervisors are called upon to function effectively in the context of differing demands for results, significant ethical, legal, and cultural consideration, gaps in training, increasing pressure to use empirically supported practices, differences pertaining to services being provided by persons with and without prior SUDs, and differing models for intervention [4]. As a result, the demand on SUD treatment supervisors is more complex and demanding than what might be found in other contexts. The question then arises about how to think of optimal clinical supervision. The Center for Substance Abuse Treatment [8] attempted to define effectively functioning clinical supervisors as those who are

### *Supervision of Substance Abuse Therapeutics Emphasizing the Discrimination Model… DOI: http://dx.doi.org/10.5772/intechopen.97626*

knowledgeable about SUDs as well as all other areas of therapeutic practice. Much of this definition was grounded in technical skills of supervisors because of the complexities of clinical tasks for therapists. While this need for the highest quality supervision is seemingly irrefutable, there is a relative dearth of recent empirical literature to support this idea. There is some evidence to support the role of supervision in the job performance of therapists [5, 9]. Laschober and colleagues [2] reported the results of an investigation of the quality of counselor preparation as a function of supervision effectiveness. Harkening to the complexities of supervisory tasks, the authors confirmed the demands on practitioners and supervisors discussed above, and described the perceptions of SUD counselors in this regard. It is important to note that Laschober and her colleagues concluded that significant emphasis must be placed on the quality of the supervisory relationship. Their work was a survey design that lacked the elements necessary to infer causality between effective clinical supervision and the job performance of counselors, but it did support the link between supervisory skill and counselor outcomes. This remains an area in which experimental designs are still needed.

As just described, there is real importance to the development of a strong supervisory alliance. This reality has been echoed in many works in the field (e.g. [10, 11]). This connection has been discussed in the literature of both the supervision of mental health and SUD clinicians. The supervisory alliance is a medium for social influence in a critical professional area [12, 13]. The working alliance in supervision is most commonly defined as a supportive relationship that includes three components: agreement on goals, agreement on tasks to pursue the goals, and the bond that develops between the supervisor and therapist. [14–16]. There are some reports of research that suggest that the alliance and the associated mentoring are a distinct predictor of therapist proficiency relative to technical proficiency of the supervisor [2].

### **2. The discrimination model**

There is undisputed importance to the identification, examination, and application of effective and appropriate models for clinical work. This is also true for clinical supervision for SUDs. Optimal supervision requires a keen sense for the wide range of difficulties of the therapist, and models of supervision can hasten and sharpen the processes by which supervisors identify and work with training needs. Suitable models of supervision may function as a guard against toxic fluctuations in the strategies used by supervisors [11].

### **2.1 Development and concept of the discrimination model**

In 1979, Bernard introduced the "Discrimination Model" (DM) of supervisor training, at least partly in response to confusion in the literature about the significance of supervision, a dearth of literature regarding the training of supervisors, and a wish to promote an effective training model that addresses the processes of supervision. The majority of the following description comes directly from Bernard's 1979 seminal paper [17]. The model has been applied in a number of subsequent works that highlight its applicability [18–22]. The discrimination model is named as such because its main function is to provide the supervisor with a variety of approaches that they may apply within a given situation at their discretion without the limitations of theory. In the discrimination model, the supervisor must identify the area of skill or behavior with which the counselor most requires assistance at a particular time (process, conceptualization, or personalization), and then subsequently assume one of three roles (teacher, counselor, or consultant) by which to provide said assistance. The variety of combinations that result from this process grant the supervisor with nine possible approaches to a given situation, allowing for the maximization of effective communication between the supervisor and the counselor. It is important to explicate these approaches as prelude to the discussion of integration with other supervisory skills.

The ultimate goal of supervisor training is to provide counselors with the necessary skills for successful intervention. Bernard divides these necessary skills into three major categories: process skills, conceptualization skills, and personalization skills. At any given time, a counselor may be exhibiting behaviors that relate to these skill categories, and the discrimination model assists the supervisor in identifying the nature of the trainee behavior for supervisory intervention. "Process" behaviors are those which relate to the conduct of the session, such as effectively opening and closing the session, implementing different intervention techniques, or encouraging communication with nonverbal cues. Process behaviors indicate to the client that the counseling has begun and how it is progressing. Counselor-trainees typically learn these skills early in their training, though they may also be skill areas that evolve throughout their career. A counselor-trainee who struggles in this area may incorrectly implement a specific technique, have difficulty maintaining a robust working alliance, or fail to effectively communicate with the client. When evaluating and assisting counselors with the development of process skills within the discrimination model, the supervisor is to focus on how these skills and techniques are executed, as opposed to whether or not they are the appropriate skills to apply within the given situation. "Conceptualization" behaviors are skills which pertain to comprehension, analysis, recognizing themes or patterns, and deciding which strategies and techniques would be most effectively applied to help the client achieve their goals. Since these behaviors take place primarily as cognitive functions, they are more difficult for a supervisor to observe within the session. Conceptualization should occur both within the session and between sessions. It is possible for a counselor the struggle with, say, recognizing patterns within the client during the session, but easily do so when writing a case report of the same client. Therefore, it is important for a supervisor to differentiate between these two areas of conceptualization and determine where the counselor-trainee is struggling in order to maximize effectiveness of supervision. Lastly, "personalization" skills are the counselor's ability to maintain professionalism, take responsibility and authority within their position as counselor, use their inner experience as professional guidance, accept challenges, feedback, or criticism from the client, avoid projecting personal beliefs and values onto the client, and maintain a basic, fundamental respect for the client. Development of these skills requires a willingness for personal growth within the counselor. Because the advancement of personalization skills requires the counselor to identify personal flaws and biases that inhibit their ability to be objective toward the client, such advancement is simultaneously emotionally difficult and perpetually necessary in all counselors. It is important the supervisor treats the learning of personalization skills as not a sign of personal shortcoming in the counselor, but as being equivalent to learning any process or conceptualization skills. The ability of the counselor to possess adequate skills in each of these three areas of behavior is vital to the success of intervention. The discrimination model aims to train both the counselor and the supervisor to recognize which areas specific behaviors pertain to and better understand where issues arise.

As the supervisor is able to recognize an issue as falling into one of these three areas, the supervisor must determine the best approach with which to present instruction. Bernard identifies three possible approaches or roles the supervisor may take on in order to do so: teacher, counselor, or consultant. When taking on the *Supervision of Substance Abuse Therapeutics Emphasizing the Discrimination Model… DOI: http://dx.doi.org/10.5772/intechopen.97626*

"teacher" role, the supervisor's goal is to impart knowledge and information to the counselor-trainee. This might include, but not be limited to, introducing relevant professional literature or directly explaining a concept or technique. Within the "counselor" role, the supervisor works with the personal needs of the counselor, helping them to overcome personal or emotional barriers that inhibit their development as a counselor. While maintaining appropriate professional boundaries, the supervisor evokes the inner subjective experience to facility the trainee having the most fluid and adaptative access to this part of their reaction and approach to a client. Lastly, when taking the role of "consultant," the supervisor acts less authoritatively, engaging in reciprocal dialog and offering suggestions and discussions of professional and case material in order to come to solutions or more advanced understanding in the trainee. It is deeply important that the supervisor chooses their role based on the needs of the counselor within the situation. The model does not work if the supervisor chooses a role because it is most comfortable or natural to their disposition.

### **2.2 Application of the discrimination model**

Bernard [23] saw supervision as an activity that emerged more from the training of therapists than the nature of therapy relationships despite the fact that many models of supervision closely followed models of psychotherapy. Given the abovenoted significance of mentorship in supervision the skilled and purposeful application of the seemingly simple discrimination model may be critical. It is important, then, to consider how the DM is used.

The discrimination model offers an array of approaches that a supervisor can employ by first identifying the skill type within which an issue occurs, and then assuming the role which they feel is best fit for the situation. For example, a counselor-trainee may approach the supervisor expressing that they wish to use a technique that they have not learned with a client. This would be an instance of building process skills, and the supervisor may take on the role of "teacher", providing the counselor-trainee with resources and information on how to use the desired technique. In another instance, the supervisor may notice that the counselor-trainee is more hesitant to work with clients of the opposite gender, an issue which relates to the counselor-trainee's personalization skills. Here, the supervisor might choose to take on the role of counselor and attempt to help the counselor-trainee understand what aspects of their own world view may be contributing to this bias. Although it may be tempting to associate specific supervisor roles with specific skill areas, such as, for example, assuming the development of process skills always necessitates the teacher role, it is important to remember that any combination may occur. The discrimination model is most effective when the supervisor's approach is selected based solely on the circumstances of the given situation.

Use of the supervisor role from the DM is based on the real needs of the supervisee and this may not be directly evidenced by the manifest nature of the dilemma as just described. For example, when confronting ethical, legal, and professional issues in SUD treatment, the trainee may have a lack of information for which they need instruction, a need for help considering alternatives about which they are already familiar, or more personal assistance working through more subjective blocks to effective and appropriate application of relevant standards. Thus, the supervisor must develop an appreciate the dynamics of a supervisees dilemma before adopting the teacher, consultant, or counselor role with a specific dilemma.

The complex skill needs of the therapist in SUD treatment may make the simple structure of the DM a useful framework for the consideration of the areas of supervision that merit the greatest focus. Given the extent and nature of the complexities of the SUD diagnosis and treatment planning, conceptual problems are readily encountered. Between diagnostic categories, complexities of treatment planning, and implementation of a treatment program, the therapist has a significant array of ideas to consider and integrate. In addition, the SUD treatment environment can be highly evocative for the professional therapy environment, and it is natural for an inexperienced therapist could need support and counsel with the emotional components of the work. Finally, SUD treatment can be very difficult to implement, and the process tasks of a therapist can be very important to address to maximize the likelihood of proper treatment implementation.

Specific settings can further highlight the utility of the DM. Byrne and Sias [24] reported on the application of the DM model to supervision of direct care professionals in adolescent residential treatment programs. In particular, they focused on therapist intentionality, flexibility, and professionalism as target themes for supervision activities. The authors highlighted how the conceptualization role could be tailored to the exact needs of the trainees. With widely varying amounts of experience and training, the therapist would have differing needs for how to understand clinical situations. In addition, careful focus on conceptualization allows the supervisor to be responsive to the different needs while allowing for team collaboration in shared understanding of clinical dilemmas. This focus enhanced the effectiveness of the therapists. Their effectiveness was further enhanced by a suitable attention to personalization. By encouraging the therapist to employ their own personal style to interventions and being careful of their own reactions in an evocative environment, focus could remain on planned interventions without the interference of unmodulated therapist emotions.

The DM can also magnify the impact of specialized or advanced supervisory functions. The prospect of the "parallel process" in supervision is also a challenge to supervision that is such an example for the DM. The idea of a parallel process began in psychodynamic writings as a replication of the therapy relationship and supervision outside of the awareness of the participants [25]. The concept was not initially named in the seminal literature, but the parallel process concept received increasing attention and has evolved into a well-articulated principle. The parallel process notion was clarified extensively in the literature, beginning with Doehrman's [26] work. Doehrman's work was a landmark contribution in identifying issues of power, control, dependency, intimacy, and judgment as manifest in the parallel process of supervision [27]. The concept of the parallel process began to receive successful empirical examination in subsequent decades [28]. The parallel process is now clarified as a set of sometimes parallel phenomena between the supervision relationship and the treatment relationship. Many authors now recognize the phenomenon with or without the psychodynamic trappings and independent of theoretical orientations.

### **2.3 Limitations of the discrimination model**

With any clinical approach there are limitations that may be anticipated. For now, we will consider limitations of the DM that are associated with the application of the model. Some approaches to, activities of, and contexts for supervision are inconsistent with parts of the nine "cells" in the model. The cells of the model have to be applied in a manner that is optimally targeted to the specific milieu. Therapists in such a context must learn about the significance of supervision, the responsibilities and functions of supervisors, and the responsibilities of therapists in the supervisory conditions. For example, quick application of supervision that occurs in front of clients can be corrosive to the delicate work that needs to happen within the supervision. This could easily complicate the delivery of group services in the

### *Supervision of Substance Abuse Therapeutics Emphasizing the Discrimination Model… DOI: http://dx.doi.org/10.5772/intechopen.97626*

SUD treatment context. In addition, the model does not prescribe exact approaches for exact situations and has not been empirically investigated for doing so. As a result, the model is useful for considering possible approaches and enjoys some rich descriptions of its application, but the DM is not yet supported by well-designed empirical work.

The model does not appear to provide a locus for what may be considered "external" or "political" considerations or when disciplinary action is in the offing. There are a number of possible components that fit in this area of concern. First, if supervision needs to turn to issues of therapist accountability, it is not clear what supervisory function is invoked. That is, when there are deficiencies in practical dimensions of a therapist's work and development efforts seem to have been exhausted, the preferred cells in the DM are not clear. Perhaps obviously, the counselor would not be the preferred role. It is possible that the consultant role could be invoked, particularly in situations in which the therapist was bringing some of the issues to the table on their own. In the end, however, if discussions of objective components of performance or considerations of job action were imperative, the DM may be irrelevant or at least not instructive.

A political consideration might be the career development of the therapist. It is quite appropriate for such discussions to be some part of supervision and mentorship, but the DM might not be helpful. One might argue that the consultant role would be useful in general professional mentorship, but this has not been suggested or discussed in the literature [29].

A final limitation of note was raised by the work of Crunk and Barden [18] who began a discussion of the relative lack of research into the integration of the discrimination model with other supervisory factors. In particular, their work integrated the "common factors" of supervision that by themselves have already received such robust support [30]. Their preliminary efforts are a part of future developments that are spawned by the discrimination model but are yet to be realized.

### **3. Motivational interviewing**

### **3.1 Development and concepts**

This chapter is based on the notion that Motivational Interviewing (MI: [31]) is a highly useful approach to treatment *and* supervision and with SUD patients and therapists in particular. MI was originally designed to assist with persons suffering from mental health conditions whose difficulties seemed particularly challenging because of internal conflict about treatment and behavior change. The applicability of MI to SUD treatment was readily made when MI was introduced, and its widespread utility has been reflected in the literature since then [32]. After introducing and describing MI, the discussion will turn to an integration of MI concepts and methods with the DM to maximize supervisory effectiveness.

MI is a technique which focuses on working with the client to uncover motivation for change that is already posited as being present within the client. The goal of MI is to use the client's own desires and feelings in order to overcome resistance to change which would otherwise inhibit the therapeutic process [33]. MI develops many of its key goals and practices based upon Rogers' [34] necessary and sufficient conditions for constructive personality change. Rogers proposes six conditions which must be met in order for personality change to occur within the therapeutic setting.

The first and most basic of these conditions is that two people must be in psychological contact. In other words, there must be some sort of relationship between the counselor and the client of which both parties are aware. Conditions 2–6 relate to the nature of this relationship. The second condition is that the client must be in some state of incongruity. Within this state of incongruity, the client is experiencing a disconnect between their perceived self and their actual behaviors and experience. This idea relates closely with Festinger's theory of cognitive dissonance, a principle which is also frequently employed within MI [35]. Rogers' third condition for change is that the counselor is consistent and genuine within their relationship with the client. The counselor must be aware and accepting of their own feelings within the relationship, and must not attempt to act in any way that is disingenuous or performative. The fourth condition requires the counselor to experience unconditional positive regard toward the client. The counselor must aim to be accepting of all of the client's experiences or statements, without the presence of judgment or persuasion. The fifth condition proposes that the counselor must hold an empathetic understanding of the client's internal perception of their own experiences, and effectively communicate this understanding to the client. It is important not only that the counselor is able to understand the client's experiences as if they themselves were experiencing them from the client's perspective, but that the client feels understood as a result of this. Lastly, Rogers' sixth condition for change is that the client is aware of the unconditional positive regard, acceptance, and empathy which the counselor feels toward them.

Miller and Rollnick [31] described four general concepts that were important for the implementation of MI. These were 1) express empathy, 2) develop discrepancy, and 3) roll with resistance, and 4) support self-efficacy. It is important to clarify these foundational elements and recall that these factors are central to the conditions in the relationship and may underlie and/or precede a variety of other interventions. First, motivational interviewing includes the expression of reflective listening to communicate understanding of what a client is saying. The second component is the cultivation of the client experience of any inconsistency between the client's most cherished values and their recent behavior. The third element of MI is the practice of understanding and tolerating a client's resistance to change in contrast with a more confrontational stance with forces that seem to interfere with change. Finally, MI encourages clients to believe that wished-for change can happen.

### **3.2 Application of motivational interviewing for supervision**

Clarke and Giordano [33] articulated a compelling case for the applicability of MI in supervision. This relevance is rooted in the fundamentally essential nature of the relationship in therapy *and* supervision. Bordin [14] described the working alliance in supervision in part by applying therapeutic principles to supervision. He stated that a working alliance in supervision included shared goals, mutual understanding of the work to be done, and a constructive timbre of the working bond as foundational themes. Clarke and Giordano extended Bordin's supervisory alliance notion to include a greater range of supervision complexities. A significant part of this development was to highlight the difficulties associated with conditions in which Bordin's three conditions of the alliance were awry any way. In particular, difficulties with any of the three areas of the working alliance in supervision can promote anxiety and resistance in the therapist to learning and change. The presence of such conflict, then, highlights the need for supervisory methods that address the resistance. As discussed when MI was defined above, the principles and practices of MI are well-suited to such situations. As a result, there is a call to clarify the usefulness of MI in supervision.

### *Supervision of Substance Abuse Therapeutics Emphasizing the Discrimination Model… DOI: http://dx.doi.org/10.5772/intechopen.97626*

Because of the paucity of relevant literature, it is instructive to review Clarke and Giordano's description of supervisory components that foster anxiety and resistance in the therapist and how the key features of MI can enhance a response. As they noted, while MI has expanded rapidly in the development of therapeutic approaches, most of the work related to MI and supervision has been to clarify how to conduct supervision of therapists' MI work rather than using MI in supervision itself. This is a key distinction, and a notable exception to the relative neglect of MI as a supervisory method was Madson et al.' [4] consideration of a MI model of supervision in the context of SUD treatment.

In most supervisory contexts, it is likely that a supervisor may serve at different times as a teacher, consultant, and supporter. We will soon turn to a consideration of these roles from the DM perspective, but it is instructive to talk about the supervisory roles from an MI perspective first. As has been discussed, supervision is an intervention that is based on a relationship in which a more advanced professional provides the necessary activities to a less experienced professional for the sake of maximizing client welfare, increasing therapist competence and promoting their ongoing development [23]. In discussing the contribution of MI to the supervision of SUD treatment, Madson and his colleagues [4] stated that"a supervisor may adopt roles as educator, consultant, supporter, and evaluator" (p. 350). Here is clear groundwork for the upcoming discussion of using MI and DM jointly.

### **3.3 Limitation of motivational interviewing**

MI is widely characterized by well specified theory and technique [36]. MI has also been afforded a wide range of training resources and increasing empirical support for the efficacy of those efforts. At the same time, there is some increasing concern about the ability to evaluate MI and transfer it among settings because of inconsistencies in practice and the ongoing changes to the underlying theory that have been articulated [37]. Scholarship of MI needs to become more transparent so that developments are better examined, replicated, and advanced [38]. Such enhanced scholarship will also solidify the impact of clinical trials and the resulting guidance for practitioners.

There is still a lack of knowledge about the exact connection between the activities of MI and the outcomes that are associated with it [39]. There are a number of hypothesized mechanisms for this connection, but the specific action is not known. The relationship is considered to be an important part of how MI in addition to the technical advantage of altering the inner dialog of clients [40]. It is also possible that the investment of a client in behavioral changes could be enhanced by reducing the client talk that reinforces the persistence of old patterns [41].

### **4. The discrimination model and motivational interviewing in supervision**

It is argued here that these two models for different kinds of intervention contexts may be considered in an integrated fashion to enhance the supervision of the treatment of substance use disorders. As previously discussed, Bernard's Discrimination Model (DM: [17]) was developed as an atheoretical guide for supervisors in the decision to adopt different roles or approaches to issues manifest in supervision. In the context of teaching, consulting, or counseling roles, flexible and intentional approaches are available in any given situation [41]. In the DM, three possible supervisor roles are employed in conjunction with three possible areas of trainee concern. So, the supervisor may work from flexible roles to address the conduct of intervention, understanding of clinical dynamics, and optimizing the presence of the person of the therapist.

This chapter contends that the DM can be productively integrated with the principles and practices of Motivational Interviewing (MI) to even further strengthen the supervision of the treatment of SUDs. MI was developed with an emphasis on four basic principles for intervention in treatment and supervision [31]. Briefly, MI includes the expression of understanding, the cultivation of the awareness of tension between actions and values, gentleness with expressions of resistance to change, and support for the experience of what is possible. The four basic principles and practices in MI are designed to work with a therapist (in supervision) or a client (in treatment for SUDs) include attitudes about emotional, cognitive, and behavioral aspects of experience. Challenging these attitudes from different positions is essential for the effectiveness of interventions.

### **4.1 Joint implementation of MI and DM**

The best use of DM and MI is grounded in the common factors of psychotherapy. While there is little literature that describes the common factors in supervision [23], the common factors have been suggested as an important dimension of any form of supervision. In fact, it has been suggested that DM be expanded into a "Common Factors DM" [18]. Full treatment of the Common Factors DM is beyond the scope of this chapter, but the application of common factors to DM shows the significance of the common factors when it is combined with a supervisory approach (DM) that is so widely associated with effective supervision. The *integration* of DM and MI actually depends on the common factors. First, Bernard clearly recommended that the supervisor give careful consideration of exact supervisee needs and adopting interventions that match them carefully [17]. This attention requires the supervisory conditions that are fostered through the common factors. Therefore, when examining *any* dilemma faced in supervision, it is important to consider the exact nature of the dilemma, the subjective reaction of the supervisee, the extent to which the supervisee harbors adequate knowledge, and to the extent to which the supervisee can serve as their own expert in a particular matter (tenets of the DM).

One can readily see that in the exploration of these supervisory themes, the common factors quickly rise to the surface. The exploration of supervisory dilemmas must be conducted with empathy for the conditions of treatment relationship as well as the individual experience of the supervisee. Adding MI to the work *also* begins with the reflection of empathy by the supervisor encourages the expression of the therapist and facilitates the assessment and associated of supervisory work. The accuracy of the supervisory assessment and the effectiveness of the MI interventions are also promoted by a supervisory stance that refrains from evaluating or judging the therapist as they work to express and resolve their dilemma. Finally, it is critical that the supervisor conduct the assessment and supervisory interventions in a manner that is genuine. As MI is applied to supervision in this way, one can see some ways that MI works naturally with the DM.

The integration of MI and DM may be illustrated at the abstract level by examining the 9-cell Discrimination model grid presented by Bernard in her seminal work [17] accompanied by MI concepts. **Figure 1** shows the DM grid first advanced by Bernard with three columns for the supervisor roles (teacher, counselor, consultant) and three rows for the therapy functions that may be a supervisory focus (process, conceptualization, personalization). Each cell is populated by an index number for the list sample activities that represent one of the MI basic activities as implemented in that particular cell.

*Supervision of Substance Abuse Therapeutics Emphasizing the Discrimination Model… DOI: http://dx.doi.org/10.5772/intechopen.97626*


### **Figure 1.**

*Integrative examples of motivational interviewing functions in the discrimination model context.*

What follows are indexed examples of SUD treatment supervision activities for each of the nine cells of the DM (with a sample MI function):


The originators of MI were clear about the important principles for intervention [40]. As noted above, the MI components that are central to this discussion are well matched to the common factors and the specific techniques associated with DM. For example, genuineness in the supervisory stance is a fundamental dimension of a working alliance and a major component of the common factors approach; genuineness is also a central tenet of MI. As previously noted, the conditions of the working alliance is associated with supervision outcomes. The optimal timing of feedback is best realized when the supervisor and trainee agree that the supervisory climate reflects the mutual trust and respect that are hallmarks of a strong alliance. Feedback is also made more useful when the trainee has had an opportunity to fully discuss their perspective on the supervisory dilemma; this is a common activity that maintains the supervisory alliance. The quantity of feedback is critical in providing the optimal balance of frustration and support for a supervisee. As has often been suggested, the specificity and concreteness of observations made in the feedback can enhance the receptivity of the trainee to the information and its eventual utility. Finally, it is important to close a difficult discussion with reflections on the trainee's experience of the feedback and its discussion. This final suggestion is critical to the continued largess of the supervisory alliance. It is an opportunity review the feedback process, revise the process for future discussions, and to renew shared goals and values for the continued supervision.

### **4.2 Examples of supervision of SUD treatment using MI & DM**

Madsen and his colleagues claimed that MI is useful in a number of situations that are unique to the supervision of SUD treatment [4]. This chapter argues that the DM *adds* to the MI approach and will now expand some of Madsen's examples to illustrate the synergy that is possible with the combined application of these two approaches. It is beyond the scope of this chapter to fully explicate all possible details of the integration of these two useful models, but the discussion of some key issues in the supervision of the treatment of SUDs can be very useful and lead to further experimentation by experienced supervisors. Some basic examples of the integration are presented in the prior section and we now turn to more extensive examples.

Madsen and colleagues [4] claimed that supervision of SUD treatment from an MI perspective is most likely to include critical functions in three particular situations that are likely to be a part of the treatment of SUDs. While the exact function of the supervision may be discussed from a variety of perspectives, these situations *are* critical in the treatment of SUDs in general. Madsen's common SUD treatment scenarios include 1) when it appears that a client has lied to a therapist, 2) when a therapist is unsure of how to properly maintain privacy with the

### *Supervision of Substance Abuse Therapeutics Emphasizing the Discrimination Model… DOI: http://dx.doi.org/10.5772/intechopen.97626*

treatment, and 3) the optimal procedures for working with recidivism. When a client has lied to a therapist in a manner that is challenging to a therapist, this can be evocative to the therapist, disrupt treatment success, and present specific dimensions which may call for different types of clinical approaches. The assessment of supervisee needs when she/he has been lied to begins in a careful understanding from the supervisor of the supervisee's description of their dilemma. In such a discussion, the supervisor will use MI concepts to develop and express understanding of conflicts in the supervisee and their experience of the dilemma. It is likely that the supervisee with have a variety of conflicting thoughts and feelings. Given the nature of this supervisory condition, the DM provides a window on the nature of the clinical dilemmas and supervisee turmoil without making assumptions about the therapeutic situation. With these complex understanding, the supervisor develops an opinion about the extent to which the supervisee needs help with the conduct of the session, how to understand the session, or how to work with their own reaction. During this process, the supervisor will cultivate an awareness of any conflict that exists within the supervisee that contributes to the expressed dilemma. This awareness contributes to the understanding of the locus of the dilemma (process, personalization, conceptualization) and the nature of any resistance experienced in the supervisee. Adopting the suitable role (DM: teacher, consultant, counselor), the supervisor can then begin to consider supervisory interventions in a strategic manner. One possible version of this scenario is that the therapist has been emotionally hurt by the betrayal by the client that is embedded in the patient's deception. However, the therapist feels restricted in their ability to fully experience and work with the nature of this reaction as well as feeling constricted in their ability to use their feelings to shape interventions. This supervisor could readily begin in the counselor role from an MI approach to assist the therapist with the richness and spontaneity of their reaction until its toxic quality has dissipated. The supervision then can shift to a consultant role regarding the therapy process and assist the therapist to consider possible interventions while instilling optimism regarding their potential success as a therapist at this juncture. As this unfolds, the supervisee is naturally encouraged to experience the optimism that characterizes the last step of MI. While this description of the process associated with deception from a client with an SUD has been necessarily brief, one can readily see how DM and MI readily work together and with the common factors to bring greater focus an optimal strategy to the supervisory encounter.

In the second common scenario, the therapist is presented with privacy in SUD treatment that be challenging to therapists at all levels. A hypothetical situation helps illustrate the use of DM an MI together in dealing with a thorny privacy matter. A loved one of a person in SUD treatment has called the therapist to advise the therapist that the patient has succeeded in eluding detection of their continued use of psychoactive substances. The loved one wants to know what the patient has really told the therapist about their current level of adaptation. The loved one suspects that the client has less than candid or potentially misleading to the therapist. On one hand, the therapist believes that the family of the patient could be very instrumental in assisting with the progress of the patient. This could be particularly true if the family knew about the nature of the patient's real struggles in treatment and could respond accordingly. Since there are legal and ethical prohibitions against the therapist disclosing such information outside the treatment relationship, the therapist is frustrated that what is perceived to be a tool for treatment is not available. This may be compounded by the reluctance of the patient to be forthcoming with loved ones because of a host of factors associated with SUD and recovery. The frustration of the therapist can interfere with the spontaneous generation and implementation of effective and appropriate viable treatment approaches

because of this conflict, so the dilemma clearly merits supervisory attention. The development of the supervisory themes should progress much as described in the prior scenario. The empathic stance of the supervisor assists in the process of open communication by the therapist and allows supervisor understanding of the dilemma. This can bring to light the impediments to clear clinical thinking as well as a greater understanding of the ways in which the therapist is tempted to behave in ways that are inconsistent with prevailing professional standards. This segment of the work which is promoted by the principles of MI allows for clarification of the focus of therapeutic the supervisory attention (concerning therapy process, therapist reaction, or therapist conceptualization of the treatment dilemma). Further exploration assists the supervisor in considering the most likely supervisory role to promote the desired educational effect (teacher, consultant, counselor). It is likely in this scenario that there are a variety of alternatives in the treatment that could respond to in some fashion to the prompting of the loved one without violating professional standards regarding privacy. However, such alternatives require careful consideration of the complex factors that converge on this dilemma and the proper DM role and focus can be brought to bear through MI methods as the painful and complicated dilemmas as sorted. As a result, the supervisor might be well advised to adopt more than one of the DM rolls in order to thoroughly provide the supervisory influence needed.

A final scenario to be considered is the somewhat common but regrettable circumstance of the SUD patient relapsing to substance use during the course of treatment. Despite the fact that such an occurrence is not particularly uncommon, its occurrence can be particularly difficult for early career therapists and an occasion for which heightened supervision can be critical for therapists at any level. The relapse of a patient can suggest failure to a therapist and be discouraging in the context of the therapist's considerable investment in learning to be a therapist and believing deeply in the importance of the work. This sensation can also be enhanced by their sentiments and perceptions associated with the work with a particular patient. Therapist responses to patient relapse can also be exacerbated by the therapist's reaction to treatment approaches espoused by the facility in which they work and the therapist's knowledge of treatment approaches in general. Given the possible emotionality and professional complexity of responding to a relapse, the initial assessment conducted by the supervisor as described in the prior two scenarios may garner even more importance and sensitivity. Despite these challenges, the principles that have already been described remain relevant in this particular treatment possibility. The supervisor is advised to listen carefully to how the dilemma uniquely impacts the therapist and the nature of the clinical restriction that follows. The integration of DM and MI can be particularly noticeable in this scenario because the patient relapse is not the end of the possibilities for the patient or for the treatment. The therapist's perception of the situation may be aggravated by policies and procedures of a treating facility and relevant legal situations for the patient, but it is unlikely that the long-term considerations are determined by a single relapse. As a result of the complexity of this dilemma, the supervisor must take care at the assessment phase to interact with the therapist in a way that helps the therapist come to an understanding of the supervisory goals and methods around this specific therapeutic occurrence.

### **5. Discussion**

This chapter has described the Discrimination Model of Supervision, the Motivational Interviewing approach to intervention, and how the two may be *Supervision of Substance Abuse Therapeutics Emphasizing the Discrimination Model… DOI: http://dx.doi.org/10.5772/intechopen.97626*

considered together in the context of the common factors of supervision as a way to promote the most sensitive and powerful supervision of the therapy of SUDs. MI was originally designed as a foundation for clinical work in which the service recipient was in conflict about change. After widespread and dissemination and some empirical support, MI was extended into the realm of supervision. The DM has been discussed and applied widely and appears to enjoy considerable clinical utility. Unfortunately, there is a paucity of empirical support for the structure of efficacy of the model. With the well-supported context of the common factors, this chapter has argued that MI and DM are significant contributions to the supervision of treatment of SUDs. Abstract considerations of combining the perspectives were followed by practical examples that demonstrated how these ideas could be integrated in practice.

Since this is one of the first attempts to integrate these two strong traditions, there is no empirical support for any of the intuitively plausible suggestions made in this work. As already noted, this further extends areas of clinical practice, such as the DM, for which there is a dearth of empirical support. Empirical support for these ideas will require difficult research designs with carefully delineated controls and predictions. In addition, employment of these methods will continue to evolve in parallel with any research efforts. Clearly this is an area of supervision practice in early stages. However, given the pressure on SUD treatment resources, supervision of such work should be supported through the continued promotion of clinical practice, cultivation of enhanced supervisory methods, and extensive research. The research must pursue support for the efficacy of supervision that uses DM and MI in combination in general as well as in specific conditions of SUD treatment.

### **Conflict of interest**

The authors have no conflict of interest, financial or otherwise.

### **Author details**

John A. Mills\* and Maren Krizner Indiana University of Pennsylvania, Indiana, PA, USA

\*Address all correspondence to: jamills@iup.edu

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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### **Chapter 9**

## An Evaluation of Diverse Therapeutic Interventions for Substance Use Disorders: Serotonergic Hallucinogens, Immunotherapy, and Transcranial Magnetic Stimulation

*William M. Meil, William Farrell and Reem Satti*

### **Abstract**

Substance Use Disorders are a substantial public health concern whose treatment remains challenging. High rates of relapse are in fact a hallmark of drug addiction despite the wide variety of psychotherapeutic and pharmacotherapeutic approaches. This chapter discusses three innovative and controversial therapeutic approaches for Substance Use Disorders that have received considerable attention: the use of classic serotonergic hallucinogenic drugs (LSD and psilocybin), addiction immunotherapy and anti-addiction vaccines, and the use of transcranial magnetic stimulation. These treatments are not necessarily new but are discussed because they represent a diverse set of approaches that address varied aspects of drug addiction. Furthermore, they have an accumulated body of research from which to assess their future viability. For each of these therapeutic approaches this chapter considers the theoretical basis for use, history, status of the literature supporting their use, limitations, and potential applications. While these three interventions represent highly varied approaches to the treatment of Substance Use Disorders, this diversity may be necessary given the complex nature of addictive disorders.

**Keywords:** Pharmacotherapy, hallucinogens, addiction vaccines, addiction immunotherapy, transcranial magnetic stimulation

### **1. Introduction**

Substance Use Disorders (SUDs) are likely to be chronic conditions for many effected individuals [1, 2] and are associated with a variety of negative physical and psychological health outcomes [3, 4]. Among those treated for drug and alcohol dependence, 40–60% relapse within a year of treatment cessation [5, 6]. Longitudinal cohort studies have demonstrated significant relapse rates across a variety of substances and yielded insight into predictors of remission and relapse. A recent meta-analysis of 21 long-term remission studies, conducted between 2000 and 2015, examined follow-up periods with a minimum of three years or reported

lifetime remission. The results showed 35–54% achieved remission after a mean follow-up of 17 years. Moreover, the pooled estimated annual remission rates suggested yearly remission was uncommon ranging between 6.8% and 9.1% [2]. The conclusion that SUDs are likely to be long-term in nature is consistent with studies likening them to other chronic diseases and highlights the need for treatment to address the chronicity of SUDs [5].

Despite the poor long-term prognosis of SUDs, research suggest treatment is often efficacious in the short-term [7] as well as able to positively affect the longterm outcomes [7, 8]. Multiple longitudinal cohort studies support the efficacy of a variety of therapeutic approaches while at the same time revealing significant heterogeneity of treatment responsivity. For example, individuals treated for Alcohol Use Disorders (AUDs) via Alcoholics Anonymous (AA), formal treatment, or a combination of the two are more likely to be abstinent after 8 years than untreated individuals, however the AA only group surpassed the formal treatment group at 1- and 3-year follow-ups [9]. Another study of adults with AUD, most of whom were entering treatment, revealed five trajectory classes distinguished by their changes in drinking patterns across three years with AA involvement predicting abstinence and/or declines in drinking over time [10]. A recent prospective longitudinal cohort study examining heroin use and treatment utilization over 10–11 years also identified five trajectory groups related to treatment utilization and continued drug use [8].

Addiction is fundamentally a brain disease in which chronic use of substances produce neuroplastic changes across multiple brain systems rendering a person more vulnerable to drug craving, escalating use, and relapse. Depending on the effected system, these changes yield increased incentive salience towards the drug and drug associated cues, attenuated reward, motivation, emotion, and altered stress responsivity. These changes are also coupled with deficits in the prefrontal

### **Figure 1.**

*Therapeutic interventions under development and their putative mechanisms of action (second row from top) and posited anti-additive effects (third row from the top).*

### *An Evaluation of Diverse Therapeutic Interventions for Substance Use Disorders… DOI: http://dx.doi.org/10.5772/intechopen.98514*

cortex and related circuitry leaving drug addicted individuals with diminished executive function and enhanced impulsivity. Moreover, the extent to which these neural adaptions change over time appears to vary, but many have been shown to be highly durable. These neural changes must also be considered within the context of an individual's genetic and epigenetic vulnerabilities, and life circumstances [11–13]. The complexity of variables which contribute to the development of SUDs make them particularly challenging to understand and treat, but they also offer a bevy of targets to develop new treatment approaches.

The purpose of this chapter is to examine three putative treatments for SUDs: serotonergic hallucinogens, immunotherapy approaches, and transcranial magnetic stimulation [TMS]. These treatments are not necessarily new but were chosen because they represent a diverse set of approaches that address varied aspects of drug addiction (see **Figure 1**). Moreover, they have an accumulated body of research from which to assess their future viability. For each of these therapeutic approaches this chapter will address the theoretical basis for use, history, status of the literature supporting their use, limitations, and potential applications.

### **2. Serotonergic hallucinogens and substance use disorders**

Hallucinogenic drugs represent a diverse set of naturally occurring and synthetic substances which vary based on their pharmacological actions and psychoactive effects. The term hallucinogen typically refers to a drug that produces perceptions in the absence of sensory stimuli. However, it is now recognized that hallucinogens produce a broader range of effects across cognition and mood and that hallucinations themselves are less common than the perceptual illusions and sensory distortions they produce. For this reason, the term psychedelic, or mind manifesting, is often used to describe this class of drugs [14, 15]. This section of the chapter focusses on lysergic acid diethylamide (LSD) and psilocybin, two hallucinogens typically referred to as classic serotonergic hallucinogens because they act primarily as agonists on the serotonin (5-HT) 2A receptor and share behavioral effects and proposed therapeutic mechanisms [14].

Psilocybin occurs naturally in more than 200 species of mushrooms and has long been consumed by indigenous cultures to engage with the spiritual world [16, 17]. Albert Hofmann isolated psilocybin and its active metabolite psilocin and subsequently synthesized them in 1958 [18]. LSD was first synthesized in 1938 by Hofmann from ergotamine, a compound found in ergot fungus. After preclinical administration failed to reveal many observable effects in laboratory animals its psychoactive properties were recognized following an accidental ingestion of the drug by Hofmann in 1943. Beginning in the mid-1950s LSD and psilocybin were widely distributed under the names Delysid and Indocybin for study of multiple psychological disorders resulting in more than 1000 papers, treating more than over 40,000 individuals by the mid-to-late 1960's [16, 18–20].

The main focus of research through the late 1960s on the efficacy of hallucinogens in the treatment of addiction was the ability of LSD to attenuate alcoholism [21]. Among the first studies was that of Hoffer & Osmond [22] who followed 24 treatment resistant alcoholics. After taking several weeks to establish a psychotherapeutic relationship, participants were administered a single dose of 200–400 micrograms of LSD while accompanied by a nurse and/or a psychiatrist and in many cases, efforts were made to create a therapeutic environment. The next day, participants were asked to write about their experience. Six participants were considered much improved (complete abstinence and positive lifestyle changes) and another six improved at the conclusion of the study [22].

This early research was influential in establishing a treatment model referred to as "psychedelic therapy" [22], though over time the nature of treatment sessions has varied greatly [21, 23]. Central to this therapeutic approach is the idea that patients will experience a psychedelic peak characterized by an ecstatic state, visual hallucinations, a loss of boundaries between the individual and the objective world, feelings of unity with others, nature, God and the universe [19, 21]. The result of this peak being the induction of a mystical experience that would profoundly alter the way a person views themselves and the world [20]. The dramatic nature of this experience is then interpreted with the assistance of a trained therapist who helps the patient appreciate the psychotherapeutic benefits of the experience [24].

In the following years more than 20 studies with larger sample sizes were published illustrating the effectiveness of LSD for treating alcoholism with many describing unprecedented levels of success [19, 25]. From*,* 1954–1960 Osmond and colleagues studied the effects of LSD on approximately 2000 alcoholics finding almost half were abstinent after a year [26]. However, by and large this body of research suffered from significant methodological flaws among them a lack of diagnostic specificity, non-random assignment of participants, lack of control and or placebo groups, inconsistent participant follow-up, participant attrition, absence of blind raters, and a lack of clarity in assessing treatment efficacy. Despite these flaws, these early findings were encouraging enough that by the late 1960s six alcoholism treatment programs in North America used LSD based therapy [19, 23, 25].

Gradually some of the methodological problems that plagued earlier studies were partially addressed and a meta-analysis was conducted of six randomized controlled studies (five of which were double-blind) between 1966 and 1970 examining the efficacy of LSD in the treatment of alcoholism [27]. Across these studies 536 adults suffering from alcoholism were compared to 211 control participants receiving a low-dose LSD, d-amphetamine, ephedrine sulphate or non-drug control. While the characteristics of LSD sessions and follow up varied considerably, the results supported the efficacy of a single dose of LSD. Decreases in alcohol misuse were observed at 2–3 and 6 months, but not 12 months post-treatment. Moreover, in three studies reporting total abstinence from alcohol, LSD showed benefits 1–3 months after discharge from treatment programs. Despite these results, research examining the utilization of LSD for alcoholism stalled by the late 1960s due to increased recreational use, its association with the drug counterculture movement, increased restrictions on human drug research, continued methodological concerns, ambiguous results, and passage of the Controlled Substances Act of 1970, which placed LSD in the most restrictive category of drugs [15, 18, 25, 28].

After a cessation of almost 30 years, controlled studies in humans using hallucinogens resumed in the late 1990s [18, 24]. However, Psilocybin, not LSD, emerged as the drug of choice to study the effects of hallucinogens on SUDs [18, 23, 24]. Multiple reasons have been put forward for psilocybin's emergence in this context. Psilocybin has a shorter duration of action compared to LSD, and psilocybin is believed to have a milder side effect profile producing less anxiety, affective disturbances, and milder vegetative side effects [16, 28]. Also, LSD may still suffer from its negative counterculture reputation of the 1960s and a litany of mass media misinformation including exaggerated claims of drug-induced insanity, chromosomal damage, and other falsehoods [14, 15]. In contrast there is growing interest in certain locales to legalize psilocybin's use in licensed facilities for mental health purposes and decriminalize it in others [29].

Among the limited number of recent studies is a small open-label trial with psilocybin for AUD [30]. Psilocybin was administered to 10 alcohol dependent individuals in context of a 12-week program of motivational enhancement therapy. Participants were initially administered 0.3 mg/kg of oral psilocybin followed by

### *An Evaluation of Diverse Therapeutic Interventions for Substance Use Disorders… DOI: http://dx.doi.org/10.5772/intechopen.98514*

a second dose of 0.3 or 0.4 mg/kg, 4 weeks later. The two doses of psilocybin were separated by four therapy sessions and the final dose was followed by another four sessions. Following the initial psilocybin treatment self-reported alcohol use significantly decreased and remained below baseline at a 36-week follow-up. In addition, significant correlations were reported between the overall intensity and mystical quality of psilocybin sessions and reductions in the percent of drinking days, alcohol craving, and self-efficacy to abstain.

Research examining psilocybin's ability to treat nicotine addiction is also promising. An open-label study was conducted with 15 treatment-resistant, nicotine dependent participants administered 2–3 moderate and high doses of oral psilocybin integrated within a 15-week cognitive behavioral therapy program. Using biologically based verification procedures at a 6-month follow-up 80% of participants were abstinent, at 12 months 67% remained nicotine free, and at 16 months 60% were abstinent. After a long-term follow-up averaging 2.5 years, 75% of study participants were verified as nicotine free. Moreover, participants abstinent at 6-months scored higher on measures of mystical experiences following psilocybin compared to those who relapsed. Greater mystical-type experiences following psilocybin administration also correlated with reduced nicotine cravings at 6 months. At the 12-month follow-up participants rated their psilocybin experience among the 5 most personally meaningful and spiritually significant of their lives [31, 32].

A variety of additional factors speak to the potential viability of serotonergic hallucinogens for the treatment of SUDs. A single or a limited number of drug administrations during supervised treatment sessions may negate a number of liabilities associated with other pharmacotherapies such as high cost, problems with medication adherence, drug interactions and side effects [24]. LSD and psilocybin have a limited addictive liability as indicated by a lack of drug self-administration by laboratory animals [28, 33], relatively slow onset of effects after oral administration not typically characterized by pleasure or craving and has no direct effects on the brain dopamine pathways [15]. Physical withdrawal symptoms do not develop even following prolonged use of LSD and psilocybin and the rapid development of dramatic tolerance, on the order of days, does not facilitate the acquisition of addictive behavior [14, 33]. Methodological details associated with the use of psilocybin for treatment of SUDs can be found in several sources [21, 31, 33].

The general public's perception that psychedelic drugs are dangerous, contradicts the fact that from a physiological perspective they are among the safest classes of drugs [15]. Both drugs are not without their liabilities [14, 15, 28, 33], yet substantial toxicity has only been associated with a small number of users [28] In the context of clinical use, the incidence of problems is substantially mitigated as patients are typically prescreened for psychotic symptoms and cardiovascular issues, receive a single or a small number of doses, pharmacotherapies may be available to reverse untoward effects, and therapeutic sessions are supervised by a trained clinician [24, 34]. Recent trials examining the efficacy of these hallucinogens for SUDs have reported no serious adverse effects [30–34] nor have trials examining these hallucinogens in patients with anxiety, depression, or healthy volunteers [18].

A variety of mechanisms have been suggested to explain the therapeutic efficacy of LSD and psilocybin for SUDs and many overlap with proposed explanations for addressing other psychological disorders [18, 34]. Depression and anxiety are hallmarks of addiction [17]. Both negative affective states have been shown to be ameliorated following LSD and psilocybin administration [18, 19, 34] and are linked to prolonged increases in optimism and wellbeing [17]. While it cannot be ruled out that these drug's effects on mood and anxiety are part of a broader mechanism, the fact that antidepressants [35] and anxiolytics [36] alone are generally not

effective treatments for managing SUDs suggest this represents at best an incomplete explanation for hallucinogens therapeutic effects for SUDs.

It has been widely suggested that LSD and psilocybin's experiential effects underly their benefits for treating SUDS [17]. Alcoholics Anonymous has long argued that addiction follows from deficits in spirituality and meaning [37]. Bill Wilson one of the co-founders of Alcoholics Anonymous, credited his experiences with hallucinogens as the reason for his own abstinence and advocated for LSD as a pathway to sobriety [38]. Spirituality has been demonstrated to play a role in the success of Alcoholics Anonymous [39] and other therapeutic approaches [40] and a sense of purpose in life decreases chronic heavy drinking [10]. The benefits of hallucinogenic-based therapeutic experiences may also lie in their intensity [17] as their effects are often described as life changing in nature [31, 32] and research has shown users who experience the most profound mystical experiences consistently undergo the greatest symptom relief [15]. Moreover, stronger mystical experiences and greater intensity of subjective effects of psilocybin are associated with alcohol and nicotine abstinence suggesting a mediating role of mystical experience in psychedelic-facilitated addiction treatment [30, 41].

Consistent with the importance of hallucinogen induced experiential effects recent research using brain imaging in healthy volunteers has shown LSD and psilocybin decrease functional connectivity in the default mode network (DMN), a pathway bilaterally spanning the medial and lateral parietal, medial prefrontal, and medial and lateral temporal cortices, and whose activity appears augmented in depressed patients [24, 42, 43]. Moreover, administration of both drugs was associated with "ego-dissolution" and "altered meaning" suggesting the importance of this circuit for the maintenance of "self" or "ego" and its processing of "meaning" [43, 44]. These results and those of other studies support the idea that classic hallucinogens may function to increase processing of positive stimuli and decrease processing of negative stimuli, elevate mood, and decrease coupling of neural networks allowing for unrestrained exploration of spirituality and meaning [21, 24]. Imaging studies of this network in those with SUD following administration of hallucinogens and after periods of abstinence are needed.

It is noteworthy that past and present research examining the efficacy of LSD and psilocybin in combination with psychotherapy for the treatment of SUD has been consistently promising [18]. Their benefits compare favorably with daily administration of naltrexone, acamprosate, and disulfiram for the treatment of AUD [27] and exceed success rates of behavioral and pharmacological interventions for nicotine dependence [31]. In addition, this approach represents a sea change in the dramatic, broad, and long-lasting nature of its effects and appears relatively safe when administered in a clinical setting. Recently a therapeutic model specifically for psilocybin-assisted treatment of AUD has been proposed [21], as have a neuroscience based mechanistic theory of explaining psilocybin's efficacy for treating SUD [28], and larger randomized studies are now being conducted on the efficacy of psilocybin for AUD, nicotine, and cocaine dependence [34, 45]. However, the above advances should be tempered with the knowledge that recent research has had small samples, this approach is demanding on both the patient and therapist, hallucinogens and hallucinogen-assisted psychotherapy have a negative reputation and are misunderstood by many [24, 45, 46].

### **3. Addiction immunotherapy: anti-addiction vaccines**

The primary immunotherapies being developed for SUDs are vaccines that cause the generation of antibodies directed against drugs of abuse such as cocaine, *An Evaluation of Diverse Therapeutic Interventions for Substance Use Disorders… DOI: http://dx.doi.org/10.5772/intechopen.98514*

nicotine, and opioid analgesics. The underlying rationale is that once drugs of abuse are bound to antibodies, the resulting complex is too large to cross the blood–brain barrier. This reduces the amount of abused substance that reaches the central nervous system (CNS) and thereby reduces the rewarding effects of the drugs. The development of vaccines for drugs of abuse is complicated by the fact that the drugs themselves are small molecules that do not inherently elicit an immune response. To overcome this obstacle, drug molecules or their derivatives (haptens) are typically attached to an immunogenic carrier molecule and administered with adjuvants to stimulate the generation of antibodies directed against the drug. Vaccine candidates have been developed against several drugs of abuse using variations on this approach [47].

Cocaine abuse represents a condition for which a vaccine could be of particular use since there are currently no approved pharmacotherapies to promote abstinence or prevent relapse. Studies in the 1990s conducted in rodents demonstrated that anti-cocaine vaccines could induce the generation of cocaine-specific antibodies and reduce cocaine levels in the brain following peripheral cocaine administration [48, 49]. Additionally, vaccination reduced the psychostimulant (locomotion and stereotopy) effects of cocaine in rats [48], and vaccination or the administration of monoclonal antibodies against cocaine reduced cocaine self-administration and the reinstatement of cocaine self-administration following extinction in rats [49, 50].

Two cocaine vaccines are currently listed on ClinicalTrials.gov. The vaccine that has been most studied is the TA-CD vaccine. This vaccine, which consists of succinylnorcocaine (SNC) attached to a recombinant cholera toxin B (rCTB) carrier administered with aluminum hydroxide adjuvant, caused the generation of cocainespecific antibodies in rats and reduced cocaine self-administration [51]. The results of a randomized, double-blind, placebo controlled, Stage I clinical trial in which 34 former cocaine abusers in a residential treatment facility were randomized to receive three vaccine injections during the first two months of the study at doses of 13, 82 or 709 mg or an equivalent number of placebo injections (n = 6) indicated that the vaccine was well tolerated and elicited the dose-dependent production of cocaine-specific antibodies which peaked after the third injection and declined over the remainder of the year-long study [52]. A subsequent open-label, outpatient, treatment study involving 18 cocaine-dependent participants indicated that participants who received a total of 2000 mg of vaccine administered in five equal injections over 12 weeks achieved higher mean peak antibody titers and reduced cocaine use over 12 weeks relative to participants who received a total of 400 mg of vaccine administered in four equal injections over 8 weeks [53]. The majority of participants who did use cocaine during the study reported a reduction in the euphoric effects of the drug. The results of a subsequent study conducted in a laboratory setting with participants who were actively abusing cocaine indicated that participants with immune responses to the TA-CD vaccine above the 50th percentile reported reduced positive subjective effects of smoked cocaine [54].

The results from a 24-week Phase IIb clinical trial conducted with 115 cocaineand opioid-dependent participants enrolled in an outpatient methadone program found that participants who mounted a robust antibody response (≥43 mg/ml) following five vaccine injections (360 mg each) administered over the course of 12 weeks had a higher number of cocaine free urine tests during weeks 9–16 of the study than participants who received placebo injections or who produced a smaller antibody response to the vaccine [55]. These participants were also more likely to exhibit a 50% reduction in cocaine use between weeks 8–20 of the study relative to those who mounted a less robust immune response to the vaccine. However, a subsequent randomized, double-blind, placebo-controlled, Phase III clinical trial involving 300 cocaine-dependent participants in outpatient treatment programs across six sites failed to demonstrate efficacy of the TA-CD vaccine [56]. Participants in this study received five vaccinations (400 mg each or placebo) over the course of 13 weeks, and 67% of the fully vaccinated participants displayed a robust antibody response (≥42 mg/ml). Vaccinated participants did not, however, have fewer cocaine-positive urine tests than participants receiving placebo injections, and participants with a robust antibody response did not exhibit a significant reduction in cocaine-positive urine tests relative to participants who mounted a lesser immune response. Participants who generated robust immune responses to the vaccine were, however, more likely to complete the study than those with weaker immune responses.

The second cocaine vaccine undergoing clinical trials is the dAd5GNE vaccine. One major drawback to the TA-CD vaccine was that it did not consistently elicit high titers of cocaine-specific antibodies. For example, in one study [55] only 38% of the vaccinated participants generated antibodies at the concentration projected to be required for efficacy. The dAd5GNE vaccine consists of the cocaine analog, GNE (6-(2R,3S)-3-(benzoyloxy)-8-methyl-8-azabicyclo [3.2.1] octane-2-carboxoamidohexanoic acid) connected to disrupted adenovirus capsid proteins administered with Adjuplex (Advanced BioAdjuvants, LLC, Omaha, NB) adjuvant, and was designed to elicit a strong immune response from humans [57]. In rodents, this vaccine has been demonstrated to elicit high and persistent titers of cocaine-specific antibodies, attenuate the passage of cocaine from the peripheral circulation to the brain, reduce cocaine self-administration on a progressive-ratio schedule, and reduce cocaine-induced reinstatement of cocaine self-administration following extinction [57, 58]. The vaccine also produced high antibody titers in Rhesus macaques, reduced the penetration of cocaine to the CNS [59], and reduced reacquisition of cocaine self-administration following extinction [60]. The dAd5GNE vaccine is currently in a Phase I clinical trial, but results are not yet available.

Vaccines have also been developed against nicotine with the intention of helping users quit and remain abstinent. Vaccines that have been or are being examined in clinical trials include NicVax, Nic-002 (Nic-Qb), TA-NIC, Niccine, and SEL-068. None of these vaccines are currently approved for the treatment of tobacco use disorder, but further refinement and evaluation appears to be warranted. Because peer reviewed data related to many of these vaccines are limited, this discussion will focus on NicVax and Nic-002 (Nic-Qb). NicVax (3′-AmNic-rEPA) was one of the earliest candidate vaccines directed against nicotine. In preclinical studies, antibodies generated in response to this vaccine in rabbits and injected into rats reduced the passage of intravenously administered nicotine to the brain in a dose-dependent manner and attenuated the effects of nicotine on systolic blood pressure and locomotor activity [61]. Similarly, active immunization of rats elicited the production of nicotine-specific antibodies and also attenuated the passage of nicotine to the brain [61]. Active immunization also reduced nicotine self-administration in rats [62].

Single photon emission computed tomography (SPECT) data collected from nicotine-dependent human participants, indicates that active immunization with NicVax reduces the binding of nicotine to β2-nicotinic acetylcholine receptors in the brain [63], and the results of a study involving 68 current smokers assigned to receive four injections of vaccine (50, 100, or 200 mg) or placebo indicated that the vaccine was well tolerated and that the nicotine-specific antibodies were elicited in quantities believed to be sufficient for efficacy at the highest dose [64]. Participants receiving the highest dose of vaccine were also more likely to achieve 30 days of abstinence than participants receiving lower doses of the vaccine or placebo injections. The results of a subsequent Phase II clinical trial [65] in which 301 smokers were assigned to receive four or five doses of NicVax (200 or 400 mg/injection) or placebo over the course of 26 weeks indicated that participants who received five

*An Evaluation of Diverse Therapeutic Interventions for Substance Use Disorders… DOI: http://dx.doi.org/10.5772/intechopen.98514*

400 mg doses of vaccine had higher prolonged abstinence rates through both 6 and 12 months relative to participants receiving placebo. In addition, participants with the highest antibody response (top 30% across all vaccine doses) were more likely to achieve eight weeks of abstinence between weeks 19–26 of the study, had higher rates of continuous abstinence from weeks 19–52 of the study, and had higher rates of 7-day point prevalence abstinence at weeks 26 and 52 of the study compared to participants receiving placebo. Participants in the high antibody response group were also more likely than participants receiving placebo to exhibit prolonged abstinence through 6 and 12-months. Unfortunately, while two subsequent Phase III clinical trials with NicVax confirmed that the vaccine was safe and well tolerated, six injections (400 mg each) of NicVax failed to significantly alter abstinence rates relative to placebo [66]. An additional Phase IIb study was conducted on the effectiveness of NicVax in combination with varenicline and motivational interviewing, however, this study too failed to establish a significant effect of NicVax on abstinence rates relative to participants receiving placebo [67].

Nic-002 (Nic-Qb), a vaccine consisting of a virus-like particle (VLP)-nicotine conjugate also showed both preclinical and clinical potential for reducing nicotine use. This vaccine yielded high titers of nicotine-specific antibodies in mice, rats, and rabbits, and vaccination of mice significantly reduced brain nicotine levels [68]. The report of the results from a European Phase I randomized, placebo controlled clinical trial in which 32 healthy human participants received two vaccinations separated by four weeks and 8 participants received control injections indicated that the vaccine was generally well-tolerated and produced a robust immune response with high affinity, nicotine-specific antibodies [68]. The results of a subsequent phase II study in which participants, were scheduled to receive five 100 mg vaccinations of Nic-002 with alum adjuvant (n = 229) over four months or alum alone as the placebo (n = 112) [69] indicated that, continuous abstinence rates from months 3 to 6 of the protocol, did not differ between the vaccination (30.1%) and placebo groups (26.1%), the 1/3 of participants with the highest antibody response had a significantly higher continuous abstinence rate from months 2 through 6 of the study (56.6.%) compared to participants receiving placebo (31.3%). Furthermore, this effect was maintained through month 12 of the study (41.5% vs. 21.3%). While researchers believed these results to be encouraging, Novartis announced that an interim analysis of data from a subsequent Phase II study indicated that the vaccine failed to improve continuous abstinence rates, likely due to insufficient antibody titers [70], and its development appears to have been halted.

Developing vaccines against opioid analgesics presents some unique challenges. One consideration is that unlike nicotine and cocaine the metabolites of many opioid drugs are active and can have physiological and psychological effects of their own. A second consideration is that if vaccines are to be used for the treatment of opioid use disorder, they should not bind to and inactivate opioids that are used to assist with treatment for the disorder or are used to prevent overdose. Finally, vaccines directed against one opioid analgesic will ideally not bind to other analgesics which may be needed for pain management. While no opioid vaccines have been tested in clinical trials, several candidate vaccines have emerged from preclinical investigations with promising results against heroin, oxycodone and fentanyl.

One example of a vaccine that appears promising for the treatment of heroin use consists of a heroin-tetanus toxoid (TT) combination [71]. Following administration heroin is rapidly metabolized to 6-acetyl morphine (6 AM) and subsequently to morphine, and these two metabolites act via mu-opioid receptors to generate heroin's antinociceptive and rewarding effects. Preclinical studies with this vaccine have demonstrated that it generates substantial antibody titers with high affinity for 6 AM and heroin and much lower affinity for morphine, oxycodone, and methadone in both mice and monkeys. Additional vaccines using haptens derived from morphine, have also been demonstrated to reduce the CNS-mediated behavioral effects of heroin [72].

Vaccines have also been developed that attenuate the behavioral and physiological effects of oxycodone and/or hydrocodone in rodents [72]. One of these vaccines, comprised of an oxycodone-based hapten conjugated to keyhole limpet hemocyanin (KLH), is notable, in part, for the specificity of its action [73]. Rats immunized with this vaccine generated antibodies with high affinity for oxycodone and, to a lesser extent oxymorphone, an active metabolite of oxycodone. Importantly cross-reactivity with naloxone and naltrexone was 1.2% or less and was undetectable for methadone and buprenorphine. Vaccination also reduces brain oxycodone levels by as much as 51% following intravenous administration of 0.5 mg/kg of oxycodone and significantly reduced the antinociceptive effects of oxycodone as indicated by performance on the hot-plate test. Furthermore, vaccination significantly reduced the acquisition of oxycodone self-administration and the number of infusions administered indicating a reduction in reinforcing effects of the drug.

Given the ongoing opioid crisis, a vaccine with clinical potential has also been developed against fentanyl [74]. This vaccine consists of a fentanyl-based hapten conjugated to either KLH or GMP-grade subunit KLH (sKLH). Vaccination elicited an immune response containing fentanyl-specific antibodies in mice and reduced the antinociceptive effects of fentanyl (0.05 mg/kg, s.c.) by 60% as assessed by the hotplate test. In addition, this vaccine elicited an immune response from rats and reduced the antinociceptive effects of fentanyl (0.05 mg/kg, s.c.) by 93% without significantly attenuating the antinociceptive effects of heroin or oxycodone. Fentanyl levels in the brain were also reduced by 30% following peripheral fentanyl administration (0.05 mg/kg, i.v.), and vaccination attenuated fentanyl-induced respiratory depression. Importantly, naloxone (0.1 mg/kg, s.c.) still reversed fentanyl-induced antinociception and respiratory depression following vaccination, indicating the vaccine does not render this important, life-saving drug ineffective.

While the results of clinical trials conducted thus far with vaccines against drugs of abuse have failed to yield consistent results indicating effectiveness, examination of the results obtained from participants who mounted a robust immune response has been encouraging. One hope is that advances in vaccine design improve will immune responses from participants [75]. Providing exogenous monoclonal antibodies against drugs of abuse to vaccinated participants might also provide a means of assuring that vaccine recipients have high antibody titers. This approach yielded improvements in combating the behavioral effects of nicotine in rats relative to vaccine administration alone [76]. It is also possible that modifying the route of administration could improve the efficacy of vaccines. For example, intranasal vaccine administration has been demonstrated to increase mucosal antibody levels against nicotine which could aid in the rapid immobilization of inhaled nicotine [77]. Intranasal administration of a cocaine vaccine has also recently been demonstrated to have advantages preventing cocaine-induced locomotion in mice [78].

Beyond simply attenuating the rewarding effects of drugs of abuse, vaccines may present additional advantages for SUD. Unlike available pharmacotherapies, the effects of vaccines can be long-lasting and require only periodic booster immunizations to maintain effectiveness. This may make vaccination more cost-effective than other treatments and preclude the need for daily adherence to drug regimens. Vaccines against drugs of abuse should also have a reasonably low behavioral/psychological side-effect profile as they do not have CNS effects of their own. Because of the lack of direct CNS effects, well designed vaccines should also not interfere with other

### *An Evaluation of Diverse Therapeutic Interventions for Substance Use Disorders… DOI: http://dx.doi.org/10.5772/intechopen.98514*

pharmacotherapies for substance use and could be combined with such therapies to enhance effectiveness. For example, while antagonist medications may be able to reduce the rewarding effects of drugs of abuse, users may increase their drug use in an attempt to override the blockade. This could leave the individual vulnerable to dangerous peripheral effects of the drugs. Vaccines may aid in combating these peripheral effects by limiting drug availability in the periphery as well. Co-administrations of vaccines against multiple drugs also has potential usefulness for individuals who abuse a mixture of substances such as fentanyl-laced heroin. The effectiveness of one such vaccine mixture (heroin/fentanyl) has recently been seen in mice [79].

Despite their promise, vaccines against drugs of abuse have several limitations. For example, vaccinated individuals could potentially increase substance intake to overwhelm the antibodies generated in response to the vaccine, and evidence of increased substance use by at least some participants has been reported in some of the studies discussed above [55, 56]. Additionally, participants with insufficient motivation to remain abstinent could discontinue treatment. Current skepticism about vaccines may also reduce the attractiveness of vaccines as an SUD treatment. Despite these limitations, with improvement, vaccination against drugs of abuse may still prove to be an efficacious tool to aid motivated individuals in recovery.

### **4. Transcranial magnetic stimulation and substance use disorders**

Transcranial Magnetic Stimulation (TMS) is a noninvasive medical procedure involving the application of fluctuating magnetic pulses generated from a coil placed over the scalp that passes through the skull and into the brain generating electrical currents which alter neural activity by electromagnetic induction. The coil design can influence intensity, localization, and depth of stimulation. Multiple TMS pulses administered consecutively are referred to as repetitive or rTMS. Low frequency rTMS (LF-rTMS; ≤ 1 Hz) typically attenuates neural excitation and cortical excitability and higher frequency rTMS (HF-rTMS; 1–20 Hz) augments neural excitation, cortical excitability, and regional cerebral blood flow. Stimulation parameters, anatomical loci, and the current cortical activity also influence its facilitative or suppressive effects. rTMS results in strong moderately localized intracranial currents in the underlying cortex but also produces long lasting complex changes, neurotransmitter release, plasticity, and connectivity in distal neural circuitry [80–83]. The present form of TMS traces its origins to Barker and Colleagues who demonstrated the effects of magnetic stimulation on human motor cortex in 1985 [84]. The therapeutic efficacy of rTMS is currently under study for many psychological disorders and has U.S. Food and Drug Administration approval for the treatment of Major Depressive Disorder in adults [80].

The methods and mechanisms associated with rTMS-induced neuroplasticity and therapeutic efficacy for SUD are complex and reviewed elsewhere [80–83], however, the majority of studies have targeted the prefrontal cortex, more specifically the dorsolateral prefrontal cortex (DLPFC) [81–83]. This structure represents a desirable target not only for its accessibility but because it has been directly linked to neuroplastic changes associated with craving, impulsivity, and executive function all of which play central roles in addiction [80, 81]. Moreover, the DLPF is highly interconnected with other cortical and subcortical circuits associated with anhedonia, escalation of use, and relapse [82]. The potential of this approach has resulted in a significant number of studies in a relatively short period across a variety of addictive substances, brain loci, and employing a wide range of rTMS methods [81–83]. Most studies on the effects of rTMS for SUD have focused on

alcohol, cocaine, and nicotine and those literatures are highlighted below. Limited research has examined opiates, methamphetamine, and cannabis [85–87].

Multiple sham-controlled studies have been conducted to examine the efficacy of HF-rTMS on individuals with AUD with mixed results. One single-blind study examined rTMS (10 Hz) in 10 sessions to the right DLPFC and measured selfreported cravings at baseline following treatment and after 4 weeks. Significant decreases in craving were reported in patients who received rTMS versus sham rTMS [88]. A similar double-blind study comparing 10 sessions of right versus left DLPFC HF-rTMS (10 Hz) stimulation following treatment in those with AUD showed no difference in efficacy based on the side of treatment of administration but a significant reduction in craving scores in those administered rTMS [89]. Other studies using rTMS on the DLPC have failed to show effects of alcohol craving in those with AUD. A single session of rTMS versus sham treatment to the right DLPFC did not reduce craving immediately following treatment or when measured at home several days later [90]. Similarly, no significant differences in alcohol craving were reported after 10 days between sham rTMS and HF-rTMS of the left DLPFC, (20 Hz) [91]. Moreover, rTMS targeting the insula in alcoholdependent participants in a double-blind, sham-controlled, randomized trial receiving 10Hz rTMS or sham stimulation 5 days a week for 3 weeks showed no effects of rTMS on craving and alcohol consumption. A recent systematic review and meta-analysis of the effects of transcranial direct current stimulation (tDCS; 11 studies) and rTMS (23 studies), most targeting aspects of the prefrontal cortex, on alcohol craving concluded there was no evidence of positive effects on alcohol craving [92]. However, the positive results found in some studies and the variability in study quality and methodology underscore the need for further research in this area [93].

To date no medication has clearly emerged as an efficacious treatment for cocaine or methamphetamine addiction [81], making the positive results with r-TMS for psychostimulant addiction particularly noteworthy. The benefits of a single 10 Hz rTMS exposure over right, but not left, DLPFC was found to transiently attenuate cocaine craving [94] and many studies have now illustrated the ability of multiple administrations to attenuate craving and use in cocaine dependent individuals. Among these is a between-subject randomized study examining stimulation of the left DLPFC using HF-rTMS (15 Hz administered during 8 sessions) versus a control group receiving a mixture of putative medications for cocaine addiction during a 29-day period. Results showed significantly more cocaine-free urine tests and lower craving scores in the rTMS treatment group [95]. In a study examining use, craving, and other markers indicative of cocaine dependence 20 individuals with cocaine use disorder (CUD) received 2 weeks of rTMS administration (15 Hz; 5 days/week, twice daily totaling 20 sessions) of the left DLPC, followed by 2 weeks of maintenance sessions (15 Hz, 1 day/week, twice a day). Of the 16 participants who completed rTMS treatment, 56% had negative urine tests, craving scores significantly decreased as did participants depressive symptoms, anhedonia, and anxiety [96]. Other studies have reported benefits of rTMS for CUD when applied to the medial prefrontal cortex [81] and rTMS induced reductions in methamphetamine craving [85]. As with other rTMS research, study protocols vary greatly when examining rTMS for psychostimulant craving and addiction, and it is of note that investigators are now attempting to synthesize knowledge gained across studies to design and optimize a rTMS protocols for treating CUD [97].

The significant degree of support for the efficacy of rTMS for SUD comes from research on nicotine dependence [83]. Multiple studies have reported 1–2 rTMS

### *An Evaluation of Diverse Therapeutic Interventions for Substance Use Disorders… DOI: http://dx.doi.org/10.5772/intechopen.98514*

sessions applied to the left DLPC results in reduced craving for cigarettes [83]. Repeated rTMS has also consistently yielded attenuated nicotine craving though the persistence of the effects remains unclear. For example, a randomized shamcontrolled study administering 10 daily (10 Hz) rTMS to the left DLPC reduced cigarette consumption as measured by self-report and urine cotinine levels and cue-induced craving, though these effects dissipated with time [98]. The majority of studies of rTMS for SUD have focused on the efficacy of rTMS alone while some started to examine it in combination with other therapies. One study examined participants randomly assigned to receive 13 daily treatments of high-frequency, lowfrequency or sham rTMS with and without cue exposure prior to treatment. Deep rTMS was bilaterally administered above the lateral prefrontal cortex and insula. High, but not low, frequency deep rTMS significantly attenuated cigarette smoking and when combined with smoking cues further facilitated reduction in cigarette use leading to an abstinence rate of 44% following the treatment and an estimated abstinence rate of 33% at 6 months [99]. A recent systematic review of the efficacy of rTMS for nicotine consumption and craving concluded that no recommendation beyond the possibility that HF-rTMS of the left DLPFC is effective for attenuating craving and consumption could be made and that while rTMS may be most effective when combined with other approaches, recent results obtained when combining approaches require replication and more rigorous evaluation [100].

Because rTMS is a neural circuit-based treatment approach rather than neurotransmitter focused and is directly administered to the brain, rather than systemically given, it is well tolerated. Adverse events are uncommon and tend to include transient headache and scalp discomfort. However, caution applying rTMS may be warranted in those with greater seizure risk such as individuals actively using psychostimulants or undergoing alcohol withdrawal [80]. rTMS may also be advantageous as it circumvents issues of medication adherence, cost, and side effects associated with most pharmacotherapies. The long-term efficacy of rTMS for decreasing drug craving in those with SUD is a potential concern given most studies assess these variables following relatively short-term administration periods (days-weeks) [81–83] or after limited follow-up periods [89]. However, one recent study suggests rTMS effects have the potential to be more protracted [85].

While initial rTMS results investigating craving and substance use among those with SUD are promising current findings still require replication in double blind studies with larger sample sizes [81–83]. Moreover, studies showing reduction in symptoms of SUD beyond craving are uncommon [82] and given long-term effects from rTMS are only achieved following weeks of stimulation sessions the approach may be time intensive and costly [86]. Several aspects of rTMS treatment are robust and reliable such as regional specificity, depth of magnetic field, dose dependent amplification of behavior, polysynaptic engagement, and frequency dependent effects. However, many treatment parameters are yet to be determined including the optimal number of daily sessions, the optimal number of total sessions, efficacy of rTMS for attenuating drug consumption when applied to regions other than the DLPFC, optimal coil orientation relative to anatomy, and an appreciation of the synergy between rTMS and other therapeutic approaches [80–82]. It is also worth highlighting that much of our understanding of addiction has moved away from purely drug-centered model which focuses on the neurochemical changes that result from drug exposure towards a more individual-centered model whereby individual differences in vulnerability to developing addiction are recognized. With this paradigm shift future application of rTMS might benefit from using individual MRIs and TMS navigator devices to individualize and maximize its physiological and therapeutic effects [82, 93].

### **5. Conclusion**

The process of bringing a new therapeutic approach into practice in a larger population is multifaceted and hinges on regulatory procedures, safety, efficacy, need, cost, among other variables. Moreover, this process is rarely linear as new research is published and the zeitgeist for various therapies changes. Where there remains little controversy is that while SUD treatment has seen growing success, evidenced-based therapeutic options are still limited and not effective for all patients. Developing novel approaches continues to be paramount given the psychological, social, healthcare, and economic costs of drug addiction.

The reemergence of research on serotonergic hallucinogens, most notably psilocybin, is of particular significance as it appears effective and well tolerated for treating SUD in the limited research that has been conducted. This conclusion is further bolstered by research examining the efficacy of psilocybin and related drugs for the variety of psychological disorders that are also part of the milieu of addiction. The dramatic and long-lasting nature of psilocybin's effects on meaning, spirituality and drug use appears to address the chronic nature of SUD in ways not achieved by most treatment approaches. Likewise, the potential therapeutic use of rTMS for SUD and other psychological disorders is notable for its efficacy, safety, and anti-craving effects, the latter of which is both central to addiction yet remains particularly challenging to resolve. The promise of these two approaches is hard to overstate yet in the absence of findings from larger randomized, double-blind clinical trials these approaches will continue to be viewed as merely promising. Anti-addiction vaccines, while potentially beneficial, require further technical refinement and appreciation of their place among therapeutic modalities.

As research on these approaches progresses it is not too early to consider how these therapies might be scaled to treat the large number of people affected by SUD. While some of these questions have begun to be addressed, such as the optimization of treatment protocols and how to best integrate them with other treatment modalities, larger issues loom. Who will be trained to administer these therapies and where will they be administered? Overcoming the public's negative perception and misunderstanding of hallucinogenic drugs, electroshock therapy, and vaccine hesitancy are all barriers to scaling these therapeutic approaches which are unfamiliar to most and therefore susceptible to misunderstanding and misinformation. The use of newer pharmacotherapies for SUD over the past 30 years has been slow to be adopted by healthcare providers partially due to their lack of awareness and comfort with these new approaches. The inclusion of these interventions in graduate education across medical, psychological, and healthcare occupations might promote their integration as future treatment options for those with SUD. Consideration of these issues today will likely ease the transition of these and other novel therapeutic techniques for SUD into widespread use moving forward.

*An Evaluation of Diverse Therapeutic Interventions for Substance Use Disorders… DOI: http://dx.doi.org/10.5772/intechopen.98514*

### **Author details**

William M. Meil\*, William Farrell and Reem Satti Department of Psychology, Indiana University of Pennsylvania, Indiana, Pennsylvania, USA

\*Address all correspondence to: meil@iup.edu

© 2021 The Author(s). Licensee IntechOpen. This chapter is distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/ by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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## *Edited by William M. Meil and John A. Mills*

This book addresses the diagnosis and treatment of drug addiction. Chapters in this book span biological, psychological, cultural, and health-based perspectives and emphasize meeting people as they really are in order to obtain tangible advances in clinical practice. These works represent the integration of the past, present, and likely future directions of both diagnosis and treatment. Addiction is an individual and systemic challenge to society and scientific advances and cultural diversity are highlighted here as paths forward towards addressing current diagnostic and treatment obstacles.

Published in London, UK © 2021 IntechOpen © Urilux / iStock

Addictions - Diagnosis and Treatment

Addictions

Diagnosis and Treatment

*Edited by William M. Meil and John A. Mills*