include some assumed to be physiologically related to the drug
dependence process (e.g., anxiety or stress), while others are assumed
to function at more of a behavioral level (e.g., the sight of drug-
associated stimuli).

Types of Treatment for Drug Dependence

Treatment approaches can be divided into those which involve the
administration of drugs (Pharmacologic Treatment Approaches) and
those which do not (Nonpharmacologic or Behavioral Treatment
Approaches). Sophisticated methods involving both pharmacologic
and behavioral approaches are more recent developments and show
considerable promise for the treatment of dependence to alcohol,
opioid, cocaine-like drugs, and nicotine (Grabowski, Stitzer, Henning-
field 1984). Although considered separately in this Section, pharma-
cologic and behavioral treatment approaches are commonly com-
bined and may be most effective when used in combination (Grabow-
ski, Stitzer, Henningfield 1984; Crowley and Rhine 1985). Combined
treatment approaches specific to cigarette smoking are discussed in
Chapter VII.

Pharmacologic Treatment of Drug Dependence

Four pharmacologically based approaches for the treatment of
drug dependence can be differentiated: (1) replacement or substitu-
tion therapy (e.g., methadone for opiate dependence), in which a
more manageable (and ideally, less addicting) form of the drug is
provided; (2) blockade therapy (e.g., naltrexone for opiate depen-
dence), in which the behavior-controlling effects of the abused drug
are blocked by pretreatment with an antagonist; (3) nonspecific
pharmacotherapy, in which the patient is treated symptomatically
(e.g, use of clonidine during opioid detoxification); and (4) deterrent
therapy, in which administration of the treatment drug results in the
occurrence of aversive effects when the abused drug is subsequently
taken (e.g., the use of disulfiram to treat alcoholism (Grabowski,
Stitzer, Henningfield 1984; Jaffe 1985). Each of these approaches has
been described in greater detail elsewhere and will be only briefly
described below (Cooper, Altman, Brown, Czechowicz 1983; Bigelow,
Stitzer, Liebson 1985; Jaffe 1985; Jasinski, in press; Jasinski and
Henningfield 1988; Jarvik and Henningfield, in press).

Replacement Therapy

The most widely investigated and evaluated pharmacologic treat-
ment approach for drug dependence is replacement therapy. The
general principle of replacement therapy is to provide the patient
with a safer and more manageable form of drug that directly
alleviates signs and symptoms normally suppressed by the substance

326
upon which the patient is dependent (Jaffe 1985, 1987; Jasinski and
Henningfield 1988). Ideally, it should also be of lower dependence
potential so that its use may be more readily discontinued than use
of the original form on which the person is dependent.

Replacement therapies function through four general actions: (1)
they block the onset of the physiologically mediated aspects of
withdrawal; (2) they maintain a level of tolerance that attenuates
the reinforcing properties of the abused chemical; (3) they treat
(“suppress”) other signs and symptoms such as dysphoria that may
constitute vulnerability and pose an impediment to normal function-
ing and well-being; (4) they directly suppress drug-taking behavior,
much as caloric loading can suppress eating.

The drugs that are widely used to alleviate withdrawal symptoms
by providing some level of pharmacologic replacement are the
following: methadone for opiate withdrawal (Cooper, Altman,
Brown, Czechowicz 1983), benzodiazepines for alcohol withdrawal
(Sellers et al. 1983; Newsome and Seymour 1983; Liskow and
Goodwin 1987), and nicotine polacrilex gum for tobacco withdrawal
(Chapters IV and VII). The potential effectiveness of these agents in
prevention or relief of withdrawal symptoms has been well docu-
mented (Jaffe 1985). However, relief of early withdrawal symptoms
does not necessarily yield improved overall treatment outcomes.
Primary withdrawal symptoms for all dependence-producing drugs
are time limited, and their duration does not span the entire high-
risk period for postcessation relapse. These observations are consis-
tent with the finding that withdrawal symptomology is only one of
several potential relapse determinants.

Besides relief of withdrawal symptoms, there are several other
functions that a replacement therapy might serve that would make
continued long-term treatment beneficial. One of these functions is a
reduction in the need for the primary addicting drug, along with a
similar reduction in drug seeking. Just as importantly, the replace-
ment therapy may reduce or eliminate symptomology (e.g., anxiety,
antisocial behavior, inability to concentrate on tasks) that may
interfere with the person’s ability to perform in occupational
settings and maintain social relationships. Analogously, nicotine
replacement therapy during cigarette abstinence can reduce or
eliminate tobacco intake and symptoms that interfere with normal
social or occupational activities, even though urges to smoke may not
be eliminated (Chapter VII).

The constraints on the efficacy of replacement therapies are
generally similar across drug classes. Most importantly, the clinical
application of replacement therapies is impeded by the influence of
nonpharmacologic factors, which vary among individuals and/or
situations (e.g., the specific drug delivery system customarily used
and ritualistic aspects of the behavior). Pharmacologically related

327
differences may also mitigate acceptability of the replacement drug;
e.g., orally administered replacements are generally not as satisfying
to the user as i.v. or inhalation systems, such as the “crack” form of
cocaine or tobacco smoke. In addition, replacement therapies do not
reliably diminish the urge to use the drug or specific drug formula-
tion (e.g., cigarette brand or alcoholic beverage) to which a person is
accustomed. (Issues related to craving are discussed in greater detail
in Chapters IV and VII; Childress et al., in press; Henningfield and
Brown 1987.)

Blockade Therapy

A pharmacologic alternative to replacement therapy is to produce
a pharmacologic blockade of receptors which mediate the reinforcing
as well as the toxic effects of the drug (Jaffe 1985). For opioid
agonists such as morphine and heroin, the short-acting antagonist
naloxone can be used to reverse the effects of an overdose of the
opioid agonist. The longer acting antagonist naltrexone can be given
on a daily basis to opioid users to prevent them from experiencing
the reinforcing and toxic effects of opioid agonists. Unfortunately,
clinical trials have shown that there is frequently poor compliance
with blockade therapy (Ginzburg 1986). Lack of compliance results in
limited clinical utility. No clinically tested antagonist treatments
are currently available for the treatment of alcohol or nicotine
dependence, although experimental research with the nicotine
blocker, mecamylamine, suggests that such an approach may hold
promise (Chapter VII; Jarvik and Henningfield, in press).

Nenspecific Pharmacotherapy or Symptomatic Treatment

Administration of and abstinence from dependence-producing
drugs produce a cascade of effects involving a variety of neurochemi-
cal and physiological effects. As discussed with regard to nicotine in
Chapters III and VI, such drug actions mediate many of the desirable
and undesirable effects. In principle, it is possible to target treat-
ment approaches on a symptomatic basis.

One example of such an approach is the use of an antidepressant
(desipramine) to help achieve and maintain abstinence from cocaine
(Gawin and Kleber 1984); cocaine abstinence is often accompanied by
symptoms of depression. Somewhat analogous is the use of clonidine
to treat opioid withdrawal symtomology (Gold, Dackis, Washton
1984). Clonidine seems to exert its primary actions by suppressing
aspects of opioid withdrawal that are mediated by the activity of the
sympathetic nervous system (SNS). In one study, clonidine was just
as effective as morphine in the reduction of certain physiological
signs of opioid withdrawal (Jasinski, Johnson, Kocher 1985); how-
ever, in that study, clonidine did not reduce the self-reported

328
“discomfort” as effectively as did morphine. These observations are
consistent with the conclusion that some but not all of the effects of
the opioid withdrawal syndrome are mediated by the SNS and that
treatment of these effects may provide limited but objective benefit.
An analogous approach has been explored for application of cloni-
dine in the treatment of tobacco withdrawal (Glassman et al. 1984,
1988), but conclusions are only suggestive of the possible viability of
this approach (Chapter VII; Jarvik and Henningfield, in press).

Pharmacologic Deterrenis

Drug taking can sometimes be reduced or eliminated if the
consequences are immediate and/or severe enough (Crowley and
Rhine 1985). There has been some effort to develop pharmacologic
treatments that ensure immediate, reliable, and highly aversive (but
safe) effects following self-administration of the drug of dependence.
Only one such agent has provided a near approximation of these
criteria: disulfiram, which is used in the treatment of alcoholism
(Jaffe and Ciraulo 1985; Miller and Hester 1986a). When disulfiram
has been taken, a small amount of alcohol can produce rather severe
discomfort and acute illness. Reviews of controlled treatment
outcome studies (Miller and Hester 1986a) suggest that many of the
therapeutic effects of disulfiram may also derive from placebo
effects. Thus, in some studies (e.g., Fuller and Roth 1979), outcomes
have been similar for placebo and active drug groups, with only
medication-compliant individuals (about 20 percent in each group)
showing good outcomes.

No deterrents comparable to disulfirum in potential efficacy have
been clinically tested for treatment of dependence on opioids or
nicotine (see also Chapter VII). As with antagonists, a practical
problem in treatments using deterrents is compliance, i.e., maintain-
ing adequate levels of use of the medication itself. A deterrent is
ineffective if it is not taken, and development of contingencies to
ensure that the patient takes the deterrent has proceeded slowly
(Bigelow, Stitzer, Liebson 1984, 1985; Stitzer, Bigelow, Liebson,
McCaul 1984). Therefore, even if theoretically effective deterrents
become available for treatment of other drug dependencies, their
utility might be limited.

Behavioral Treatment Strategies

Despite the powerful sequelae which may accompany both drug
administration and drug abstinence, most drug-dependent persons
(possibly excluding opioid users) are not systematically treated with
pharmacologic approaches. Drug dependent persons may eventually
“spontaneously remit” (discussed earlier in this Chapter), but many
others enter formal treatment programs that provide supportive and

329
behavioral therapy. Behavioral treatment approaches have a hetero-
geneous array of theoretical bases and means of implementation
(Stitzer, Bigelow, McCaul 1983). Although the term “behavioral
treatment” is often reserved for approaches which involve the
systematic application of behavior modification, it is sometimes
applied to any nonpharmacologic approach. Thus, behavioral strate-
gies may involve group support, individual counseling, skills train-
ing, or family intervention (Krasnegor 1979a; Grabowski, Stitzer,
Henningfield 1984). The present Section will provide a brief review
of behavioral approaches aimed largely at relapse prevention.

The major challenge in the treatment of drug dependence is no
longer in the initial attainment of abstinence; rather it is in the
maintenance of abstinence. In fact, it is worth noting that the shift
in emphasis from achievement of abstinence to the maintenance of
abstinence is an important advance in treatment efficacy in itself
(McAuliffe et al. 1986). This current focus has resulted in the
development of nonpharmacologically based approaches aimed at
what is often termed relapse prevention. In the past decade, relapse
prevention interventions have been increasingly founded on empiri-
cal investigations of situational precipitants of relapse and/or have
addressed factors known to predict relapse that can be manipulated
(Catalano and Hawkins 1985; Catalano et al., in press; Hawkins and
Catalano 1985; Marlatt and Gordon 1985; Tucker, Vuchinich, Harris
1985; Brownell et al. 1986; Todd, 1984).

A specific goal of approaches to relapse prevention is to increase
the impact of those factors that are negatively associated with
relapse and to decrease the impact of factors that are positively
associated with relapse. These approaches have led to the develop-
ment of a number of techniques that hold promise for prevention of
posttreatment relapse. Some of the better documented approaches
are summarized below.

Relapse Prevention Skills

Marlatt and his associates (Marlatt and Gordon 1980, 1985;
Cummings, Gordon, Marlatt 1980) have developed a cognitive
behavioral model of relapse which includes skills training for each
phase of the relapse process. They advocate training: (1) to recognize
“apparently irrelevant decisions leading to relapse”; (2) to identify
and cope with personal high-risk relapse situations; (3) to practice
behaviors which increase perceptions of self-efficacy and control
such as reading, relaxation, and meditation; (4) to recognize the
negative effects in biphasic drug action which follow immediate
positive effects; (5) to cope with a slip; and (6) in some cases, to
practice a relapse under controlled circumstances called a “pro-
grammed relapse” (although the general efficacy of this approach
has not been confirmed).

330
Reports of skills training with alcoholics far outnumber reports of
similar training with users of other drugs. Treatment in these
studies usually involves assertion/social skills training, problem-
solving training, and/or practice of high-risk situations using a
combination of methods, including didactic presentation, modeling,
role play, feedback, generation and evaluation of alternative prob-
lem solutions, and homework assignments. Skills improvement has
been achieved as indicated by role play, self-report, and question-
naire measures, and a positive impact of skills training procedures
has been shown in the treatment of alcohol use (Watson and Maisto
1983; Van Hasselt, Hersen, Milliones 1978) and cigarette smoking
(Shiffman 1982; Hall, Rugg et al. 1984).

The effectiveness of skills training with users of drugs other than
alcohol has not been as thoroughly evaluated as for alcohol. In five
single-case and uncontrolled group studies involving primarily
opioid users, two reported reduced drug use at followup (Cheek et al.
1973; Polakow and Doctor 1973); four found self-reported improve-
ments in social functioning (Cheek et al. 1973; Matefy 1973; Polakow
and Doctor 1973; Wolpe 1965); and one reported improved role play
performance (Callner 1973). Four studies of users of a variety of
illicit drugs (Callner and Ross 1978; Hawkins, Catalano, Wells 1986;
Smith 1982; Lin et al. 1982) have reported improvements in skills
related to high-risk relapse situations, and one found decreased use
of marijuana (Smith 1982). In one study, skill changes generalized to
untrained situations and were maintained 1-year posttreatment
(Hawkins, Catalano, Wells 1986). As discussed in Chapter VII,
preliminary studies suggest that skills training strategies may be of
some utility in the treatment of tobacco dependence. For example,
Hall, Rugg, Tunstall, and Jones (1984) found that smokers receiving
relapse prevention skills training were significantly less likely to
relapse than smokers assigned to a discussion control condition.
Subsequent studies and reviews indicate mixed results (Hall et al.
1985; Schwartz 1987).

Leisure Activity Skills

In recognition of the association of relapse with an absence of
active leisure activity, a number of aftercare programs have
attempted to increase participation of clients in organizations
beyond work or treatment (Catalano and Hawkins 1985; McAuliffe
et al. 1986; Nurco et al. 1983; Wolf and Kerr 1979). Controlled studies
have shown that drug users can be encouraged to participate in
voluntary community organizations and activities following inpa-
tient treatments and that these contacts can be maintained over a 1-
year period following treatment, but in these studies there were no
beneficial effects in reducing relapse rates (Catalano and Hawkins
1985; Hawkins and Catalano 1985).

331
For alcoholics and cigarette smokers, physical exercise has been
examined as a potential relapse prevention strategy. Murphy,
Marlatt, and Pagano (1986) found that problem drinkers trained in
running reported greater reductions in drinking at followup than did
drinkers trained in meditation. In a retrospective self-report study,
Koplan, Powell, Sikes, Shirley, and Campbell (1982) found at 1-year
followup that of the 2,500 runners competing in the 10K Peachtree
Road Race in Atlanta and returning questionnaires, 81 percent of
males and 74 percent of females who smoked cigarettes before they
started running had stopped smoking after they began running.

Stress Management Skills

As discussed earlier in this Chapter and in Chapters VI and VII,
negative emotions associated with stressful events or interpersonal
interactions have been strongly implicated in relapse precipitation.
In principle, such emotional states can be addressed through stress
management training, relaxation, meditation, or other “lifestyle”
interventions (Marlatt and Gordon 1985; Charlesworth and Dempsey
1982). Although stress reduction techniques are frequently included
as a part of drug abuse treatment, there are a surprisingly small
number of well-controlled studies addressing the effectiveness of
anxiety-reduction techniques with drug-abusing clients (Marlatt and
Gordon 1985). As indicated earlier in this Section, there is evidence
that programs which may reduce anxiety by use of aerobic exercise
or relaxation practice can bring about significant reductions in
alcohol use among heavy drinkers (Marlatt and Marques 1977;
Marlatt et al. 1984; Murphy, Marlatt, Pagano, 1986). Further
research is needed to assess the effectiveness of these techniques in
reducing the use of substances following treatment for alcohol,
opioid, and tobacco dependence.

Motivation Enhancing Treatments

Treatment interventions in which the primary purpose is to
improve or bolster motivation for continued abstinence can take
many forms. Many drug-dependent persons enter treatment as the
result of some form of pressure from friends, employers, family,
medical practitioners, or legal agencies. Sometimes treatments can
be designed that incorporate these sources of community pressure
and support for abstinence. The present Section will focus on
interventions that involve social support from professional thera-
pists, peers, and family.

Social support strategies designed to bolster environmental sup-
port for abstinence include enlistment of support from families and
existing social networks, the creation of new primary social support
such as self-help groups or linkages with community volunteers, and

332
supportive services provided by professional human service workers.
Only preliminary systematic research has been conducted utilizing
such interventions; however, the approach appears of similar
applicability and utility in the treatment of opioid, alcohol, and
tobacco dependence (Ashery 1979; Nurco et al. 1983; Leach 1973;
Madsen 1974; Janis and Hoffman 1970).

Professional contact is a special kind of support strategy which has
been used in drug use treatment. Typically, it involves ongoing
contact with professionals from the primary treatment program.
This approach may include booster sessions of individual or group
counseling, followup phone calls or letters from therapists, or
followup visits by counselors to former clients in the community to
review progress and problems. Fitzgerald and Mulford (1985) found
that bimonthly phone calls to alcoholic patients by an alcohol
counselor did not affect drinking outcome. Pokorny and others (1973)
found that weekly group therapy sessions following 60-day inpatient
treatment for alcoholism produced relapse results equivalent to
more expensive 90-day inpatient treatment with no followup.
Colletti and Supnick (1980) found that weekly contact with thera-
pists during the first month following treatment for smoking
resulted in better smoking outcomes at 6 months than when subjects
received no aftercare, though these differences were not maintained
at 12-month followup. Chapter VII describes additional analogous
strategies used to treat tobacco dependence.

Family support is a potentially cost-effective and long-lasting form
of motivation enhancement. The potential importance of family
support is emphasized by the correlation between stable family
environment and good treatment outcomes previously discussed. In
recognition of this relationship, self-help groups to assist family
members of addicts and alcoholics have proliferated since the early
1970s. They include Alcoholics Anonymous (AA), Narcotics Anony-
mous (NA), and Families Anonymous groups for families coping with
alcoholism and drug abuse (Ashery 1979; Brown and Ashery 1979),
and service-agency-based aftercare groups for families (Dunlop,
Skorney, Hamilton 1982). Agencies which have also focused on
broader informal social networks have also arisen (Collins and
Pancoast 1976; Gottlieb 1981; Speck and Attneave 1973; Whittaker
and Garbarino 1983). A study by Stanton, Todd, and Steier (1979)
provides support for the benefits of involving the families of opioid
users in treatment. They found that in families of opioid users which
received structured family therapy, there were more days free of the
use of opioids, nonopioid illegal drugs, and alcohol than for opioid
users whose families did not receive such treatments. While not
reporting drug use outcomes, others have enlisted family members
and close friends of drug dependent persons as supportive sponsors
in drug treatment programs (Sorensen and Gibson 1983; Callan,

333
Garrison, Zerger 1975). Such networks are being increasingly
developed in recent years to help tobacco dependent persons
(Chapter VII; see also Schwartz 1987).

Peer support constitutes a potentially powerful motivation-en-
hancing approach. A difficulty of peer support is that it often
involves establishing a new peer group for the drug dependent
person if his or her current peer group continues to support drug use.
Self-help groups such as AA and NA, for example, provide former
substance abusers with a new social support network of individuals
in like circumstances (Ashery 1979; Nurco et al. 1983). Descriptive
followup studies of non-probability samples of AA members have
suggested that AA is an effective approach for assisting some
recovering alcoholics to maintain their sobriety (Leach 1973; Madsen
1974; Maxwell 1962). Several studies of the effectiveness of residen-
tial AA programs have also found better outcomes associated with
participation (Alford 1980; Smith 1984, 1985). However, these studies
have either failed to utilize control groups or utilized “matched”
comparison groups that differ on pretreatment criteria which may
influence outcome. Thus, these studies do not provide conclusive
efficacy data.

A few studies have attempted to create or enhance existing peer
social support, with mixed results. For example, a volunteer sponsor
program for “‘skid-row” alcoholics was described by Fagan (1986), in
which sponsor groups from churches were assigned alcoholics in a
rehabilitation program. This program was not evaluated in a
controlled manner. Janis and Hoffman (1970) investigated the effects
of a self-help social support intervention on relapse following
smoking cessation treatment. Clients paired in a high-partner-con-
tact condition (daily calls for 5 weeks) were more successful in
maintaining abstinence at 1- and 10-year followups than were clients
in low-contact or control conditions. The critical dimension appeared
to be quality of peer support.

Conclusions

1.The pharmacologic and behavioral processes that determine
tobacco addiction are similar to those that determine addiction
to drugs such as heroin and cocaine.

2. Environmental factors including drug-associated stimuli and
social pressure are important influences of initiation, patterns
of use, quitting, and relapse to use of opioids, alcohol, nicotine,
and other addicting drugs.

3. Many persons dependent upon opioids, alcohol, nicotine, or
other drugs are able to give up their drug use outside the
context of treatment programs; other persons, however, re-

334
quire the assistance of formal cessation programs to achieve
lasting drug abstinence.

4, Relapse to drug use often occurs among persons who have
achieved abstinence from opioids, alcohol, nicotine, or other
drugs.

5. Behavioral and pharmacologic intervention techniques with
demonstrated efficacy are available for the treatment of
addiction to opioids, alcohol, nicotine, and other drugs.

335
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