20 Apr The Effective Use of ABA in Treating Substance Use Disorders

Our country faces a substance abuse epidemic. Over 20 million Americans have some form of Substance Use Disorder. Wide-spread addiction problems irreparably harm individuals and families. According to the CDC, 130 Americans die each day from an opioid overdose. Moreover, drug and alcohol use disorders in parents can lead to neglect or abuse of their children. Effective treatments are an essential tool in the battle against this growing addiction crisis. Methods from the field of Applied Behavior Analysis (ABA) are proven tools in the treatment of substance dependence.

Addiction as a Learned Behavior

Decades of laboratory and clinical research suggest that addiction is a learned behavior that can be effectively treated using the principles of ABA. Classical and operant conditioning are at play in the development, maintenance, and relapse of substance use disorders. Classical (or Pavlovian) conditioning occurs with repeated pairings of drug use with emotional, environmental, and subjective cues. Operant (or instrumental) learning happens when taking substances provides a reinforcing effect such as reward or escape. Dr. Roy A. Wise, Senior investigator at the National Institute on Drug Abuse, suggested that dopamine release strongly reinforces the behavior of repetitive drug use. Moreover, repeated drug use leads to sensitization that overly incentivizes the act of taking drugs. The sensitization of dopamine release causes excessive drug cravings, which lead to addictive behavior. 

Recent literature addresses the idea that Pavlovian cues may elicit drug cravings as a conditioned response. For addicted individuals, conditioned cues (such as the lights from a bar) were previously paired with positive activities. These contextual cues elicit specific cravings and goal-directed behavior chains. At the sight of bar lights, the person changes direction, enters the bar, speaks to the bartender, places an order, and consumes a drink. In individuals with addiction, goal-directed behavior eventually shift to habitually-controlled and, ultimately, compulsive behavior.  

Addiction is a nuanced problem with layers of genetic and environmental risk factors. Effective treatment seeks the root of the problem. Specific antecedents and precursors often preceded substance abuse. Through careful observations and data collection, clinicians can identify client-specific triggers and develop individualized treatment plans. ABA tools such as operant conditioning and contingency management are remarkably adaptable across various populations. 

Contingency Management

Based on the principles of operant conditioning, contingency management programs provide reinforcers contingent upon negative toxicology screens. This approach has shown consistent success across populations and substances. Operant contingency management interventions are among the most thoroughly researched types of addiction treatment. A meta-analysis published in The American Journal of Psychiatry shows that contingency management interventions had the most substantial effect of all the psychosocial treatments reviewed.

Digitized records and modern technology make contingency management interventions easier than ever. Clinicians can maintain program fidelity using an Electronic Health Record (EHR) specific to the behavioral health field. The right EHR will seamlessly integrate contingency management into individualized treatment plans. Mobile apps let the client receive rewards and self-monitor personal behavioral goals. 

Voucher Programs

Voucher-based reinforcement is one of the most widely used contingency management interventions. It proved successful in treating cocaine dependence in the early 1990s. The client receives a voucher of monetary value for negative drug toxicology results. Voucher programs use a unique schedule of increasing reinforcement. The monetary value of the voucher increases with each consecutive negative drug test. The incentives reset if the client misses a scheduled screening or tests drug-positive. 

When implementing voucher programs, clinicians begin with a dense schedule of reinforcement. For the first three weeks, the client takes a drug screening three times per week. The plan fades to twice a week and then once a week until stability is maintained. 

Community Reinforcement Approach

Community-based interventions use a range of recreational, family, social, and vocational reinforcers alongside a voucher program to help the client create a lifestyle that is more rewarding than substance use. The goal of the community reinforcement approach is to maintain abstinence long enough for natural reinforcers to sustain a drug-free life beyond the vouchers. 

Weekly counseling sessions focus on improving interpersonal relationships, learning skills to minimize drug use, developing recreational activities and social networks, and building vocational skills. These sessions occur contemporaneously with regular toxicology screenings with voucher reinforcement. As with voucher-based reinforcement, the monetary value increases with sustained abstinence. 

Relapse Prevention

As with any treatment, setbacks may occur during the behavior change process. However, a combination of cognitive therapy and behavior analysis may decrease the probability of a relapse. Congestive-behavioral relapse prevention focuses on skill-building and coping responses. Specific intervention techniques can help the client anticipate and deal with high-risk situations.

Clinicians often make a distinction between a lapse (slip or mistake) and a relapse (major setback). A relapse is not a discrete event, but rather part of an ongoing process. Most declines are immediately preceded by a high-risk situation such as emotional or cognitive states, conditioned drug cues, or acute withdrawal. What constitutes a high-risk event varies across individuals and within the same individual over time. Behavior change strategies and coping responses reduce the likelihood of relapsing.

ABA provides a toolbox of techniques to assist clients on the road to recovery. Clinicians can treat substance use disorders through a combination of contingency management, community reinforcement, and relapse prevention methods. Evidence-based strategies in conjunction with a behavioral health EHR prepare clinicians to combat the substance abuse crisis facing our nation. By tracking individual data, therapists can monitor progress and assist clients on the road to recovery.