Replacing what drug and alcohol addicts use as reinforcers for good behavior could be key in treating addictions, says Dr. John Roll.
“In our lives we need good stuff to happen,” he said. “If we don’t have that, I believe we seek it out. And one thing I know – the first time you put a needle in your arm or snort or smoke a substance, the way our brain is wired, we will experience that as good.”
Roll is a researcher and vice chancellor for Washington State University Health Sciences Spokane.
A homeless man who can’t see any good coming in the foreseeable future, someone suffering from chronic pain or someone in a deep depression may turn to drugs for “good stuff,” he said.
But Roll said data from numerous studies show that if actual “good stuff” in an addict’s environment is increased, their reliance on drugs for that reinforcement decreases.
That, he said, can change their life.
Success with such programs will have a lot to do with resources, and those are limited right now, he said.
“It is a failing on the part of society, because (addiction) shouldn’t be happening at all,” he said. “It is not a moral failing on the part of the person.”
In 1991, a study on monkeys self-administering cocaine showed that when the number of banana pellets offered rose, the amount of self-administered cocaine declined, he said.
The same approach was used with human recreational cocaine users in an outpatient study in Vermont.
Roll said participants could choose from small units of cocaine or small amounts of money between 50 cents and $2. The same results were seen, he said. Studies with other drugs have had the same results, he said.
People had thought cocaine use could not be controlled, but this showed it clearly could be, he said.
This method, called contingency management, is endorsed today by the National Institute on Drug Abuse and is used to treat a range of substance abuse.
It has proven to be 61 percent more likely to have a successful outcome than any other addiction treatment, he said.
“You can modify behavior by using rewards or punishment,” he said.
“Punishment doesn’t teach you what to do, it tells you what not to do,” he said. “It’s more instructive to say what to do. When you’re punishing someone, it is a harsh and demeaning atmosphere.”
Rewards show “yes, this is a good thing,” he said.
“If you’re in treatment for addiction, it’s not an easy place to find yourself … there hasn’t been a lot of affirmation up until then,” he said.
In drug abuse treatment, reinforcers or rewards can include things as simple as award ceremonies, key chains or certificates, he said.
Studies conducted using reward vouchers for clean urine tests from people who had been dependent drug users not only retain them in voluntary studies longer, but help them stay sober longer through the study than those who didn’t get the vouchers, he said.
Roll said it is important that those vouchers build up natural reinforcers in their lives, such as healthy activities or attendance at events with their families.
The reward – or punishment – being contingent on the person’s behavior is also vital to success. The behavior and consequence have to be as close together in time as possible to be effective, he said.
When one community involved in a study feared this method could become too expensive, participants were rewarded with pulling a ticket from a fish bowl that only gave them a chance to win a variety of prizes. This still showed the same positive results, he said.
He compared the average three-month cost of such a treatment plan – $255 – to the average Medicaid cost for one day of inpatient care – $800.
Between 20 percent and 65 percent of individuals with severe mental illness also report recently using illicit drugs, which makes their symptoms more severe, increases the chance they will be homeless and increases visits to the emergency room, he said.
Roll said In a 12-week trial of contingency management for individuals with mental illness, those rewarded for positive behavior were more likely to be abstinent from drug use than those without rewards. Those without the management program had more inpatient days following the study, he said.
“So it seems to work pretty well for these groups, as well,” he said.
Roll said if relatively simple steps can lead these populations not to use, a huge difference can be made in the environment they live in, he said. It may not address all those with serious mental health illnesses, but it can help get them on their way, he said.
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