48 Monitor on Psychology • February 2015
benefit over and above the standard buprenorphine treatment
(JAMA Psychiatry, 2011).
“That doesn’t mean the behavioral treatment wasn’t useful
to those people,” she says. “But it wasn’t something we were able
to capture in that study design as improving outcomes.”
“It’s really a bit of a mixed picture,” says Potter. “What we’re
really trying to understand now is in what circumstances does
what type of behavioral treatment work?”
Psychologist Nancy M. Petry, PhD, professor and director of
the REWARD Center at the University of Connecticut School
of Medicine, is a fan of contingency management, a behavioral
approach that uses incentives to encourage patients to stay
drug-free. Patients who achieve and maintain abstinence can
earn the chance to win monetary-based prizes when they
achieve and maintain abstinence.
The approach works so well that the Department of
Veterans Affairs is putting it into practice in its substance abuse
treatment clinics, an experience Petry and colleagues describe in
a 2014 paper in the American Journal of Addictions.
Although some perceive contingency management to be
expensive, Petry has found that lower-cost prizes work just
as well as some higher-cost alternatives when it comes to
motivating abstinence. In one study, for example, Petry and
colleagues found that $300 prizes worked just as well as $900 in
incentives when it came to reducing cocaine use in methadone
patients (Journal of Consulting and Clinical Psychology, 2014).
“Overall costs of these reinforcement procedures can be less
than the costs of more traditional psychotherapies, and they
produce better outcomes,” she says.
Of course, say Petry and Potter, it would be a mistake to
think that behavioral treatment alone would be the optimal way
to treat someone with a significant opioid use disorder.
“The addictive nature of the opioid is so profound, it is very
difficult to kick it without some kind of opioid replacement
therapy,” says Potter.
Changing treatment delivery
Psychologists and others are also exploring new ways of
The Oregon Health Authority, for instance, is now
integrating addiction services into primary care in the 16
coordinated care organizations that serve its Medicaid
That kind of integration should be the wave of the future,
argues psychologist Dennis McCarty, PhD, who directs the
division of health services research at the Oregon Health and
Science University in Portland.
That’s because the current approach, which relies on
specialty addiction treatment, isn’t sufficient, says McCarty,
noting that while 22 million to 23 million Americans each year
meet criteria for dependence or abuse of alcohol or other drugs,
just 3 million get treatment. “Most of the 20 million unserved
individuals are receiving primary care and acute medical care,
however, so integrated care may be more effective at engaging
them in care.”
That treatment gap has financial as well as human
costs, says McCarty, noting that people often end up in the
emergency room or the inpatient unit. In a study of patients
in two large health systems, McCarty and co-authors found
that the mean health-care costs for patients with opioid
dependence was $31,055 per year when they received little or
no addiction treatment but fell to $13,578 for patients receiving
buprenorphine and addiction counseling (Addiction Science and
Clinical Practice, 2014). As an added benefit, integrating opioid
treatment into primary care also reduces the stigma associated
with seeking addiction treatment, says McCarty.
An inadequately prepared workforce is one reason there’s
such a big gap between the number of people who need
treatment and those who get it, says psychologist Lisa A.
“The number of psychologists working in addiction in
direct clinical care is relatively small. They need more
of a role, to be honest.”
Jennifer Sharpe Potter, PhD
University of Texas Health Science Center