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A review of the community reinforcement approach in the treatment of opioid dependence.

This article reviews the use of Community Reinforcement Approach (CRA) in the treatment of opioid-dependent patients. Community Reinforcement Approach was first utilized in the early 1980s for opioid dependence. CRA, "is a broad-spectrum behavioral treatment approach for substance abuse problems . . . that utilizes social, recreational, familial, and vocational reinforcers to aid clients in the recovery process" (Meyers & Smith 1995). Elements of CRA include the following: motivational induction, monitoring pharmacotherapy, functional analysis, skills training, job finding, marital counseling, and social recreational counseling. The skills training embedded in CRA contain the following coping skills: drug refusal, communication skills, problem solving skills, and relapse prevention. The number of research trials examining the effectiveness of psychotherapy in the treatment of opioid-dependent individuals have been few, but clearly important in view of the widespread availability and use of heroin worldwide as well as the serious medical complications that result from opioid dependence.


Few clinical trials have investigated the usefulness of psychotherapy in opioid-dependent individuals. One of the earliest trials by Nyswander and group completed in 1958 offered free psychotherapy to patients addicted to opioids. They found that few individuals accepted their offer (n = 70) and those that did had high attrition rates: only 13 patients completed their treatment trial (Nyswander et al. 1958). Though the patients who completed treatment benefited, Nyswander and group concluded that the role of psychotherapy in opioid-dependent patients was minimal since few patients were recruited into treatment and only a small number of patients completed treatment. However, their study was prior to the introduction of methadone maintenance. After methadone maintenance was introduced to the United States in 1964, several other psychotherapy clinical trials were initiated. The most notable early trials were those completed by the groups at Yale University and the Philadelphia Veteran's Administration (Rounsaville et al. 1983; Woody et al. 1983). Rounsaville and colleagues (1983) at Yale did not find any significant difference between the control and the experimental group (Short-term Interpersonal Therapy), but there were some previously outlined design problems that may have altered their results. In contrast Woody and colleagues (1983) demonstrated significant improvement in outcomes using two distinct forms of psychotherapy, Supportive Expressive Therapy and Cognitive Therapy, in a population treated at the Philadelphia Veterans' Administration methadone clinic. These results were later replicated in a community methadone clinic population (Woody et al. 1995).

Prior to the following investigations, the Community Reinforcement Approach (CRA) had never been evaluated in an opioid-dependent population, but had been utilized in other drug-dependent populations. Azrin initially examined the use of CRA in an alcohol-dependent population in rural Pennsylvania. In combination with disulfiram, Azrin and colleges found CRA to be successful in this population (Meyers & Smith 1995; Azrin et al. 1982). This was later replicated at the University of New Mexico as described by Meyers and Miller (2001). The Community Reinforcement Approach has been adapted successfully in combination with a voucher incentive program for the treatment of cocaine-dependent patients (Higgins et al. 1994; Higgins et al. 1993). One of the major components of CRA, Job Club, has been evaluated on its own and found to be beneficial (Azrin & Basel 1982). Additionally, Job Club was specifically modified for patients in a methadone clinic in San Francisco and found to enhance employment status (Hall, Loeb & Allen 1984). Two recent reviews demonstrated broad utility of CRA (Roozen et al. 2004; Meyers & Miller 2001). The goal of the present study was to review all published research to date that examined the use of the Community Reinforcement Approach in the treatment of opioid dependence (see Table 1).


The present author and colleagues examined the usefulness of CRA and Relapse Prevention (RP) in an opioid-dependent population maintained on methadone (Abbott et al. 1998). Relapse Prevention was added to CRA and delivered after the CRA sessions were completed. This occurred when patients had been in treatment for approximately six months, so the six-month outcome was primarily the result of CRA intervention.

Patients were recruited between 1991 and 1993 from consecutive admissions to the University of New Mexico's Center on Alcoholism, Substance Abuse, and Addictions (CASAA), participation was voluntary. The inclusion criteria were the following: opioid-dependence according to DSM-III-R criteria, stable residence in the county, age 18 or older, and eligible for methadone maintenance according to the Food and Drug Administration (FDA) requirements (US DHHS 1989). Exclusion criteria were: acute psychosis, pregnancy, significant other in the trial, discharge from CASAA's treatment center within the past six months, or gross cognitive impairment.

Patients qualifying for the study were assigned to one of three treatment groups: standard, CRA, and CRA/RP, by a permuted block design. Blocks were formed by five dichotomized control factors: gender, ethnicity (Hispanic, non-Hispanic), Addiction Severity Index (drug use severity rating), and admission mandated by the criminal justice system.


Treatment interventions were specified in manuals specifically developed for the project. Patients attended 20 treatment sessions in the standard and CRA groups; CRA/RP received an additional six sessions of Relapse Prevention for a total of 26 sessions. Therapists saw all patients twice weekly for the first two weeks and then once a week until they completed treatment. Once the treatment sessions were completed all patients were seen once a month by their therapist for follow-up sessions. All patients were initiated on methadone prior to their counseling sessions. Patients in all three groups received equivalent doses of methadone in the range of 60-70 mg of methadone.

Standard treatment was based on but modified the Philadelphia Veterans Affairs Medical Center's methadone counselor's manual (Abbott et al. 1998). This intervention consisted of the following elements: explicit statements of the program's rules, comprehensive treatment planning, attention to adequate doses of methadone, weekly random urine drug screens with feedback, AIDS information, treatment sessions focused on current problems, and liaison with community resources.

The CRA group received social skills training originally developed by Azrin and group (1982) for alcohol-dependent individuals and modified by our clinic for this study for opioid-dependent patients (Meyers & Smith 1995; Azrin et al. 1982). CRA is a treatment intervention based on social learning theory that arranges both personal and environmental abstinence reinforcers; this project used key elements of CRA. CRA utilizes functional analysis for individuals to identify positive abstinence reinforcers in their life and cues or triggers to drug use. Specific sessions focus on problem-solving skills, drug refusal training, communication skills, and social/recreational counseling (Meyers & Smith 1995; Azrin et al. 1982). Patients without jobs were referred to the Job Finding Club and patients with spouses experiencing conflict were provided marital counseling (Azrin & Basel 1982; Azrin, Naster & Jones 1973).


Relapse Prevention (RP) was modified after Marlatt and Gordon's (1985) work and focuses on two key areas: cognitive restructuring and further enhancement of behavioral skills. This intervention consisted of six manual-guided sessions: (1) rationale of RP treatment, description of the stages of change, elements of relapse, and use of self-monitoring cards; (2) evaluation of the patients' expectations of drug effects; (3) self confidence in managing high-risk situations; (4) methods to avoid relapse; (5) cognitive and affective components of the abstinence violation effect (AVE); and (6) an emergency plan to manage both high-risk situations and relapse.


Research assistants, blind to treatment assignment, administered all the assessment instruments. At intake and three, six, 12, and 18 months follow-up they administered the Addiction Severity Index (ASI; McLellan et al. 1985), the Beck Depression Inventory (BDI; Beck et al. 1961), the Weissman Social Adjustment Scale-Self-Report (SAS-S-R; Weissman & Bothwell 1976), the Symptom Checklist90-Revised (SCL-90-R; Derogatis 1983), and the Risk Assessment Battery (RAB; Navaline et al. 1994). The RAB measures risk-taking behaviors that are divided into two subscales: injection drug use and sexual behaviors. After patients were in treatment for a minimum of one month, the Structured Clinical Interview for DSM-III-R patient version (SCID-P; Spitzer, Williams & Gibbon 1988), and the Structured Clinical Interview for DSM-III-R personality disorders (SCID-II; Spitzer, Williams & Gibbon 1990) were administered. Observed random urine drug screens were collected at intake, weekly through the first six months of treatment, and at follow-up interviews. The urine specimens for nine drugs of abuse were analyzed by the Enzyme Multiplied Immunoassay Technique (Syva Corp).


Over 263 patients were evaluated for the treatment trial and 181 (68.8%) patients were randomized to three groups: standard (n = 67), CRA (n = 52), and CRA plus Relapse Prevention (n = 62). Of the 181 patients randomized, 165 patients were considered engaged in treatment, attending three or more treatment sessions. We followed up 151 of the engaged patients (91%) at six months.

In this sample of engaged patients (n = 165), the average age was 37 (SD = 9.1); 69.3% were men and 78.9% were Hispanic. Marital status was the following: 27.1% married, 39.2% widowed, divorced or separated, and 33.7% single. The average years of education was 11.51 (SD = 1.91) and 54.8% were employed at admission. All patients had extensive histories of drug use and mental disorders. The average years of heroin use was 11.73 (SD = 8.30); average use of cocaine use was 1.43 (SD = 2.93); and average years of problematic alcohol use was 4.13 (SD = 5.59). The frequency of mental disorders was as follows: 53% (n = 88) had current Axis I disorders and 86% (n = 142) had some lifetime Axis I disorder. The primary psychiatric disorders were mood and anxiety disorders.

Results at Six Months

When we examined urine drug screens for opioid use at six months, we found a trend favoring the CRA group in reduction of opioid use (Abbott et al. 1998). Additionally, we analyzed the likelihood of achieving three, eight, 12, and 16 consecutive weeks free from opioid use. At all intervals the CRA group preformed better than the standard group. This reached significance for three consecutive weeks free from opioids; the CRA group (89%) was significantly more likely than the standard group (78%) to have three consecutive weeks free from opioids.

There was further evidence of reduced drug use by the CRA group when we compared the ASI drug composite scores. These analyses indicated that the CRA group demonstrated more improvement in their drug use than did the group in the standard condition (Abbott et al. 1998). The following ASI scores showed improvement over six months: employment, alcohol, drug, legal, and psychiatric; the exceptions to this were the medical and family/social composite scores.

Other measures of six-month outcome (BDI, SCL-90-R, SAS-S-R, and the RAB) showed significant improvement over pretreatment levels, but no significant between-group differences. We also examined any overall differences in retention rates across treatment groups and found none. However, we did find a differential dropout rate of patients after they were engaged in treatment. Patients who were Hispanic, incarcerated longer, and currently suffering from a mood disorder were more likely to drop out prior to completing treatment. This was particularly significant for patients with a major mood disorder (Abbott et al. 1999).

The study is notable for being the first study to investigate the efficacy of CRA among opioid-dependent individuals in a methadone maintenance program. Outcomes may be partially confounded by collapsing the CRA and the CRA/RP group, but at six months very few of the Relapse Prevention sessions had been provided. The other limitation was the number of missing urine drug screens (29%). However, these missing urine drug screens were equally distributed between the control and the experimental group.


Bickel and colleagues (1997) adapted the use of CRA in combination with contingency management strategies for improving opioid detoxification rates from buprenorphine (Bickel et al. 1997). Their group assessed the addition of behavioral treatment (CRA plus contingency management) in enhancing detoxification with buprenorphine over a 26week outpatient detoxification.


They randomized thirty-nine patients (25 male and 14 female) with a mean age of 34 years to a buprenorphine dose-taper with either behavioral (n = 19) or standard treatment (n = 20). Patients met the following criteria: opioid-dependence according to DSM-III-R criteria, eligible for methadone treatment under Food and Drug Administration guidelines, 18 years or older, free of psychosis, dementia or major medical disorders and were not pregnant.


The behavioral treatment included two components: (1) a voucher incentive program rewarding opioid-free urines and engaging in the therapeutic activities, and (2) CRA. The voucher program systematically reinforced abstinence from opioids as measured by urinalysis results and completion of therapeutic activities by the patient. Urine specimens were collected on Monday, Wednesday, and Fridays and were observed by staff. Specimens that were negative for opioids (opiates, propoxyphene, and methadone) earned points that had a monetary value that could be redeemed for material items. For further details of the voucher system see the original article (Bickel et al. 1997).

CRA was implemented in two to three one-hour sessions per week. These sessions included the following CRA elements: discussion of antecedents and consequences of opioid use, establishing recreational and leisure activities, and as-needed relationship and employment counseling. Significant others were actively involved in integrating the CRA and contingency management activities.

Standard treatment consisted of lifestyle counseling which focused on compliance with program rules, and developing strategies to reduce drug use, seek employment or improve living arrangements. The individual counseling sessions were once a week for duration of 37 minutes.

Detoxification from buprenorphine lasted for 160 days. All patients had a stabilization and reduction phase. The length of these phases depended on the initial stabilization dose. Once stabilized, buprenorphine was reduced approximately 10% every five days for the remainder of the 160 days.


Bickel and his group (1997) demonstrated that the behavioral intervention improved treatment outcome. Fifty-three percent (53%) of the patients receiving the behavioral intervention completed the detoxification versus 20% in the standard condition. They also examined the groups at four, eight, 12, and 16 weeks continuous abstinence from opioids. At all intervals the behavioral group performed better than the standard group; only the eight-week interval was significant. The contribution of CRA to the outcome associated with the behavioral package was not specified in their study, but it is clear that the addition of the combined behavioral strategies had a beneficial effect. This is notable in view of prior disappointing results in detoxification from opioids utilizing either methadone or buprenorphine without behaviorally enhanced treatment (Bickel et al. 1988; Milby 1988).

In this study there are clear differences in the doses of the two therapies CRA and standard treatment. The CRA group received about four times the amount of treatment as compared to the standard group. Outcome differences may be related to the dose of treatment and not specific content of treatment. Another limitation to the study is that the same therapists provided both forms of treatment. Therapists may expect the standard treatment to be less effective and inadvertently convey this to the patients. To limit this possibility they took steps to ensure fidelity of treatment. The other limitations were the limited power that was due to the small number of patients and limited generalizability due to the characteristics of the patients.


Roozen and group (2003) examined the utility of combining CRA and naltrexone to prevent relapse in an opioid-dependent population treated in the Netherlands. Heroin addicts receiving naltrexone and CRA were compared to patients receiving methadone maintenance.


This was a naturalistic open-label study comparing two groups of opioid-dependent patients. The experimental group consisted of 24 heroin addicts treated with naltrexone and CRA for a period of over two years. The comparison group was 20 patients in a methadone maintenance program. The study was conducted in an outpatient treatment facility, Kentron, in Rosenal, the Netherlands, between February 1996 and May 1998. Of the 24 experimental subjects, 21 were previous participants at the methadone clinic. Subjects were detoxified from opioids prior to initiation of naltrexone using a rapid detoxification procedure. They detoxified five patients by tapering methadone. After withdrawal from opioids patients were maintained on naltrexone 25mg a day and provided CRA counseling up to three times a week for the first month. CRA contained the following elements: functional analysis, psycho-education, pharmacotherapy, compliance therapy, urine monitoring, marriage/relation therapy, support of social network, career orientation, job counseling, education and hobbies, problem solving, social skills and cognitive restructuring.


The two groups were comparable on all variables except the number of times the patients were arrested. The naltrexone group was arrested more frequently than the methadone group (96% naltrexone vs. 57% methadone).

After six months of treatment, 14 of 24 patients in the naltrexone group were still abstinent (58%) and at one year of treatment 12 of 22 were abstinent (55%). Use of other drugs such as cocaine, amphetamines and benzodiazepines were reduced or stopped in most patients in the naltrexone group. Marijuana use remained unchanged for most individuals. Those who relapsed (n = 10) were more likely to be polydrug users and had high scores on the B-cluster personality disorder traits as measured by the VKP (Vragenlij st kenmerken van de persoonlijkheid).

This was an encouraging study in that a large percentage of patients continued on naltrexone and were abstinent not only from opioids but other drugs. The results are promising especially with the patients' long history of addiction and failed attempts at detoxification. However, this was not a randomized controlled trial and a follow-up randomized trial would be necessary to confirm these initial positive outcomes.


Bickel and Marsch (2002) have presented preliminary results on computer-assisted therapy for opioid dependent individuals. Patients were randomly assigned to one of three groups: CRA with vouchers for opioid- and cocaine-free urines delivered by a therapist, CRA with vouchers delivered by the computer and a control group consisting of treatment typically found in methadone programs.


The computerized treatment system was interfaced with a semi quantitative urinalysis (UA) machine. The computer program updated voucher earnings based on UA reports. Patients completed evidence-based modules on skills training, role-playing and homework based on their specific treatment plan. The computerized treatment program contained about 50 individual interactive modules. Some modules used video to teach skills and other modules used the fluency based computer instruction technology (Copyright HealthSim, Inc. 1997) described by Bickel and Marsch (2002). Electronic reports of the patient's treatment activities and UA results were sent to the therapist.


Over 80 opioid-dependent patients entered into the study; about 25% of the patients were also dependent on cocaine. After 12 weeks of treatment the standard treatment had 35% opioid-free urines, therapist treatment 56% opioid-free urines and computerized treatment 50% opioidfree urines. Estimates of cost were the following: standard treatment $20,000, therapist treatment $60,000 and computer-assisted treatment $16,500. There were no differences between groups in retention, ASI drug composite scores or therapeutic alliance.

These early results suggest that computer-assisted treatment is generally as effective as therapist-delivered treatment and can reduce the cost of providing treatment. Providers may be able to see larger numbers of patients and provide standardized evidence-based treatment. However, these promising preliminary findings must be confirmed by additional controlled trials.


Clearly, CRA will provide the treatment community with another valuable tool to use for individuals with opioid dependence, particularly in combination with the use of methadone and buprenorphine. Patients treated with CRA in combination with methadone maintenance have shown improvement in a number of critical areas. These include the reduction of opioid use as well as other drugs of abuse, and in one study, improved legal status, less psychiatric symptoms, and improved vocational and social functioning.

Further, CRA coupled with vouchers can assist in the difficult task of retaining patients in treatment long enough to improve opioid detoxification rates from buprenorphine. Previous reviews of this area have shown that few individuals have completed detoxification successfully (Milby 1988). This is yet another example of the successful combination of psychosocial interventions and pharmacotherapy (Onken, Blain & Boren 1995).

Once a patient is detoxified from methadone and potentially other opioids the combination of CRA and naltrexone may be helpful to sustain abstinence and reduce use of illicit opioids and other drugs of abuse (Roozen, Kerkhof & van den Brink 2003). The treatment and prevention of relapse to opioid use is critical once methadone or buprenorphine have been tapered and stopped.

The preliminary study by Bickel and Marsch (2002) is of interest because this allows CRA to be standardized in a computerized format that can be broadly disseminated to treatment programs. This format could standardize the training of therapists, increase the fidelity of the applied CRA, and has the potential of increasing the number of patients who can be treated and reducing the cost of treatment. Therapist could assign elements of the computer program as homework and review at the next available treatment session. Further, it provides treatment tools that a patient could utilize without immediate access to a therapist. For example, the computer program could be placed on the web site of the treatment program to allow patients access to the treatment modules after hours. The therapist could than track the patient's progress online. This would be especially important in treatment programs that have too few therapists for the high patient demand and in rural areas where access to treatment may be limited. The other vital area for needed research is in the application of these CRA modules to office-based practice with buprenorphine. Physicians have limited time and may not be able to link patients to treatment services. The CRA computer modules would provide an alternative way of patients accessing treatment. And lastly, the CRA computer modules could be used with patients in "interim" methadone or buprenorphine programs, prior to officially enrolling into the full opioid treatment program (Schwartz et. al. 2006; Krook 2002). Patients in interim methadone or buprenorphine programs are on methadone and buprenorphine solely with very limited counseling services. The CRA computer modules could extend counseling services to this group of patients waiting to be enrolled into a full opioid treatment program.

The treatment of opioid dependence with CRA is in its initial period of examination and there is need for further investigation of its usefulness. CRA has been successfully coupled with vouchers for detoxification of opioid dependence and in the treatment of cocaine dependence, but the use of CRA and vouchers has not been specifically evaluated in the treatment of opioid-dependent patients on maintenance methadone. The other area that would be beneficial to explore is the combination of CRA and case management in the treatment of opioid-dependence. Case management would be a logical extension of CRA since by design CRA has a link to the reinforcing capability of the "community" and case management would support this goal and could further develop reinforcement provided by community agencies and providers of such necessities as food, transportation, housing, financial support, and access to leisure activities. There is preliminary data that case management is useful in a population of opioid-dependent patients, and the pairing of CRA and case management appears to be both a practical and useful match (McLellan et al. 2005).

Furthermore, CRA may have utility for opioid-dependent individuals not yet in treatment. More recent data has demonstrated that CRA strategies are not only effective for patients in treatment, but also useful in encouraging individuals to access treatment. Much of this work has been done with families concerned about their loved ones who are in need of treatment, but need motivation and encouragement to access treatment services (Meyers et al. 1999).


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Patrick J. Abbott, M.D., Clinical Professor, University of New Mexico School of Medicine, Department of Psychiatry and Medical Director at the University of New Mexico Hospitals Addiction and Substance Abuse Programs (ASAP), Albuquerque, NM.

Please address correspondence and reprint requests to Patrick J. Abbott, M.D., University of New Mexico Hospitals, Addiction and Substance Abuse Programs (ASAP), 2450 Alamo SE, Albuquerque, New Mexico 87106. Email:
CRA Treatment in Opioid Dependence

Author            N     Study Type     Outcome

Abbott et.       181    Randomized     Six month F/U: Reduction of
  al. 1998              trial          opioid use, improvement in ASI
Bickel et.        39    Randomized     26 week F/U: Improved
  al. 1997              trial          completion rate in the
                                       experimental group and
                                       reduction of opioid use
Roozen et.        24    Naturalistic   Six month F/U: Decrease in
  al. 2003              open           opioid, cocaine, amphetamine,
                        label trial    and benzodiazepine use
Bickel &          80    Randomized     12 week F/U: Decrease in
  Marsch 2002           trial          opioid use
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Author:Abbott, Patrick J.
Publication:Journal of Psychoactive Drugs
Article Type:Report
Date:Dec 1, 2009
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