I

National Institute on Drug Abuse

National Institutes of Health

U.S. Department of Health and Human Services

principles of

drug addiction

treatment

A research-based guide

third edition
II

National Institute on Drug Abuse

National Institutes of Health

U.S. Department of Health and Human Services

principles of

drug addiction

treatment

A research-based guide

third edition
iiii iii

Martin W. Adler, Ph.D.

Temple University School of Medicine 

Kathleen Brady, M.D., Ph.D.

Medical University of South Carolina 

Greg Brigham, Ph.D.

Maryhaven, Inc. 

Kathleen M. Carroll, Ph.D.

Yale University School of Medicine 

Richard R. Clayton, Ph.D.

University of Kentucky 

Linda B. Cottler, Ph.D.

Washington University 

School of Medicine 

David P. Friedman, Ph.D.

Wake Forest University

Bowman Gray School of Medicine 

Reese T. Jones, M.D.

University of California at San Francisco 

Nancy K. Mello, Ph.D.

Harvard Medical School 

William R. Miller, Ph.D.

University of New Mexico 

Charles P. O’Brien, M.D., Ph.D.

University of Pennsylvania 

Jeffrey Selzer, M.D.

Zucker Hillside Hospital 

Eric J. Simon, Ph.D.

New York University 

Langone Medical Center 

Jose Szapocznik, Ph.D.

University of Miami

Miller School of Medicine 

George Woody, M.D.

University of Pennsylvania 

The National Institute on Drug Abuse wishes to thank the following 

individuals for reviewing this publication.

All materials in this volume are in the public domain and may be used 

or reproduced without permission from the Institute or the authors. 

Citation of the source is appreciated. 

<PM=;/W^MZVUMV\LWM[VW\MVLWZ[MWZNI^WZIVa[XMKQÅKKWUUMZKQIT

product or company. Trade, proprietary, or company names appearing in 

this publication are used only because they are considered essential in the

context of the studies described. 

NIH Publication No. 12–4180

Printed 1999; Reprinted July 2000, February 2008; 

Revised April 2009; December 2012

Acknowledgments Contents

ii Acknowledgments v Preface 2 Principles of Effective Treatment 7 Frequently Asked Questions 7 Why do drug-addicted persons keep using drugs? 8 What is drug addiction treatment? 

11 How effective is drug addiction treatment? 

12 Is drug addiction treatment worth its cost? 

14 How long does drug addiction 

treatment usually last? 

14 What helps people stay in treatment? 

15 How do we get more substanceabusing people into treatment?

16 How can family and friends make a difference 

in the life of someone needing treatment? 

16 Where can family members go for 

information on treatment options?

18 How can the workplace play a role 

in substance abuse treatment? 

19 What role can the criminal justice system 

play in addressing drug addiction? 

20 What are the unique needs of women 

with substance use disorders?

21 What are the unique needs of pregnant 

women with substance use disorders?

22 What are the unique needs of adolescents 

with substance use disorders?
iv

v

Drug addiction is a complex illness. It is characterized by intense and, at times, 

uncontrollable drug craving, along with compulsive drug 

seeking and use that persist even in the face of devastating 

consequences. This update of the National Institute on 

Drug Abuse’s Principles of Drug Addiction Treatment is 

intended to address addiction to a wide variety of drugs, 

including nicotine, alcohol, and illicit and prescription 

drugs. It is designed to serve as a resource for healthcare 

providers, family members, and other stakeholders trying 

to address the myriad problems faced by patients in need 

of treatment for drug abuse or addiction. 

Addiction affects multiple brain circuits, including 

those involved in reward and motivation, learning and 

memory, and inhibitory control over behavior. That is 

why addiction is a brain disease. Some individuals are 

more vulnerable than others to becoming addicted, 

depending on the interplay between genetic makeup, age 

WN M`XW[]ZM\WLZ]O[IVLW\PMZMV^QZWVUMV\ITQVÆ]MVKM[

While a person initially chooses to take drugs, over time 

the effects of prolonged exposure on brain functioning 

compromise that ability to choose, and seeking and 

consuming the drug become compulsive, often eluding 

a person’s self-control or willpower. 

But addiction is more than just compulsive drug taking—

it can also produce far-reaching health and social 

consequences. For example, drug abuse and addiction 

increase a person’s risk for a variety of other mental and 

physical illnesses related to a drug-abusing lifestyle or the 

toxic effects of the drugs themselves. Additionally, the 

dysfunctional behaviors that result from drug abuse can 

interfere with a person’s normal functioning in the family, 

the workplace, and the broader community. 

Because drug abuse and addiction have so many 

dimensions and disrupt so many aspects of an individual’s 

life, treatment is not simple. Effective treatment programs 

Preface

 )ZM\PMZM[XMKQÅKLZ]OILLQK\QWV

treatments for older adults?

24 Can a person become addicted to medications

prescribed by a doctor?

24 Is there a difference between physical 

dependence and addiction? 

25 How do other mental disorders coexisting with 

drug addiction affect drug addiction treatment?

26 Is the use of medications like methadone 

and buprenorphine simply replacing 

one drug addiction with another? 

27 Where do 12-step or self-help programs 

Å\QV\WLZ]OILLQK\QWV\ZMI\UMV\'

28 Can exercise play a role in the treatment process?

28 How does drug addiction treatment help 

reduce the spread of HIV/AIDS, hepatitis 

C (HCV), and other infectious diseases?

31 Drug Addiction Treatment in the United States

32 Types of Treatment Programs

37 Treating Criminal Justice-Involved Drug 

Abusers and Addicted Individuals

39 Evidence-Based Approaches to 

Drug Addiction Treatment

39 Pharmacotherapies

48 Behavioral Therapies

60 Behavioral Therapies Primarily for Adolescents

69 Resources
vi

1

typically incorporate many components, each directed 

to a particular aspect of the illness and its consequences. 

Addiction treatment must help the individual stop 

using drugs, maintain a drug-free lifestyle, and achieve 

productive functioning in the family, at work, and in 

society. Because addiction is a disease, most people 

cannot simply stop using drugs for a few days and be 

cured. Patients typically require long-term or repeated 

episodes of care to achieve the ultimate goal of sustained 

IJ[\QVMVKMIVLZMKW^MZaWN \PMQZTQ^M[1VLMML[KQMV\QÅK

research and clinical practice demonstrate the value 

of continuing care in treating addiction, with a variety 

of approaches having been tested and integrated in 

residential and community settings. 

As we look toward the future, we will harness new research 

ZM[]T\[WV\PMQVÆ]MVKMWN OMVM\QK[IVLMV^QZWVUMV\WV

gene function and expression (i.e., epigenetics), which 

are heralding the development of personalized treatment 

QV\MZ^MV\QWV[<PM[MÅVLQVO[_QTTJMQV\MOZI\ML_Q\P

current evidence supporting the most effective drug abuse 

and addiction treatments and their implementation, which 

IZMZMÆMK\MLQV\PQ[O]QLM

Nora D. Volkow, M.D.

Director

National Institute on Drug Abuse

Nearly four decades of scientific 

research and clinical practice 

have yielded a variety of effective 

approaches to drug addiction treatment. 
2

3

Principles 

of Effective 

Treatment

1. Addiction is a complex but treatable 

disease that affects brain function and 

behavior. Drugs of abuse alter the brain’s structure 

and function, resulting in changes that persist long after 

drug use has ceased. This may explain why drug abusers 

are at risk for relapse even after long periods of abstinence 

and despite the potentially devastating consequences.

2. No single treatment is appropriate 

for everyone. Treatment varies depending on 

the type of drug and the characteristics of the patients. 

Matching treatment settings, interventions, and services 

to an individual’s particular problems and needs is critical 

to his or her ultimate success in returning to productive 

functioning in the family, workplace, and society.

3. Treatment needs to be readily available. 

Because drug-addicted individuals may be uncertain 

about entering treatment, taking advantage of available 

services the moment people are ready for treatment is 

critical. Potential patients can be lost if treatment is not 

immediately available or readily accessible. As with 

other chronic diseases, the earlier treatment is offered 

in the disease process, the greater the likelihood of 

positive outcomes.

4. Effective treatment attends to multiple 

needs of the individual, not just his 

or her drug abuse. To be effective, treatment 

must address the individual’s drug abuse and any 

associated medical, psychological, social, vocational, 

and legal problems. It is also important that treatment 

be appropriate to the individual’s age, gender, ethnicity, 

and culture.

5. Remaining in treatment for an adequate 

period of time is critical. The appropriate 

duration for an individual depends on the type and degree 

of the patient’s problems and needs. Research indicates 

that most addicted individuals need at least 3 months in 

\ZMI\UMV\\W[QOVQÅKIV\TaZML]KMWZ[\WX\PMQZLZ]O][M

and that the best outcomes occur with longer durations 

of treatment. Recovery from drug addiction is a longterm process and frequently requires multiple episodes of 

treatment. As with other chronic illnesses, relapses to drug 

abuse can occur and should signal a need for treatment to 

be reinstated or adjusted. Because individuals often leave 

treatment prematurely, programs should include strategies 

to engage and keep patients in treatment.

6. Behavioral therapies—including 

individual, family, or group counseling—

are the most commonly used forms of 

drug abuse treatment. Behavioral therapies 

vary in their focus and may involve addressing a patient’s 

motivation to change, providing incentives for abstinence, 

building skills to resist drug use, replacing drug-using 

activities with constructive and rewarding activities, 

improving problem-solving skills, and facilitating better 

interpersonal relationships. Also, participation in group 

therapy and other peer support programs during and 

following treatment can help maintain abstinence.

7. Medications are an important element of 

treatment for many patients, especially 

when combined with counseling and 

other behavioral therapies. For example, 

methadone, buprenorphine, and naltrexone (including 

a new long-acting formulation) are effective in helping 

individuals addicted to heroin or other opioids stabilize 

their lives and reduce their illicit drug use. Acamprosate, 

LQ[]TÅZIUIVLVIT\ZM`WVMIZMUMLQKI\QWV[IXXZW^ML

for treating alcohol dependence. For persons addicted 

to nicotine, a nicotine replacement product (available 

as patches, gum, lozenges, or nasal spray) or an oral 

medication (such as bupropion or varenicline) can be 

an effective component of treatment when part of a 

comprehensive behavioral treatment program.

23
4

5

8. An individual’s treatment and services 

plan must be assessed continually and 

modified as necessary to ensure that 

it meets his or her changing needs. A 

patient may require varying combinations of services and 

treatment components during the course of treatment and 

recovery. In addition to counseling or psychotherapy, a 

patient may require medication, medical services, family 

therapy, parenting instruction, vocational rehabilitation, 

and/or social and legal services. For many patients, a 

continuing care approach provides the best results, with 

the treatment intensity varying according to a person’s 

changing needs.

9. Many drug-addicted individuals also 

have other mental disorders. Because 

drug abuse and addiction—both of which are mental 

disorders—often co-occur with other mental illnesses, 

patients presenting with one condition should be assessed 

for the other(s). And when these problems co-occur, 

treatment should address both (or all), including the use of 

medications as appropriate.

10. Medically assisted detoxification 

is only the first stage of addiction 

treatment and by itself does little to 

change long-term drug abuse. Although 

UMLQKITTaI[[Q[\MLLM\W`QÅKI\QWVKIV[INMTaUIVIOM\PM

acute physical symptoms of withdrawal and can, for 

some, pave the way for effective long-term addiction 

\ZMI\UMV\LM\W`QÅKI\QWVITWVMQ[ZIZMTa[]NÅKQMV\\WPMTX

addicted individuals achieve long-term abstinence. Thus, 

patients should be encouraged to continue drug treatment 

NWTTW_QVOLM\W`QÅKI\QWV5W\Q^I\QWVITMVPIVKMUMV\IVL

incentive strategies, begun at initial patient intake, can 

improve treatment engagement.

4

11. Treatment does not need to be 

voluntary to be effective. Sanctions or 

enticements from family, employment settings, and/or the 

KZQUQVITR][\QKM[a[\MUKIV[QOVQÅKIV\TaQVKZMI[M\ZMI\UMV\

entry, retention rates, and the ultimate success of drug 

treatment interventions.

12. Drug use during treatment must be 

monitored continuously, as lapses 

during treatment do occur. Knowing their 

drug use is being monitored can be a powerful incentive 

for patients and can help them withstand urges to use 

drugs. Monitoring also provides an early indication of a 

return to drug use, signaling a possible need to adjust an 

individual’s treatment plan to better meet his or her needs. 

13. Treatment programs should test 

patients for the presence of HIV/AIDS, 

hepatitis B and C, tuberculosis, and 

other infectious diseases, as well 

as provide targeted risk-reduction 

counseling, linking patients to 

treatment if necessary. Typically, drug abuse 

treatment addresses some of the drug-related behaviors 

that put people at risk of infectious diseases. Targeted 

counseling focused on reducing infectious disease risk 

can help patients further reduce or avoid substancerelated and other high-risk behaviors. Counseling can 

also help those who are already infected to manage their 

illness. Moreover, engaging in substance abuse treatment 

can facilitate adherence to other medical treatments. 

Substance abuse treatment facilities should provide onsite, 

rapid HIV testing rather than referrals to offsite testing—

research shows that doing so increases the likelihood 

that patients will be tested and receive their test results. 

Treatment providers should also inform patients that 

highly active antiretroviral therapy (HAART) has proven 

effective in combating HIV, including among drugabusing populations, and help link them to HIV treatment 

if they test positive.
6

7

1. Why do drug-addicted persons keep 

using drugs?

Nearly all addicted individuals believe at the outset that 

they can stop using drugs on their own, and most try 

to stop without treatment. Although some people are 

successful, many attempts result in failure to achieve longterm abstinence. Research has shown that long-term drug 

abuse results in changes in the brain that persist long after 

a person stops using drugs. These drug-induced changes 

in brain function can have many behavioral consequences, 

including an inability to exert control over the impulse 

\W][MLZ]O[LM[XQ\MIL^MZ[MKWV[MY]MVKM[ ̧\PMLMÅVQVO

characteristic of addiction. 

Long-term drug use results in significant 

changes in brain function that can 

persist long after the individual stops 

using drugs. 

Understanding that addiction has such a fundamental 

JQWTWOQKITKWUXWVMV\UIaPMTXM`XTIQV\PMLQNÅK]T\a

of achieving and maintaining abstinence without 

treatment. Psychological stress from work, family problems, 

psychiatric illness, pain associated with medical problems, 

social cues (such as meeting individuals from one’s drugusing past), or environmental cues (such as encountering 

streets, objects, or even smells associated with drug abuse) 

can trigger intense cravings without the individual even 

being consciously aware of the triggering event. Any 

one of these factors can hinder attainment of sustained 

abstinence and make relapse more likely. Nevertheless, 

research indicates that active participation in treatment is 

IVM[[MV\QITKWUXWVMV\NWZOWWLW]\KWUM[IVLKIVJMVMÅ\

even the most severely addicted individuals. Frequently Asked 

Treatment varies depending on the 

Questions

type of drug and the characteristics 

of the patient. The best programs 

provide a combination of therapies 

and other services.
9

combination of treatments will vary depending on the 

patient’s individual needs and, often, on the types of drugs 

they use. 

Drug addiction treatment can include 

medications, behavioral therapies, or 

their combination. 

Treatment medications, such as methadone, 

buprenorphine, and naltrexone (including a new longacting formulation), are available for individuals addicted 

to opioids, while nicotine preparations (patches, gum, 

lozenges, and nasal spray) and the medications varenicline 

and bupropion are available for individuals addicted to 

\WJIKKW,Q[]TÅZIUIKIUXZW[I\MIVLVIT\ZM`WVMIZM

medications available for treating alcohol dependence,1

which commonly co-occurs with other drug addictions, 

including addiction to prescription medications. 

Treatments for prescription drug abuse tend to be 

similar to those for illicit drugs that affect the same brain 

systems. For example, buprenorphine, used to treat heroin 

addiction, can also be used to treat addiction to opioid 

pain medications. Addiction to prescription stimulants, 

which affect the same brain systems as illicit stimulants like 

cocaine, can be treated with behavioral therapies, as there 

are not yet medications for treating addiction to these 

types of drugs. 

Behavioral therapies can help motivate people to 

participate in drug treatment, offer strategies for coping 

with drug cravings, teach ways to avoid drugs and prevent 

relapse, and help individuals deal with relapse if it 

occurs. Behavioral therapies can also help people improve 

communication, relationship, and parenting skills, as well 

as family dynamics. 

2. What is drug addiction treatment?

Drug treatment is intended to help addicted individuals 

stop compulsive drug seeking and use. Treatment can 

occur in a variety of settings, take many different forms, 

and last for different lengths of time. Because drug 

addiction is typically a chronic disorder characterized by 

occasional relapses, a short-term, one-time treatment is 

][]ITTaVW\[]NÅKQMV\.WZUIVa\ZMI\UMV\Q[ITWVO\MZU

process that involves multiple interventions and regular 

monitoring. 

There are a variety of evidence-based approaches 

to treating addiction. Drug treatment can include 

behavioral therapy (such as cognitive-behavioral 

therapy or contingency management), medications, or 

\PMQZKWUJQVI\QWV<PM[XMKQÅK\aXMWN \ZMI\UMV\WZ

The best treatment programs provide a combination of therapies 

and other services to meet the needs of the individual patient.

Components of Comprehensive Drug Abuse Treatment

HIV/AIDS

Services

Educational Services

Child Care

Services

Financial

Services Medical

Services

Housing / Transportation Services

Mental Health Services

Family

Services Vocational

Services

Legal

Services

Intake Processing/

Assessment

Treatment Plan

Pharmacotherapy

Continuing Care

Clinical 

and Case

Management

Behavioral 

Therapy and 

Counseling

Substance Use Monitoring

Self-Help/Peer 

Support Groups

8

1 Another drug, topiramate, has also shown promise in studies and is sometimes prescribed (off-label) 

for this purpose although it has not received FDA approval as a treatment for alcohol dependence.
10 11

3. How effective is drug addiction 

treatment?

In addition to stopping drug abuse, the goal of treatment 

is to return people to productive functioning in the family, 

workplace, and community. According to research that 

tracks individuals in treatment over extended periods, 

most people who get into and remain in treatment stop 

using drugs, decrease their criminal activity, and improve 

their occupational, social, and psychological functioning. 

For example, methadone treatment has been shown to 

increase participation in behavioral therapy and decrease 

both drug use and criminal behavior. However, individual 

treatment outcomes depend on the extent and nature of 

the patient’s problems, the appropriateness of treatment 

and related services used to address those problems, and 

the quality of interaction between the patient and his or 

her treatment providers. 

Relapse rates for addiction resemble 

those of other chronic diseases such 

as diabetes, hypertension, and asthma. 

Like other chronic diseases, addiction can be managed 

successfully. Treatment enables people to counteract 

addiction’s powerful disruptive effects on the brain and 

behavior and to regain control of their lives. The chronic 

nature of the disease means that relapsing to drug abuse is 

not only possible but also likely, with symptom recurrence 

rates similar to those for other well-characterized chronic 

medical illnesses—such as diabetes, hypertension, and 

I[\PUI[MMÅO]ZM1+WUXIZQ[WVWN :MTIX[M:I\M[

Between Drug Addiction and Other Chronic Illnesses”)—

that also have both physiological and behavioral 

components. 

Many treatment programs employ both individual and 

group therapies. Group therapy can provide social 

reinforcement and help enforce behavioral contingencies 

that promote abstinence and a non-drug-using lifestyle. 

Some of the more established behavioral treatments, such 

as contingency management and cognitive-behavioral 

therapy, are also being adapted for group settings to 

QUXZW^MMNÅKQMVKaIVLKW[\MNNMK\Q^MVM[[0W_M^MZ

particularly in adolescents, there can also be a danger 

of unintended harmful (or iatrogenic) effects of group 

treatment—sometimes group members (especially groups 

of highly delinquent youth) can reinforce drug use and 

thereby derail the purpose of the therapy. Thus, trained 

counselors should be aware of and monitor for such effects. 

Because they work on different aspects of addiction, 

combinations of behavioral therapies and medications 

(when available) generally appear to be more effective than 

either approach used alone.

Finally, people who are addicted to drugs often suffer from 

other health (e.g., depression, HIV), occupational, legal, 

familial, and social problems that should be addressed 

concurrently. The best programs provide a combination of 

therapies and other services to meet an individual patient’s 

needs. Psychoactive medications, such as antidepressants, 

anti-anxiety agents, mood stabilizers, and antipsychotic 

medications, may be critical for treatment success when 

patients have co-occurring mental disorders such as 

depression, anxiety disorders (including post-traumatic 

stress disorder), bipolar disorder, or schizophrenia. In 

addition, most people with severe addiction abuse multiple 

drugs and require treatment for all substances abused.

Treatment for drug abuse and addiction 

is delivered in many different settings 

using a variety of behavioral and 

pharmacological approaches.
12 13

health and social costs by far more than the cost of the 

treatment itself. Treatment is also much less expensive 

than its alternatives, such as incarcerating addicted 

persons. For example, the average cost for 1 full year 

of methadone maintenance treatment is approximately 

$4,700 per patient, whereas 1 full year of imprisonment 

costs approximately $24,000 per person.

Drug addiction treatment reduces 

drug use and its associated health 

and social costs.

According to several conservative estimates, every dollar 

invested in addiction treatment programs yields a return 

of between $4 and $7 in reduced drug-related crime, 

criminal justice costs, and theft. When savings related to 

healthcare are included, total savings can exceed costs 

by a ratio of 12 to 1. Major savings to the individual and 

\W[WKQM\aIT[W[\MUNZWUNM_MZQV\MZXMZ[WVITKWVÆQK\[#

greater workplace productivity; and fewer drug-related 

accidents, including overdoses and deaths.

Unfortunately, when relapse occurs many deem treatment 

a failure. This is not the case: Successful treatment for 

addiction typically requires continual evaluation and 

UWLQÅKI\QWVI[IXXZWXZQI\M[QUQTIZ\W\PMIXXZWIKP\ISMV

for other chronic diseases. For example, when a patient is 

receiving active treatment for hypertension and symptoms 

decrease, treatment is deemed successful, even though 

symptoms may recur when treatment is discontinued. 

For the addicted individual, lapses to drug abuse do not 

indicate failure—rather, they signify that treatment needs 

to be reinstated or adjusted, or that alternate treatment 

Q[VMMLML[MMÅO]ZM1?PaQ[)LLQK\QWV<ZMI\UMV\

Evaluated Differently?”).

4. Is drug addiction treatment worth 

its cost?

Substance abuse costs our Nation over $600 billion 

annually and treatment can help reduce these costs. Drug 

addiction treatment has been shown to reduce associated 

8

7

6

5

4

3

2

1

0

8

7

6

5

4

3

2

1

0

Why is addiction treatment evaluated differently?

Both require ongoing care

SEVERITY OF CONDITION

STAGE OF TREATMENT

PRE DURING POST PRE DURING POST

Hypertension Treatment Addiction Treatment

DRUG ADDICTION

TYPE I DIABETES

30 to 50%

40 to 60%

HYPERTENSION

50 to 70%

ASTHMA

50 to 70%

Percentage of Patients Who Relapse

Comparison of Relapse Rates 

Between Drug Addiction and 

Other Chronic Illnesses
14 15

pressure from the criminal justice system, child protection 

services, employers, or family. Within a treatment program, 

successful clinicians can establish a positive, therapeutic 

relationship with their patients. The clinician should 

ensure that a treatment plan is developed cooperatively 

with the person seeking treatment, that the plan is 

followed, and that treatment expectations are clearly 

understood. Medical, psychiatric, and social services 

should also be available.

Whether a patient stays in treatment 

depends on factors associated with 

both the individual and the program.

Because some problems (such as serious medical or 

mental illness or criminal involvement) increase the 

likelihood of patients dropping out of treatment, intensive 

interventions may be required to retain them. After a 

course of intensive treatment, the provider should ensure 

a transition to less intensive continuing care to support 

and monitor individuals in their ongoing recovery.

7. How do we get more substanceabusing people into treatment?

1\PI[JMMVSVW_VNWZUIVaaMIZ[\PI\\PM1\ZMI\UMV\

gap” is massive—that is, among those who need treatment 

for a substance use disorder, few receive it. In 2011, 21.6 

million persons aged 12 or older needed treatment for an 

illicit drug or alcohol use problem, but only 2.3 million 

received treatment at a specialty substance abuse facility. 

Reducing this gap requires a multipronged approach. 

Strategies include increasing access to effective treatment, 

achieving insurance parity (now in its earliest phase of 

implementation), reducing stigma, and raising awareness 

5. How long does drug addiction 

treatment usually last? 

Individuals progress through drug addiction treatment 

at various rates, so there is no predetermined length of 

treatment. However, research has shown unequivocally 

that good outcomes are contingent on adequate treatment 

length. Generally, for residential or outpatient treatment, 

participation for less than 90 days is of limited effectiveness, 

IVL\ZMI\UMV\TI[\QVO[QOVQÅKIV\TaTWVOMZQ[ZMKWUUMVLMLNWZ

maintaining positive outcomes. For methadone maintenance, 

12 months is considered the minimum, and some opioidILLQK\MLQVLQ^QL]IT[KWV\QV]M\WJMVMÅ\NZWUUM\PILWVM

maintenance for many years.

Good outcomes are contingent on 

adequate treatment length.

Treatment dropout is one of the major problems 

encountered by treatment programs; therefore, motivational 

techniques that can keep patients engaged will also improve 

outcomes. By viewing addiction as a chronic disease and 

offering continuing care and monitoring, programs can 

succeed, but this will often require multiple episodes of 

treatment and readily readmitting patients that have relapsed.

6. What helps people stay in treatment?

Because successful outcomes often depend on a person’s 

[\IaQVOQV\ZMI\UMV\TWVOMVW]OP\WZMIXQ\[N]TTJMVMÅ\[

strategies for keeping people in treatment are critical. 

Whether a patient stays in treatment depends on factors 

associated with both the individual and the program. 

Individual factors related to engagement and retention 

typically include motivation to change drug-using behavior; 

degree of support from family and friends; and, frequently, 
16 17

among both patients and healthcare professionals of 

the value of addiction treatment. To assist physicians in 

identifying treatment need in their patients and making 

appropriate referrals, NIDA is encouraging widespread 

use of screening, brief intervention, and referral to 

treatment (SBIRT) tools for use in primary care settings 

through its NIDAMED initiative. SBIRT, which evidence 

shows to be effective against tobacco and alcohol use—

and, increasingly, against abuse of illicit and prescription 

drugs—has the potential not only to catch people before 

serious drug problems develop but also to identify people 

in need of treatment and connect them with appropriate 

treatment providers.

8. How can family and friends make a 

difference in the life of someone 

needing treatment?

Family and friends can play critical roles in motivating 

individuals with drug problems to enter and stay in 

treatment. Family therapy can also be important, 

especially for adolescents. Involvement of a family 

UMUJMZWZ[QOVQÅKIV\W\PMZQVIVQVLQ^QL]IT1⁄4[\ZMI\UMV\

XZWOZIUKIV[\ZMVO\PMVIVLM`\MVL\ZMI\UMV\JMVMÅ\[

9. Where can family members go for 

information on treatment options?

Trying to locate appropriate treatment for a loved one, 

M[XMKQITTaÅVLQVOIXZWOZIU\IQTWZML\WIVQVLQ^QL]IT1⁄4[

XIZ\QK]TIZVMML[KIVJMILQNÅK]T\XZWKM[[0W_M^MZ\PMZM

are some resources to help with this process. For example, 

NIDA’s handbook Seeking Drug Abuse Treatment: Know 

What to AskWNNMZ[O]QLIVKMQVÅVLQVO\PMZQOP\\ZMI\UMV\

program. Numerous online resources can help locate a 

local program or provide other information, including: 

 The Substance Abuse and Mental Health Services 

Administration (SAMHSA) maintains a Web site (findtreatment.samhsa.gov) that shows the location of 

residential, outpatient, and hospital inpatient treatment 

programs for drug addiction and alcoholism throughout 

the country. This information is also accessible by 

calling 1-800-662-HELP. 

 The National Suicide Prevention Lifeline (1-800-273-

TALK) offers more than just suicide prevention—it 

can also help with a host of issues, including drug 

and alcohol abuse, and can connect individuals with a 

nearby professional. 

 The National Alliance on Mental Illness (nami.org) and 

Mental Health America (mentalhealthamerica.net) are 

ITTQIVKM[WN VWVXZWÅ\[MTNPMTX[]XXWZ\WZOIVQbI\QWV[

for patients and families dealing with a variety of 

UMV\ITLQ[WZLMZ[*W\PPI^M;\I\MIVLTWKITINÅTQI\M[

throughout the United States and may be especially 

helpful for patients with comorbid conditions. 

 The American Academy of Addiction Psychiatry and 

the American Academy of Child and Adolescent 

Psychiatry each have physician locator tools posted on 

their Web sites at aaap.org and aacap.org, respectively. 

 Faces & Voices of Recovery (facesandvoicesofrecovery.

org), founded in 2001, is an advocacy organization for 

individuals in long-term recovery that strategizes on 

ways to reach out to the medical, public health, criminal 

justice, and other communities to promote and celebrate 

recovery from addiction to alcohol and other drugs.

 The Partnership at Drugfree.org (drugfree.org) is an 

organization that provides information and resources 

on teen drug use and addiction for parents, to help 

them prevent and intervene in their children’s drug use 

WZÅVL\ZMI\UMV\NWZIKPQTL_PWVMML[Q\<PMaWNNMZI

toll-free helpline for parents (1-855-378-4373).
18 19

 The American Society of Addiction Medicine (asam.

org) is a society of physicians aimed at increasing access 

to addiction treatment. Their Web site has a nationwide 

directory of addiction medicine professionals.

 NIDA’s National Drug Abuse Treatment Clinical Trials 

Network (drugabuse.gov/about-nida/organization/

cctn/ctn) provides information for those interested 

in participating in a clinical trial testing a promising 

substance abuse intervention; or visit clinicaltrials.gov.

 NIDA’s DrugPubs Research Dissemination Center 

(drugpubs.drugabuse.gov) provides booklets, pamphlets, 

fact sheets, and other informational resources on drugs, 

drug abuse, and treatment. 

 The National Institute on Alcohol Abuse and 

Alcoholism (niaaa.nih.gov) provides information on 

alcohol, alcohol use, and treatment of alcohol-related 

problems (niaaa.nih.gov/search/node/treatment). 

10. How can the workplace play a role 

in substance abuse treatment?

Many workplaces sponsor Employee Assistance Programs 

(EAPs) that offer short-term counseling and/or assistance 

in linking employees with drug or alcohol problems to 

local treatment resources, including peer support/recovery 

groups. In addition, therapeutic work environments that 

provide employment for drug-abusing individuals who 

can demonstrate abstinence have been shown not only to 

promote a continued drug-free lifestyle but also to improve 

job skills, punctuality, and other behaviors necessary for 

active employment throughout life. Urine testing facilities, 

trained personnel, and workplace monitors are needed to 

implement this type of treatment.

11. What role can the criminal justice 

system play in addressing drug 

addiction?

It is estimated that about one-half of State and Federal 

prisoners abuse or are addicted to drugs, but relatively 

few receive treatment while incarcerated. Initiating drug 

abuse treatment in prison and continuing it upon release 

is vital to both individual recovery and to public health 

and safety. Various studies have shown that combining 

prison- and community-based treatment for addicted 

offenders reduces the risk of both recidivism to drugrelated criminal behavior and relapse to drug use—which, 

in turn, nets huge savings in societal costs. A 2009 study 

in Baltimore, Maryland, for example, found that opioidaddicted prisoners who started methadone treatment 

(along with counseling) in prison and then continued it 

after release had better outcomes (reduced drug use and 

criminal activity) than those who only received counseling 

while in prison or those who only started methadone 

treatment after their release.

Individuals who enter treatment 

under legal pressure have outcomes 

as favorable as those who enter 

treatment voluntarily.

The majority of offenders involved with the criminal 

justice system are not in prison but are under community 

supervision. For those with known drug problems, drug 

addiction treatment may be recommended or mandated 

as a condition of probation. Research has demonstrated 

that individuals who enter treatment under legal pressure 

have outcomes as favorable as those who enter treatment 

voluntarily. 

The criminal justice system refers drug offenders into 

treatment through a variety of mechanisms, such as 
20 21

diverting nonviolent offenders to treatment; stipulating 

treatment as a condition of incarceration, probation, or 

pretrial release; and convening specialized courts, or 

drug courts, that handle drug offense cases. These courts 

mandate and arrange for treatment as an alternative to 

incarceration, actively monitor progress in treatment, and 

arrange for other services for drug-involved offenders. 

The most effective models integrate criminal justice and 

drug treatment systems and services. Treatment and 

criminal justice personnel work together on treatment 

planning—including implementation of screening, 

placement, testing, monitoring, and supervision—as 

well as on the systematic use of sanctions and rewards. 

Treatment for incarcerated drug abusers should include 

continuing care, monitoring, and supervision after 

incarceration and during parole. Methods to achieve better 

KWWZLQVI\QWVJM\_MMVXIZWTMXZWJI\QWVWNÅKMZ[IVLPMIT\P

providers are being studied to improve offender outcomes. 

(For more information, please see NIDA’s Principles of 

Drug Abuse Treatment for Criminal Justice Populations: A 

Research-Based Guide [revised 2012].) 

12. What are the unique needs 

of women with substance 

use disorders?

Gender-related drug abuse treatment should attend 

not only to biological differences but also to social and 

MV^QZWVUMV\ITNIK\WZ[ITTWN _PQKPKIVQVÆ]MVKM\PM

motivations for drug use, the reasons for seeking treatment, 

the types of environments where treatment is obtained, the 

treatments that are most effective, and the consequences 

of not receiving treatment. Many life circumstances 

predominate in women as a group, which may require 

a specialized treatment approach. For example, research 

has shown that physical and sexual trauma followed by 

post-traumatic stress disorder (PTSD) is more common 

in drug-abusing women than in men seeking treatment. 

7\PMZNIK\WZ[]VQY]M\W_WUMV\PI\KIVQVÆ]MVKM\PM

treatment process include issues around how they come 

into treatment (as women are more likely than men to seek 

the assistance of a general or mental health practitioner), ÅVIVKQITQVLMXMVLMVKMIVLXZMOVIVKaIVLKPQTLKIZM

13. What are the unique needs of 

pregnant women with substance 

use disorders?

Using drugs, alcohol, or tobacco during pregnancy 

exposes not just the woman but also her developing 

fetus to the substance and can have potentially 

deleterious and even long-term effects on exposed 

children. Smoking during pregnancy can increase 

risk of stillbirth, infant mortality, sudden infant death 

syndrome, preterm birth, respiratory problems, slowed 

fetal growth, and low birth weight. Drinking during 

pregnancy can lead to the child developing fetal alcohol 

spectrum disorders, characterized by low birth weight 

and enduring cognitive and behavioral problems. 

Prenatal use of some drugs, including opioids, may 

cause a withdrawal syndrome in newborns called 

neonatal abstinence syndrome (NAS). Babies with NAS 

are at greater risk of seizures, respiratory problems, 

NMMLQVOLQNÅK]T\QM[TW_JQZ\P_MQOP\IVLM^MVLMI\P

Research has established the value of evidence-based 

treatments for pregnant women (and their babies), 

including medications. For example, although no 

medications have been FDA-approved to treat opioid 

dependence in pregnant women, methadone maintenance 

combined with prenatal care and a comprehensive 

drug treatment program can improve many of the 

detrimental outcomes associated with untreated heroin 

abuse. However, newborns exposed to methadone 
22 23

during pregnancy still require treatment for withdrawal 

symptoms. Recently, another medication option for opioid 

dependence, buprenorphine, has been shown to produce 

fewer NAS symptoms in babies than methadone, resulting 

in shorter infant hospital stays. In general, it is important 

to closely monitor women who are trying to quit drug use 

during pregnancy and to provide treatment as needed.

14. What are the unique needs of 

adolescents with substance 

use disorders?

Adolescent drug abusers have unique needs stemming 

from their immature neurocognitive and psychosocial 

stage of development. Research has demonstrated that 

the brain undergoes a prolonged process of development 

IVLZMÅVMUMV\NZWUJQZ\P\PZW]OPMIZTaIL]T\PWWL

Over the course of this developmental period, a young 

person’s actions go from being more impulsive to being 

UWZMZMI[WVMLIVLZMÆMK\Q^M1VNIK\\PMJZIQVIZMI[

most closely associated with aspects of behavior such 

as decision-making, judgment, planning, and selfcontrol undergo a period of rapid development during 

adolescence and young adulthood. 

Adolescent drug abuse is also often associated with 

other co-occurring mental health problems. These 

QVKT]LMI\\MV\QWVLMÅKQ\PaXMZIK\Q^Q\aLQ[WZLMZ),0,

WXXW[Q\QWVITLMÅIV\LQ[WZLMZIVLKWVL]K\XZWJTMU[I[

well as depressive and anxiety disorders. 

Adolescents are also especially sensitive to social cues, with 

XMMZOZW]X[IVLNIUQTQM[JMQVOPQOPTaQVÆ]MV\QITL]ZQVO

this time. Therefore, treatments that facilitate positive 

parental involvement, integrate other systems in which the 

adolescent participates (such as school and athletics), and 

recognize the importance of prosocial peer relationships 

are among the most effective. Access to comprehensive 

assessment, treatment, case management, and familysupport services that are developmentally, culturally, and 

gender-appropriate is also integral when addressing 

adolescent addiction. 

Medications for substance abuse among adolescents may 

in certain cases be helpful. Currently, the only addiction 

medications approved by FDA for people under 18 

are over-the-counter transdermal nicotine skin patches, 

chewing gum, and lozenges (physician advice should be 

[W]OP\ÅZ[\*]XZMVWZXPQVMIUMLQKI\QWVNWZ\ZMI\QVO

opioid addiction that must be prescribed by specially 

trained physicians, has not been approved for adolescents, 

but recent research suggests it could be effective for those 

as young as 16. Studies are under way to determine the 

[INM\aIVLMNÅKIKaWN \PQ[IVLW\PMZUMLQKI\QWV[NWZ

opioid-, nicotine-, and alcohol-dependent adolescents and 

for adolescents with co-occurring disorders.

15. Are there specific drug addiction 

treatments for older adults?

With the aging of the baby boomer generation, the 

composition of the general population is changing 

dramatically with respect to the number of older adults. 

Such a change, coupled with a greater history of lifetime 

drug use (than previous older generations), different 

cultural norms and general attitudes about drug use, 

and increases in the availability of psychotherapeutic 

medications, is already leading to greater drug use by 

older adults and may increase substance use problems 

in this population. While substance abuse in older adults 

often goes unrecognized and therefore untreated, research 

indicates that currently available addiction treatment 

programs can be as effective for them as for younger adults.
24 25

16. Can a person become addicted 

to medications prescribed by a 

doctor? 

Yes. People who abuse prescription drugs—that is, taking 

them in a manner or a dose other than prescribed, or 

taking medications prescribed for another person—risk 

addiction and other serious health consequences. Such 

drugs include opioid pain relievers, stimulants used to treat 

ADHD, and benzodiazepines to treat anxiety or sleep 

disorders. Indeed, in 2010, an estimated 2.4 million people 

12 or older met criteria for abuse of or dependence on 

prescription drugs, the second most common illicit drug 

use after marijuana. To minimize these risks, a physician 

(or other prescribing health provider) should screen 

patients for prior or current substance abuse problems and 

assess their family history of substance abuse or addiction 

before prescribing a psychoactive medication and monitor 

patients who are prescribed such drugs. Physicians also 

need to educate patients about the potential risks so that 

they will follow their physician’s instructions faithfully, 

safeguard their medications, and dispose of them 

appropriately. 

17. Is there a difference between 

physical dependence and addiction? 

Yes. Addiction—or compulsive drug use despite harmful 

consequences—is characterized by an inability to stop 

using a drug; failure to meet work, social, or family 

obligations; and, sometimes (depending on the drug), 

\WTMZIVKMIVL_Q\PLZI_IT<PMTI\\MZZMÆMK\XPa[QKIT

dependence in which the body adapts to the drug, 

requiring more of it to achieve a certain effect (tolerance) 

IVLMTQKQ\QVOLZ]O[XMKQÅKXPa[QKITWZUMV\IT[aUX\WU[

if drug use is abruptly ceased (withdrawal). Physical 

dependence can happen with the chronic use of many 

drugs—including many prescription drugs, even if taken 

as instructed. Thus, physical dependence in and of itself 

does not constitute addiction, but it often accompanies 

ILLQK\QWV<PQ[LQ[\QVK\QWVKIVJMLQNÅK]T\\WLQ[KMZV

particularly with prescribed pain medications, for which 

the need for increasing dosages can represent tolerance 

or a worsening underlying problem, as opposed to the 

beginning of abuse or addiction. 

18. How do other mental disorders 

coexisting with drug addiction 

affect drug addiction treatment? 

Drug addiction is a disease of the brain that frequently 

occurs with other mental disorders. In fact, as many as 

6 in 10 people with an illicit substance use disorder also 

suffer from another mental illness; and rates are similar 

for users of licit drugs—i.e., tobacco and alcohol. For 

\PM[MQVLQ^QL]IT[WVMKWVLQ\QWVJMKWUM[UWZMLQNÅK]T\\W

treat successfully as an additional condition is intertwined. 

Thus, people entering treatment either for a substance 

use disorder or for another mental disorder should be 

assessed for the co-occurrence of the other condition. 

Research indicates that treating both (or multiple) illnesses 

simultaneously in an integrated fashion is generally the 

best treatment approach for these patients. 
26 27

19. Is the use of medications like 

methadone and buprenorphine 

simply replacing one addiction with 

another? 

No. Buprenorphine and methadone are prescribed or 

administered under monitored, controlled conditions 

and are safe and effective for treating opioid addiction 

when used as directed. They are administered orally or 

[]JTQVO]ITTaQM]VLMZ\PM\WVO]MQV[XMKQÅMLLW[M[IVL

their effects differ from those of heroin and other abused 

opioids. 

Heroin, for example, is often injected, snorted, or smoked, 

KI][QVOIVITUW[\QUUMLQI\M1Z][PoWZJZQMN XMZQWL

of intense euphoria, that wears off quickly and ends in 

I1KZI[Po<PMQVLQ^QL]IT\PMVM`XMZQMVKM[IVQV\MV[M

craving to use the drug again to stop the crash and 

reinstate the euphoria. 

The cycle of euphoria, crash, and craving—sometimes 

repeated several times a day—is a hallmark of addiction 

and results in severe behavioral disruption. These 

characteristics result from heroin’s rapid onset and short 

duration of action in the brain. 

As used in maintenance treatment, 

methadone and buprenorphine are 

not heroin/opioid substitutes. 

In contrast, methadone and buprenorphine have gradual 

onsets of action and produce stable levels of the drug 

in the brain. As a result, patients maintained on these 

medications do not experience a rush, while they also 

markedly reduce their desire to use opioids. 

If an individual treated with these medications 

tries to take an opioid such as heroin, the euphoric 

effects are usually dampened or suppressed. Patients 

undergoing maintenance treatment do not experience 

the physiological or behavioral abnormalities from 

ZIXQLÆ]K\]I\QWV[QVLZ]OTM^MT[I[[WKQI\ML_Q\PPMZWQV

use. Maintenance treatments save lives—they help to 

stabilize individuals, allowing treatment of their medical, 

psychological, and other problems so they can contribute 

effectively as members of families and of society. 

20. Where do 12-step or self-help 

programs fit into drug addiction 

treatment? 

Self-help groups can complement and extend the 

effects of professional treatment. The most prominent 

[MTNPMTXOZW]X[IZM\PW[MINÅTQI\ML_Q\P)TKWPWTQK[

Anonymous (AA), Narcotics Anonymous (NA), and 

Cocaine Anonymous (CA); all of which are based on the 

12-step model. Most drug addiction treatment programs 

encourage patients to participate in self-help group 

therapy during and after formal treatment. These groups 

can be particularly helpful during recovery, offering an 

added layer of community-level social support to help 

people achieve and maintain abstinence and other healthy 

lifestyle behaviors over the course of a lifetime. 
28 29

21. Can exercise play a role in the 

treatment process? 

Yes. Exercise is increasingly becoming a component of 

many treatment programs and has proven effective, when 

combined with cognitive-behavioral therapy, at helping 

XMWXTMY]Q\[UWSQVO-`MZKQ[MUIaM`MZ\JMVMÅKQITMNNMK\[

by addressing psychosocial and physiological needs that 

nicotine replacement alone does not, by reducing negative 

feelings and stress, and by helping prevent weight gain 

following cessation. Research to determine if and how 

exercise programs can play a similar role in the treatment 

of other forms of drug abuse is under way. 

22. How does drug addiction treatment 

help reduce the spread of HIV/

AIDS, hepatitis C (HCV), and other 

infectious diseases? 

Drug-abusing individuals, including injecting and noninjecting drug users, are at increased risk of human 

QUU]VWLMÅKQMVKa^QZ][01>PMXI\Q\Q[+^QZ][

(HCV), and other infectious diseases. These diseases 

are transmitted by sharing contaminated drug injection 

equipment and by engaging in risky sexual behavior 

sometimes associated with drug use. Effective drug abuse 

treatment is HIV/HCV prevention because it reduces 

activities that can spread disease, such as sharing injection 

equipment and engaging in unprotected sexual activity. 

Counseling that targets a range of HIV/HCV risk 

behaviors provides an added level of disease prevention. 

Drug abuse treatment is HIV and 

HCV prevention. 

Injection drug users who do not enter treatment are up to 

six times more likely to become infected with HIV than 

those who enter and remain in treatment. Participation in 

treatment also presents opportunities for HIV screening 

and referral to early HIV treatment. In fact, recent 

research from NIDA’s National Drug Abuse Treatment 

Clinical Trials Network showed that providing rapid 

onsite HIV testing in substance abuse treatment facilities 

increased patients’ likelihood of being tested and of 

receiving their test results. HIV counseling and testing are 

key aspects of superior drug abuse treatment programs 

and should be offered to all individuals entering treatment. 

Greater availability of inexpensive and unobtrusive rapid 

HIV tests should increase access to these important aspects 

of HIV prevention and treatment.
30 31

Drug Addiction 

Treatment in the 

United States

Drug addiction is a complex disorder 

that can involve virtually every aspect 

of an individual’s functioning—in the 

family, at work and school, and in the 

community. Because of addiction’s complexity and 

pervasive consequences, drug addiction treatment 

typically must involve many components. Some of those 

components focus directly on the individual’s drug use; 

others, like employment training, focus on restoring the 

addicted individual to productive membership in the 

family and society (see diagram on page 8), enabling 

him or her to experience the rewards associated with 

abstinence. 

Treatment for drug abuse and addiction is delivered in 

many different settings using a variety of behavioral 

and pharmacological approaches. In the United States, 

more than 14,500 specialized drug treatment facilities 

provide counseling, behavioral therapy, medication, case 

management, and other types of services to persons with 

substance use disorders. 

Along with specialized drug treatment facilities, drug 

IJ][MIVLILLQK\QWVIZM\ZMI\MLQVXPa[QKQIV[1⁄4WNÅKM[IVL

mental health clinics by a variety of providers, including 

counselors, physicians, psychiatrists, psychologists, nurses, 

and social workers. Treatment is delivered in outpatient, 

QVXI\QMV\IVLZM[QLMV\QIT[M\\QVO[)T\PW]OP[XMKQÅK

treatment approaches often are associated with particular 

treatment settings, a variety of therapeutic interventions or 

services can be included in any given setting. 

Because drug abuse and addiction are major public 

health problems, a large portion of drug treatment is 

funded by local, State, and Federal governments. Private 

and employer-subsidized health plans also may provide 

coverage for treatment of addiction and its medical 

consequences. Unfortunately, managed care has resulted 

in shorter average stays, while a historical lack of or 

QV[]NÅKQMV\KW^MZIOMNWZ[]J[\IVKMIJ][M\ZMI\UMV\PI[

Treatment for drug abuse and 

addiction is delivered in many different 

settings, using a variety of behavioral 

and pharmacological approaches.
32 33

Further Reading:

3TMJMZ0,7]\XI\QMV\LM\W`QÅKI\QWVNZWUWXQI\M[

Primary Psychiatry 1:42–52, 1996.

Long-Term Residential Treatment

Long-term residential treatment provides care 24 hours 

a day, generally in nonhospital settings. The best-known 

residential treatment model is the therapeutic community 

(TC), with planned lengths of stay of between 6 and 

UWV\P[<+[NWK][WV\PM1ZM[WKQITQbI\QWVoWN \PM

individual and use the program’s entire community—

including other residents, staff, and the social context—as 

active components of treatment. Addiction is viewed in 

the context of an individual’s social and psychological 

LMÅKQ\[IVL\ZMI\UMV\NWK][M[WVLM^MTWXQVOXMZ[WVIT

accountability and responsibility as well as socially 

productive lives. Treatment is highly structured and can 

be confrontational at times, with activities designed to 

help residents examine damaging beliefs, self-concepts, 

and destructive patterns of behavior and adopt new, 

more harmonious and constructive ways to interact with 

others. Many TCs offer comprehensive services, which can 

include employment training and other support services, 

WV[Q\M:M[MIZKP[PW_[\PI\<+[KIVJMUWLQÅML\W\ZMI\

individuals with special needs, including adolescents, 

women, homeless individuals, people with severe mental 

disorders, and individuals in the criminal justice system 

(see page 37).

Further Reading:

Lewis, B.F.; McCusker, J.; Hindin, R.; Frost, R.; and 

/IZÅMTL..W]ZZM[QLMV\QITLZ]O\ZMI\UMV\XZWOZIU["

Project IMPACT. In: J.A. Inciardi, F.M. Tims, and B.W. 

Fletcher (eds.), Innovative Approaches in the Treatment of 

Drug Abuse, Westport, CT: Greenwood Press, pp. 45–60, 

1993. 

curtailed the number of operational programs. The recent 

passage of parity for insurance coverage of mental health 

and substance abuse problems will hopefully improve 

this state of affairs. Health Care Reform (i.e., the Patient 

8ZW\MK\QWVIVL)NNWZLIJTM+IZM)K\WN 1)+)oIT[W

stands to increase the demand for drug abuse treatment 

services and presents an opportunity to study how 

QVVW^I\QWV[QV[MZ^QKMLMTQ^MZaWZOIVQbI\QWVIVLÅVIVKQVO

can improve access to and use of them.

Types of Treatment Programs 

Research studies on addiction treatment typically have 

KTI[[QÅMLXZWOZIU[QV\W[M^MZITOMVMZIT\aXM[WZUWLITQ\QM[

Treatment approaches and individual programs continue 

to evolve and diversify, and many programs today do 

VW\Å\VMI\TaQV\W\ZILQ\QWVITLZ]OILLQK\QWV\ZMI\UMV\

KTI[[QÅKI\QWV[-`IUXTM[WN [XMKQÅKZM[MIZKPJI[ML

treatment components are described on pages 30–35. 

5W[\PW_M^MZ[\IZ\_Q\PLM\W`QÅKI\QWVIVLUMLQKITTa

UIVIOML_Q\PLZI_ITWN\MVKWV[QLMZML\PMÅZ[\[\IOMWN 

\ZMI\UMV\,M\W`QÅKI\QWV\PMXZWKM[[Ja_PQKP\PMJWLa

clears itself of drugs, is designed to manage the acute and 

potentially dangerous physiological effects of stopping 

LZ]O][M)[[\I\MLXZM^QW][TaLM\W`QÅKI\QWVITWVMLWM[VW\

address the psychological, social, and behavioral problems 

associated with addiction and therefore does not typically 

produce lasting behavioral changes necessary for recovery. 

,M\W`QÅKI\QWV[PW]TL\P][JMNWTTW_MLJaINWZUIT

assessment and referral to drug addiction treatment. 

Because it is often accompanied by unpleasant and 

potentially fatal side effects stemming from withdrawal, 

LM\W`QÅKI\QWVQ[WN\MVUIVIOML_Q\PUMLQKI\QWV[

administered by a physician in an inpatient or outpatient 

[M\\QVO#\PMZMNWZMQ\Q[ZMNMZZML\WI[1UMLQKITTaUIVIOML

withdrawal.” Medications are available to assist in the 

withdrawal from opioids, benzodiazepines, alcohol, 

nicotine, barbiturates, and other sedatives.
34 35

Further Reading:

Hubbard, R.L.; Craddock, S.G.; Flynn, P.M.; Anderson, 

J.; and Etheridge, R.M. Overview of 1-year follow-up 

outcomes in the Drug Abuse Treatment Outcome Study 

(DATOS). Psychology of Addictive Behaviors 11(4):291–

298, 1998. 

Miller, M.M. Traditional approaches to the treatment 

of addiction. In: A.W. Graham and T.K. Schultz (eds.), 

Principles of Addiction Medicine (2nd ed.). Washington, 

D.C.: American Society of Addiction Medicine, 1998.

Outpatient Treatment Programs

Outpatient treatment varies in the types and intensity of 

services offered. Such treatment costs less than residential 

or inpatient treatment and often is more suitable for 

people with jobs or extensive social supports. It should 

be noted, however, that low-intensity programs may offer 

little more than drug education. Other outpatient models, 

such as intensive day treatment, can be comparable 

to residential programs in services and effectiveness, 

depending on the individual patient’s characteristics and 

needs. In many outpatient programs, group counseling 

can be a major component. Some outpatient programs 

are also designed to treat patients with medical or other 

mental health problems in addition to their drug disorders. 

Further Reading:

Hubbard, R.L.; Craddock, S.G.; Flynn, P.M.; Anderson, 

J.; and Etheridge, R.M. Overview of 1-year follow-up 

outcomes in the Drug Abuse Treatment Outcome Study 

(DATOS). Psychology of Addictive Behaviors 11(4):291–

298, 1998. 

Institute of Medicine. Treating Drug Problems. 

Washington, D.C.: National Academy Press, 1990. 

Sacks, S.; Banks, S.; McKendrick, K.; and Sacks, J.Y. 

5WLQÅML\PMZIXM]\QKKWUU]VQ\aNWZKWWKK]ZZQVOLQ[WZLMZ["

A summary of four studies. Journal of Substance Abuse 

Treatment 34(1):112–122, 2008. 

Sacks, S.; Sacks, J.; DeLeon, G.; Bernhardt, A.; and 

;\IQVM[/5WLQÅML\PMZIXM]\QKKWUU]VQ\aNWZUMV\ITTa

QTTKPMUQKIT1IJ][MZ[o"*IKSOZW]VL#QVÆ]MVKM[#XZWOZIU

LM[KZQX\QWV#XZMTQUQVIZaÅVLQVO[Substance Use and Misuse

32(9):1217–1259, 1997. 

Stevens, S.J.; and Glider, P.J. Therapeutic communities: 

Substance abuse treatment for women. In: F.M. Tims, G. 

DeLeon, and N. Jainchill (eds.), Therapeutic Community: 

Advances in Research and Application, National Institute 

on Drug Abuse Research Monograph 144, NIH Pub. No. 

!·=;/W^MZVUMV\8ZQV\QVO7NÅKMXX· 

1994. 

Sullivan, C.J.; McKendrick, K.; Sacks, S.; and Banks, S.M. 

5WLQÅML\PMZIXM]\QKKWUU]VQ\aNWZWNNMVLMZ[_Q\P51+)

disorders: Substance use outcomes. American Journal of 

Drug and Alcohol Abuse 33(6):823–832, 2007.

Short-Term Residential Treatment

Short-term residential programs provide intensive but 

ZMTI\Q^MTaJZQMN \ZMI\UMV\JI[MLWVIUWLQÅML[\MX

approach. These programs were originally designed to 

treat alcohol problems, but during the cocaine epidemic 

of the mid-1980s, many began to treat other types of 

substance use disorders. The original residential treatment 

model consisted of a 3- to 6-week hospital-based inpatient 

treatment phase followed by extended outpatient therapy 

and participation in a self-help group, such as AA. 

Following stays in residential treatment programs, it is 

important for individuals to remain engaged in outpatient 

treatment programs and/or aftercare programs. These 

programs help to reduce the risk of relapse once a patient 

leaves the residential setting.
36 37

Treating Criminal Justice–Involved Drug 

Abusers and Addicted Individuals

Often, drug abusers come into contact with the criminal 

justice system earlier than other health or social systems, 

presenting opportunities for intervention and treatment 

prior to, during, after, or in lieu of incarceration. Research 

has shown that combining criminal justice sanctions with 

drug treatment can be effective in decreasing drug abuse 

and related crime. Individuals under legal coercion tend 

to stay in treatment longer and do as well as or better 

than those not under legal pressure. Studies show that 

for incarcerated individuals with drug problems, starting 

drug abuse treatment in prison and continuing the same 

treatment upon release—in other words, a seamless 

continuum of services—results in better outcomes: less 

drug use and less criminal behavior. More information 

on how the criminal justice system can address the 

problem of drug addiction can be found in Principles of 

Drug Abuse Treatment for Criminal Justice Populations: A 

Research-Based Guide (National Institute on Drug Abuse, 

revised 2012).

McLellan, A.T.; Grisson, G.; Durell, J.; Alterman, A.I.; 

Brill, P.; and O’Brien, C.P. Substance abuse treatment in 

the private setting: Are some programs more effective than 

others? Journal of Substance Abuse Treatment 10:243–254, 

1993. 

Simpson, D.D.; and Brown, B.S. Treatment retention 

and follow-up outcomes in the Drug Abuse Treatment 

Outcome Study (DATOS). Psychology of Addictive 

Behaviors 11(4):294–307, 1998.

Individualized Drug Counseling

Individualized drug counseling not only focuses on 

reducing or stopping illicit drug or alcohol use; it also 

addresses related areas of impaired functioning—such 

as employment status, illegal activity, and family/social 

relations—as well as the content and structure of the 

patient’s recovery program. Through its emphasis on 

short-term behavioral goals, individualized counseling 

helps the patient develop coping strategies and tools to 

abstain from drug use and maintain abstinence. The 

addiction counselor encourages 12-step participation (at 

least one or two times per week) and makes referrals for 

needed supplemental medical, psychiatric, employment, 

and other services.

Group Counseling

Many therapeutic settings use group therapy to capitalize 

on the social reinforcement offered by peer discussion and 

to help promote drug-free lifestyles. Research has shown 

that when group therapy either is offered in conjunction 

with individualized drug counseling or is formatted to 

ZMÆMK\\PMXZQVKQXTM[WN KWOVQ\Q^MJMPI^QWZIT\PMZIXaWZ

contingency management, positive outcomes are achieved. 

Currently, researchers are testing conditions in which 

group therapy can be standardized and made more 

community-friendly.
38 39

This section presents examples of treatment approaches 

and components that have an evidence base supporting 

their use. Each approach is designed to address certain 

aspects of drug addiction and its consequences for the 

individual, family, and society. Some of the approaches 

are intended to supplement or enhance existing treatment 

programs, and others are fairly comprehensive in and 

of themselves. 

The following section is broken down into 

Pharmacotherapies, Behavioral Therapies, and 

Behavioral Therapies Primarily for Adolescents. 

They are further subdivided according to particular 

substance use disorders. This list is not exhaustive, 

and new treatments are continually under development.

Pharmacotherapies

Opioid Addiction

Methadone

Methadone is a long-acting synthetic opioid agonist 

medication that can prevent withdrawal symptoms and 

reduce craving in opioid-addicted individuals. It can also 

block the effects of illicit opioids. It has a long history 

of use in treatment of opioid dependence in adults and 

is taken orally. Methadone maintenance treatment is 

available in all but three States through specially licensed 

opioid treatment programs or methadone maintenance 

programs. 

Combined with behavioral treatment

Research has shown that methadone maintenance is 

more effective when it includes individual and/or group 

counseling, with even better outcomes when patients 

are provided with, or referred to, other needed medical/

psychiatric, psychological, and social services (e.g., 

employment or family services).

Evidence-Based 

Approaches to Drug 

Addiction Treatment

Each approach to drug treatment is 

designed to address certain aspects of 

drug addiction and its consequences 

for the individual, family, and society.
40 41

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UIQV\MVIVKMKIVJMXZW^QLMLQVWNÅKMJI[ML[M\\QVO[Ja

Y]ITQÅMLXPa[QKQIV[_PWPI^MZMKMQ^MLI_IQ^MZNZWU\PM

Drug Enforcement Administration (DEA), allowing them 

\WXZM[KZQJMQ\<PMI^IQTIJQTQ\aWN WNÅKMJI[ML\ZMI\UMV\

for opioid addiction is a cost-effective approach that 

increases the reach of treatment and the options available 

to patients.

Further Reading: 

Fiellin, D.A.; Pantalon, M.V.; Chawarski, M.C.; Moore, 

B.A.; Sullivan, L.E.; O’Connor, P.G.; and Schottenfeld, 

R.S. Counseling plus buprenorphine/naloxone 

maintenance therapy for opioid dependence. The New 

England Journal of Medicine 355(4):365–374, 2006. 

Fudala P.J.; Bridge, T.P.; Herbert, S.; Williford, W.O.; 

Chiang, C.N.; Jones, K.; Collins, J.; Raisch, D.; 

Casadonte, P.; Goldsmith, R.J.; Ling, W.; Malkerneker, 

U.; McNicholas, L.; Renner, J.; Stine, S.; and Tusel, D. 

for the Buprenorphine/Naloxone Collaborative Study 

/ZW]X7NÅKMJI[ML\ZMI\UMV\WN WXQI\MILLQK\QWV

with a sublingual-tablet formulation of buprenorphine 

and naloxone. The New England Journal of Medicine

349(10):949–958, 2003. 

Kosten, T.R.; and Fiellin, D.A. U.S. National 

Buprenorphine Implementation Program: Buprenorphine 

NWZWNÅKMJI[MLXZIK\QKM"+WV[MV[][KWVNMZMVKMW^MZ^QM_

The American Journal on Addictions 13(Suppl. 1):S1–S7, 

2004. 

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treatment for opioid-dependent patients. Harvard Review 

of Psychiatry 12(6):321–338, 2004. 

Further Reading:

Dole, V.P.; Nyswander, M.; and Kreek, M.J. Narcotic 

blockade. Archives of Internal Medicine 118:304–309, 

1966. 

McLellan, A.T.; Arndt, I.O.; Metzger, D.; Woody, G.E.; 

and O’Brien, C.P. The effects of psychosocial services in 

substance abuse treatment. The Journal of the American 

Medical Association 269(15):1953–1959, 1993. 

<PM:WKSMNMTTMZ=VQ^MZ[Q\a<PMÅZ[\XPIZUIKWTWOQKIT

treatment for narcotic addiction: Methadone 

maintenance. The Rockefeller University Hospital 

Centennial, 2010. Available at centennial.rucares.org/index.

php?page=Methadone_Maintenance.

Woody, G.E.; Luborsky, L.; McClellan, A.T.; O’Brien, 

C.P.; Beck, A.T.; Blaine, J.; Herman, I.; and Hole, A. 

Psychotherapy for opiate addicts: Does it help? Archives of 

General Psychiatry 40:639–645, 1983.

Buprenorphine

Buprenorphine is a synthetic opioid medication that 

acts as a partial agonist at opioid receptors—it does not 

produce the euphoria and sedation caused by heroin or 

other opioids but is able to reduce or eliminate withdrawal 

symptoms associated with opioid dependence and carries 

a low risk of overdose. 

Buprenorphine is currently available in two formulations 

that are taken sublingually: (1) a pure form of the drug 

and (2) a more commonly prescribed formulation called 

Suboxone, which combines buprenorphine with the drug 

naloxone, an antagonist (or blocker) at opioid receptors. 

Naloxone has no effect when Suboxone is taken as 

prescribed, but if an addicted individual attempts to inject 

Suboxone, the naloxone will produce severe withdrawal 

symptoms. Thus, this formulation lessens the likelihood 

that the drug will be abused or diverted to others. 
42 43

or parolees. Recently, a long-acting injectable version of 

naltrexone, called Vivitrol, was approved to treat opioid 

addiction. Because it only needs to be delivered once a 

month, this version of the drug can facilitate compliance 

and offers an alternative for those who do not wish to be 

placed on agonist/partial agonist medications.

Further Reading:

Cornish, J.W.; Metzger, D.; Woody, G.E.; Wilson, D.; 

McClellan, A.T.; and Vandergrift, B. Naltrexone 

pharmacotherapy for opioid dependent federal 

probationers. Journal of Substance Abuse Treatment

14(6):529–534, 1997.

Gastfriend, D.R. Intramuscular extended-release 

naltrexone: current evidence. Annals of the New York 

Academy of Sciences 1216:144–166, 2011.

Krupitsky, E.; Illerperuma, A.; Gastfriend, D.R.; and 

;QT^MZUIV*4-NÅKIKaIVL[INM\aWN M`\MVLMLZMTMI[M

injectable naltrexone (XR-NTX) for the treatment of 

opioid dependence. Paper presented at the 2010 annual 

meeting of the American Psychiatric Association, New 

Orleans, LA.

Tobacco Addiction

Nicotine Replacement Therapy (NRT)

A variety of formulations of nicotine replacement 

therapies (NRTs) now exist, including the transdermal 

nicotine patch, nicotine spray, nicotine gum, and nicotine 

lozenges. Because nicotine is the main addictive ingredient 

in tobacco, the rationale for NRT is that stable low levels 

of nicotine will prevent withdrawal symptoms—which 

often drive continued tobacco use—and help keep people 

motivated to quit. Research shows that combining the 

patch with another replacement therapy is more effective 

than a single therapy alone.

Treatment, not Substitution

Because methadone and buprenorphine are themselves 

opioids, some people view these treatments for opioid 

dependence as just substitutions of one addictive drug 

for another (see Question 19 above). But taking these 

medications as prescribed allows patients to hold jobs, 

avoid street crime and violence, and reduce their exposure 

to HIV by stopping or decreasing injection drug use and 

drug-related high-risk sexual behavior. Patients stabilized 

on these medications can also engage more readily in 

counseling and other behavioral interventions essential 

to recovery. 

Naltrexone

Naltrexone is a synthetic opioid antagonist—it blocks 

opioids from binding to their receptors and thereby 

prevents their euphoric and other effects. It has been 

used for many years to reverse opioid overdose and is also 

approved for treating opioid addiction. The theory behind 

this treatment is that the repeated absence of the desired 

effects and the perceived futility of abusing opioids will 

gradually diminish craving and addiction. Naltrexone 

Q\[MTN PI[VW[]JRMK\Q^MMNNMK\[NWTTW_QVOLM\W`QÅKI\QWV\PI\

is, a person does not perceive any particular drug effect), it 

has no potential for abuse, and it is not addictive. 

Naltrexone as a treatment for opioid addiction is usually 

prescribed in outpatient medical settings, although the 

treatment should begin afterUMLQKITLM\W`QÅKI\QWV

in a residential setting in order to prevent withdrawal 

symptoms. 

Naltrexone must be taken orally—either daily or three 

times a week—but noncompliance with treatment is a 

common problem. Many experienced clinicians have 

found naltrexone best suited for highly motivated, recently 

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of external circumstances—for instance, professionals 
44 45

treatment, social, and work settings. Combined treatment is 

urged because behavioral and pharmacological treatments 

are thought to operate by different yet complementary 

mechanisms that can have additive effects. 

Further Reading:

Alterman, A.I.; Gariti, P.; and Mulvaney, F. Short- and 

long-term smoking cessation for three levels of intensity 

of behavioral treatment. Psychology of Addictive Behaviors

15:261–264, 2001. 

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Prochaska, J.J.; and Robbins, J.A. Using extended cognitive 

behavioral treatment and medication to treat dependent 

smokers. American Journal of Public Health 101:2349–

2356, 2011.

Jorenby, D.E.; Hays, J.T.; Rigotti, N.A.; Azoulay, S.; 

Watsky, E.J.; Williams, K.E.; Billing, C.B.; Gong, J.; and 

:MM^M[3:>IZMVQKTQVM8PI[M;\]La/ZW]X-NÅKIKa

of varenicline, an Ơơ nicotinic acetylcholine receptor 

partial agonist vs. placebo or sustained-release bupropion 

for smoking cessation: A randomized controlled trial. The 

Journal of the American Medical Association 296(1):56–63, 

2006. 

King, D.P.; Paciqa, S.; Pickering, E.; Benowitz, N.L.; 

Bierut, L.J.; Conti, D.V.; Kaprio, J.; Lerman, C.; and Park, 

P.W. Smoking cessation pharmacogenetics: Analysis of 

varenicline and bupropion in placebo-controlled clinical 

trials. Neuropsychopharmacology 37:641–650, 2012.

Raupach, T.; and van Schayck, C.P. Pharmacotherapy for 

smoking cessation: Current advances and research topics. 

CNS Drugs 25:371–382, 2011.

Shah, S.D.; Wilken, L.A.; Winkler, S.R.; and Lin, S.J. 

Systematic review and meta-analysis of combination 

therapy for smoking cessation. Journal of the American 

Pharmaceutical Association 48(5):659–665, 2008.

Bupropion (Zyban

®)

Bupropion was originally marketed as an antidepressant 

(Wellbutrin). It produces mild stimulant effects by 

blocking the reuptake of certain neurotransmitters, 

especially norepinephrine and dopamine. A serendipitous 

observation among depressed patients was that the 

medication was also effective in suppressing tobacco 

craving, helping them quit smoking without also gaining 

weight. Although bupropion’s exact mechanisms of action 

in facilitating smoking cessation are unclear, it has FDA 

approval as a smoking cessation treatment.

Varenicline (Chantix

®)

Varenicline is the most recently FDA-approved medication 

for smoking cessation. It acts on a subset of nicotinic 

receptors in the brain thought to be involved in the 

rewarding effects of nicotine. Varenicline acts as a partial 

agonist/antagonist at these receptors—this means that it 

UQTLTa[\QU]TI\M[\PMVQKW\QVMZMKMX\WZJ]\VW\[]NÅKQMV\Ta

to trigger the release of dopamine, which is important 

for the rewarding effects of nicotine. As an antagonist, 

varenicline also blocks the ability of nicotine to activate 

dopamine, interfering with the reinforcing effects of 

smoking, thereby reducing cravings and supporting 

abstinence from smoking.

Combined With Behavioral Treatment

Each of the above pharmacotherapies is recommended 

for use in combination with behavioral interventions, 

including group and individual therapies, as well as 

telephone quitlines. Behavioral approaches complement 

most tobacco addiction treatment programs. They can 

amplify the effects of medications by teaching people 

how to manage stress, recognize and avoid high-risk 

situations for smoking relapse, and develop alternative 

coping strategies (e.g., cigarette refusal skills, assertiveness, 

and time management skills) that they can practice in 
46 47

is generally poor. However, among patients who are 

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patients use it episodically for high-risk situations, such as 

social occasions where alcohol is present. It can also be 

administered in a monitored fashion, such as in a clinic or 

JaI[XW][MQUXZW^QVOQ\[MNÅKIKa

Topiramate

Topiramate is thought to work by increasing inhibitory 

(GABA) neurotransmission and reducing stimulatory 

(glutamate) neurotransmission, although its precise 

mechanism of action is not known. Although topiramate 

has not yet received FDA approval for treating alcohol 

addiction, it is sometimes used off-label for this purpose. 

<WXQZIUI\MPI[JMMV[PW_VQV[\]LQM[\W[QOVQÅKIV\Ta

improve multiple drinking outcomes, compared with a 

placebo. 

Combined With Behavioral Treatment

While a number of behavioral treatments have been 

shown to be effective in the treatment of alcohol 

addiction, it does not appear that an additive effect exists 

between behavioral treatments and pharmacotherapy. 

Studies have shown that just getting help is one of the 

most important factors in treating alcohol addiction; the 

precise type of treatment received is not as important. 

Further Reading: 

Anton, R.F.; O’Malley, S.S.; Ciraulo, D.A.; Cisler, R.A.; 

Couper, D.; Donovan, D.M.; Gastfriend, D.R.; Hosking, 

J.D.; Johnson, B.A.; LoCastro, J.S.; Longabaugh, R.; 

Mason, B.J.; Mattson, M.E.; Miller, W.R.; Pettinati, H.M.; 

Randall, C.L.; Swift, R.; Weiss, R.D.; Williams, L.D.; 

and Zweben, A., for the COMBINE Study Research 

Group. Combined pharmacotherapies and behavioral 

interventions for alcohol dependence: The COMBINE 

study: A randomized controlled trial. The Journal of the 

American Medical Association 295(17):2003–2017, 2006. 

Smith, S.S; McCarthy, D.E.; Japuntich S.J.; Christiansen, 

B.; Piper, M.E.; Jorenby, D.E.; Fraser, D.L.; Fiore, M.C.; 

Baker, T.B.; and Jackson, T.C. Comparative effectiveness 

of 5 smoking cessation pharmacotherapies in primary 

care clinics. Archives of Internal Medicine 169:2148–2155, 

2009.

Stitzer, M. Combined behavioral and pharmacological 

treatments for smoking cessation. Nicotine & Tobacco 

Research 1:S181–S187, 1999.

Alcohol Addiction

Naltrexone

Naltrexone blocks opioid receptors that are involved in 

the rewarding effects of drinking and the craving for 

alcohol. It has been shown to reduce relapse to problem 

drinking in some patients. An extended release version, 

Vivitrol—administered once a month by injection—is 

also FDA-approved for treating alcoholism, and may offer 

JMVMÅ\[ZMOIZLQVOKWUXTQIVKM

Acamprosate

Acamprosate (Campral

®) acts on the gamma-aminobutyric 

acid (GABA) and glutamate neurotransmitter systems and 

is thought to reduce symptoms of protracted withdrawal, 

such as insomnia, anxiety, restlessness, and dysphoria. 

Acamprosate has been shown to help dependent drinkers 

maintain abstinence for several weeks to months, and it 

may be more effective in patients with severe dependence. 

Disulfiram

,Q[]TÅZIU)V\IJ][M

®) interferes with degradation of 

alcohol, resulting in the accumulation of acetaldehyde, 

which, in turn, produces a very unpleasant reaction 

\PI\QVKT]LM[Æ][PQVOVI][MIIVLXITXQ\I\QWV[QN I

person drinks alcohol. The utility and effectiveness of 

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48 49

include exploring the positive and negative consequences 

of continued drug use, self-monitoring to recognize 

cravings early and identify situations that might put one 

at risk for use, and developing strategies for coping with 

cravings and avoiding those high-risk situations. 

Research indicates that the skills individuals learn 

through cognitive-behavioral approaches remain after the 

completion of treatment. Current research focuses on how 

to produce even more powerful effects by combining CBT 

with medications for drug abuse and with other types of 

behavioral therapies. A computer-based CBT system has 

also been developed and has been shown to be effective 

in helping reduce drug use following standard drug abuse 

treatment.

Further Reading:

Carroll, K.M., Easton, C.J.; Nich, C.; Hunkele, K.A.; 

Neavins, T.M.; Sinha, R.; Ford, H.L.; Vitolo, S.A; 

Doebrick, C.A.; and Rounsaville, B.J. The use of 

contingency management and motivational/skills-building 

therapy to treat young adults with marijuana dependence. 

Journal of Consulting and Clinical Psychology 74(5):955–

966, 2006. 

Carroll, K.M.; and Onken, L.S. Behavioral therapies 

for drug abuse. The American Journal of Psychiatry

168(8):1452–1460, 2005. 

Carroll, K.M.; Sholomskas, D.; Syracuse, G.; Ball, S.A.; 

Nuro, K.; and Fenton, L.R. We don’t train in vain: A 

dissemination trial of three strategies of training clinicians 

in cognitive-behavioral therapy. Journal of Consulting and 

Clinical Psychology 73(1):106–115, 2005. 

Carroll, K.; Fenton, L.R.; Ball, S.A.; Nich, C.; Frankforter, 

<4#;PQ2#IVL:W]V[I^QTTM*2-NÅKIKaWN LQ[]TÅZIU

and cognitive behavior therapy in cocaine-dependent 

outpatients: A randomized placebo-controlled trial. 

Archives of General Psychiatry 61(3):264–272, 2004. 

National Institute on Alcohol Abuse and Alcoholism. 

Helping Patients Who Drink Too Much: A Clinician’s 

Guide, Updated 2005 Edition. Bethesda, MD: NIAAA, 

updated 2005. Available at pubs.niaaa.nih.gov/

publications/Practitioner/CliniciansGuide2005/clinicians_

guide.htm

Behavioral Therapies

Behavioral approaches help engage people in drug 

abuse treatment, provide incentives for them to remain 

abstinent, modify their attitudes and behaviors related 

to drug abuse, and increase their life skills to handle 

stressful circumstances and environmental cues that 

may trigger intense craving for drugs and prompt 

another cycle of compulsive abuse. Below are a 

number of behavioral therapies shown to be effective 

in addressing substance abuse (effectiveness with 

particular drugs of abuse is denoted in parentheses).

Cognitive-Behavioral Therapy 

(Alcohol, Marijuana, Cocaine, 

Methamphetamine, Nicotine)

Cognitive-Behavioral Therapy (CBT) was developed 

as a method to prevent relapse when treating problem 

drinking, and later it was adapted for cocaine-addicted 

individuals. Cognitive-behavioral strategies are based 

on the theory that in the development of maladaptive 

behavioral patterns like substance abuse, learning 

processes play a critical role. Individuals in CBT learn to 

identify and correct problematic behaviors by applying 

a range of different skills that can be used to stop drug 

abuse and to address a range of other problems that often 

co-occur with it. 

A central element of CBT is anticipating likely problems 

and enhancing patients’ self-control by helping them 

LM^MTWXMNNMK\Q^MKWXQVO[\ZI\MOQM[;XMKQÅK\MKPVQY]M[
50 51

more times weekly), participants supplying drug-negative 

urine or breath tests draw from a bowl for the chance to 

win a prize worth between $1 and $100. Participants may 

also receive draws for attending counseling sessions and 

completing weekly goal-related activities. The number 

of draws starts at one and increases with consecutive 

negative drug tests and/or counseling sessions attended 

but resets to one with any drug-positive sample or 

unexcused absence. The practitioner community has 

raised concerns that this intervention could promote 

gambling—as it contains an element of chance—and that 

pathological gambling and substance use disorders can be 

comorbid. However, studies examining this concern found 

that Prize Incentives CM did not promote gambling 

behavior.

Further Reading:

Budney, A.J.; Moore, B.A.; Rocha, H.L.; and Higgins, S.T. 

Clinical trial of abstinence-based vouchers and cognitivebehavioral therapy for cannabis dependence. Journal of 

Consulting and Clinical Psychology 74(2):307–316, 2006. 

Budney, A.J.; Roffman, R.; Stephens, R.S.; and Walker, 

D. Marijuana dependence and its treatment. Addiction 

Science & Clinical Practice 4(1):4–16, 2007. 

Elkashef, A.; Vocci, F.; Huestis, M.; Haney, M.; 

Budney, A.; Gruber, A.; and el-Guebaly, N. Marijuana 

neurobiology and treatment. Substance Abuse 29(3):17–29, 

2008. 

Peirce, J.M.; Petry, N.M.; Stitzer, M.L.; Blaine, J.; Kellogg, 

;#;I\\MZÅMTL.#;KP_IZ\b5#3ZI[VIV[Sa2#8MVKMZ

E.; Silva-Vazquez, L.; Kirby, K.C.; Royer-Malvestuto, C.; 

Cohen, A.; Copersino, M.L.; Kolodner, K.; and Li, R. 

Effects of lower-cost incentives on stimulant abstinence 

in methadone maintenance treatment: A National Drug 

Abuse Treatment Clinical Trials Network study. Archives 

of General Psychiatry 63(2):201–208, 2006. 

Carroll, K.M.; Ball, S.A.; Martino, S.; Nich, C.; Babuscio, 

T.A.; Nuro, K.F.; Gordon, M.A.; Portnoy, G.A.; and 

Rounsaville, B.J. Computer-assisted delivery of cognitivebehavioral therapy for addiction: a randomized trial 

of CBT4CBT. The American Journal of Psychiatry

165(7):881–888, 2008.

Contingency Management Interventions/

Motivational Incentives 

(Alcohol, Stimulants, Opioids, 

Marijuana, Nicotine)

Research has demonstrated the effectiveness of treatment 

approaches using contingency management (CM) 

principles, which involve giving patients tangible rewards 

to reinforce positive behaviors such as abstinence. 

Studies conducted in both methadone programs and 

psychosocial counseling treatment programs demonstrate 

that incentive-based interventions are highly effective in 

increasing treatment retention and promoting abstinence 

from drugs. 

Voucher-Based Reinforcement (VBR) augments other 

community-based treatments for adults who primarily 

abuse opioids (especially heroin) or stimulants (especially 

cocaine) or both. In VBR, the patient receives a voucher 

for every drug-free urine sample provided. The voucher 

has monetary value that can be exchanged for food items, 

movie passes, or other goods or services that are consistent 

with a drug-free lifestyle. The voucher values are low at ÅZ[\J]\QVKZMI[MI[\PMV]UJMZWN KWV[MK]\Q^MLZ]ONZMM

urine samples increases; positive urine samples reset the 

value of the vouchers to the initial low value. VBR has 

been shown to be effective in promoting abstinence from 

opioids and cocaine in patients undergoing methadone 

LM\W`QÅKI\QWV

Prize Incentives CM applies similar principles as VBR 

but uses chances to win cash prizes instead of vouchers. 

Over the course of the program (at least 3 months, one or 
52 53

Petry, N.M.; Peirce, J.M.; Stitzer, M.L.; Blaine, J.; Roll, 

J.M.; Cohen, A.; Obert, J.; Killeen, T.; Saladin, M.E.; 

Cowell, M.; Kirby, K.C.; Sterling, R.; Royer-Malvestuto, 

C.; Hamilton, J.; Booth, R.E.; Macdonald, M.; Liebert, 

M.; Rader, L.; Burns, R; DiMaria, J.; Copersino, M.; 

Stabile, P.Q.; Kolodner, K.; and Li, R. Effect of prizebased incentives on outcomes in stimulant abusers in 

outpatient psychosocial treatment programs: A National 

Drug Abuse Treatment Clinical Trials Network study. 

Archives of General Psychiatry 62(10):1148–1156, 2005. 

Petry, N.M.; Kolodner, K.B.; Li, R.; Peirce, J.M.; Roll, 

J.M.; Stitzer, M.L.; and Hamilton, J.A. Prize-based 

contingency management does not increase gambling. 

Drug and Alcohol Dependence 83(3):269–273, 2006. 

Prendergast, M.; Podus, D.; Finney, J.; Greenwell, L.; 

and Roll, J. Contingency management for treatment 

of substance use disorders: A meta-analysis. Addiction

101(11):1546–1560, 2006. 

Roll, J.M.; Petry, N.M.; Stitzer, M.L.; Brecht, M.L.; Peirce, 

J.M.; McCann, M.J.; Blaine, J.; MacDonald, M.; DiMaria, 

J.; Lucero, L.; and Kellogg, S. Contingency management 

for the treatment of methamphetamine use disorders. The 

American Journal of Psychiatry 163(11):1993–1999, 2006.

Community Reinforcement Approach Plus 

Vouchers (Alcohol, Cocaine, Opioids)

Community Reinforcement Approach (CRA) Plus 

Vouchers is an intensive 24-week outpatient therapy for 

treating people addicted to cocaine and alcohol. It uses 

a range of recreational, familial, social, and vocational 

reinforcers, along with material incentives, to make a nondrug-using lifestyle more rewarding than substance use. 

The treatment goals are twofold:  To maintain abstinence long enough for patients to 

learn new life skills to help sustain it; and

 To reduce alcohol consumption for patients whose 

drinking is associated with cocaine use

Patients attend one or two individual counseling sessions 

each week, where they focus on improving family relations, 

learn a variety of skills to minimize drug use, receive 

vocational counseling, and develop new recreational 

activities and social networks. Those who also abuse 

ITKWPWTZMKMQ^MKTQVQKUWVQ\WZMLLQ[]TÅZIU)V\IJ][M

therapy. Patients submit urine samples two or three times 

each week and receive vouchers for cocaine-negative 

samples. As in VBR, the value of the vouchers increases 

with consecutive clean samples, and the vouchers may be 

exchanged for retail goods that are consistent with a drugfree lifestyle. Studies in both urban and rural areas have 

found that this approach facilitates patients’ engagement 

in treatment and successfully aids them in gaining 

substantial periods of cocaine abstinence. 

A computer-based version of CRA Plus Vouchers called 

the Therapeutic Education System (TES) was found to be 

nearly as effective as treatment administered by a therapist 

in promoting abstinence from opioids and cocaine among 

opioid-dependent individuals in outpatient treatment. A 

version of CRA for adolescents addresses problem-solving, 

coping, and communication skills and encourages active 

participation in positive social and recreational activities. 

Further Reading: 

Brooks, A.C.; Ryder, D.; Carise, D.; and Kirby, K.C. 

Feasibility and effectiveness of computer-based therapy 

in community treatment. Journal of Substance Abuse 

Treatment 39(3):227–235, 2010.

Higgins, S.T.; Sigmon, S.C.; Wong, C.J.; Heil, S.H.; 

Badger, G.J.; Donham, R.; Dantona, R.L.; and Anthony, S. 

Community reinforcement therapy for cocaine-dependent 

outpatients. Archives of General Psychiatry 60(10):1043–

1052, 2003. 
54 55

Roozen, H.G.; Boulogne, J.J.; van Tulder, M.W.; van 

den Brink, W.; De Jong, C.A.J.; and Kerhof, J.F.M. A 

systemic review of the effectiveness of the community 

reinforcement approach in alcohol, cocaine and opioid 

addiction. Drug and Alcohol Dependence 74(1):1–13, 2004. 

Silverman, K.; Higgins, S.T.; Brooner, R.K.; Montoya, 

I.D.; Cone, E.J.; Schuster, C.R.; and Preston, K.L. 

Sustained cocaine abstinence in methadone maintenance 

patients through voucher-based reinforcement therapy. 

Archives of General Psychiatry 53(5):409–415, 1996. 

Smith, J.E.; Meyers, R.J.; and Delaney, H.D. The 

community reinforcement approach with homeless 

alcohol-dependent individuals. Journal of Consulting and 

Clinical Psychology 66(3):541–548, 1998. 

Stahler, G.J.; Shipley, T.E.; Kirby, K.C.; Godboldte, C.; 

Kerwin, M.E; Shandler, I.; and Simons, L. Development 

and initial demonstration of a community-based 

intervention for homeless, cocaine-using, AfricanAmerican women. Journal of Substance Abuse Treatment

28(2):171–179, 2005.

Motivational Enhancement Therapy 

(Alcohol, Marijuana, Nicotine)

Motivational Enhancement Therapy (MET) is a 

counseling approach that helps individuals resolve their 

ambivalence about engaging in treatment and stopping 

their drug use. This approach aims to evoke rapid and 

internally motivated change, rather than guide the 

patient stepwise through the recovery process. This 

therapy consists of an initial assessment battery session, 

followed by two to four individual treatment sessions with 

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provides feedback to the initial assessment, stimulating 

discussion about personal substance use and eliciting 

self-motivational statements. Motivational interviewing 

principles are used to strengthen motivation and build 

a plan for change. Coping strategies for high-risk 

situations are suggested and discussed with the patient. 

In subsequent sessions, the therapist monitors change, 

reviews cessation strategies being used, and continues to 

encourage commitment to change or sustained abstinence. 

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other to sessions. 

Research on MET suggests that its effects depend on 

the type of drug used by participants and on the goal 

of the intervention. This approach has been used 

successfully with people addicted to alcohol to both 

improve their engagement in treatment and reduce their 

problem drinking. MET has also been used successfully 

with marijuana-dependent adults when combined 

with cognitive-behavioral therapy, constituting a more 

comprehensive treatment approach. The results of MET 

are mixed for people abusing other drugs (e.g., heroin, 

cocaine, nicotine) and for adolescents who tend to use 

multiple drugs. In general, MET seems to be more 

effective for engaging drug abusers in treatment than for 

producing changes in drug use.

Further Reading:

Baker, A.; Lewin, T.; Reichler, H.; Clancy, R.; Carr, V.; 

Garrett, R.; Sly, K.; Devir, H.; and Terry, M. Evaluation 

of a motivational interview for substance use with 

psychiatric in-patient services. Addiction 97(10):1329–1337, 

2002. 

Haug, N.A.; Svikis, D.S.; and Diclemente, C. Motivational 

enhancement therapy for nicotine dependence in 

methadone-maintained pregnant women. Psychology of 

Addictive Behaviors 18(3):289–292, 2004. 

Marijuana Treatment Project Research Group. Brief 

treatments for cannabis dependence: Findings from a 

randomized multisite trial. Journal of Consulting and 

Clinical Psychology 72(3):455–466, 2004. 
56 57

Miller, W.R.; Yahne, C.E.; and Tonigan, J.S. Motivational 

interviewing in drug abuse services: A randomized trial. 

Journal of Consulting and Clinical Psychology 71(4):754–

763, 2003. 

Stotts, A.L.; Diclemente, C.C.; and Dolan-Mullen, P. Oneto-one: A motivational intervention for resistant pregnant 

smokers. Addictive Behaviors 27(2):275–292, 2002.

The Matrix Model (Stimulants)

The Matrix Model provides a framework for engaging 

stimulant (e.g., methamphetamine and cocaine) abusers in 

treatment and helping them achieve abstinence. Patients 

learn about issues critical to addiction and relapse, receive 

direction and support from a trained therapist, and 

become familiar with self-help programs. Patients are 

monitored for drug use through urine testing. 

The therapist functions simultaneously as teacher and 

coach, fostering a positive, encouraging relationship 

with the patient and using that relationship to reinforce 

positive behavior change. The interaction between the 

therapist and the patient is authentic and direct but not 

confrontational or parental. Therapists are trained to 

conduct treatment sessions in a way that promotes the 

patient’s self-esteem, dignity, and self-worth. A positive 

relationship between patient and therapist is critical to 

patient retention. 

Treatment materials draw heavily on other tested 

treatment approaches and, thus, include elements of 

relapse prevention, family and group therapies, drug 

education, and self-help participation. Detailed treatment 

manuals contain worksheets for individual sessions; 

other components include family education groups, 

early recovery skills groups, relapse prevention groups, 

combined sessions, urine tests, 12-step programs, relapse 

analysis, and social support groups. 

A number of studies have demonstrated that participants 

treated using the Matrix Model show statistically 

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improvements in psychological indicators, and reduced 

risky sexual behaviors associated with HIV transmission.

Further Reading:

Huber, A.; Ling, W.; Shoptaw, S.; Gulati, V.; Brethen, 

P.; and Rawson, R. Integrating treatments for 

methamphetamine abuse: A psychosocial perspective. 

Journal of Addictive Diseases 16(4):41–50, 1997. 

Rawson, R.; Shoptaw, S.J.; Obert, J.L.; McCann, M.J.; 

Hasson, A.L.; Marinelli-Casey, P.J.; Brethen, P.R.; and 

Ling, W. An intensive outpatient approach for cocaine 

abuse: The Matrix model. Journal of Substance Abuse 

Treatment 12(2):117–127, 1995. 

Rawson, R.A.; Huber, A.; McCann, M.; Shoptaw, S.; 

Farabee, D.; Reiber, C.; and Ling, W. A comparison 

of contingency management and cognitive-behavioral 

approaches during methadone maintenance treatment 

for cocaine dependence. Archives of General Psychiatry

59(9):817–824, 2002.

12-Step Facilitation Therapy 

(Alcohol, Stimulants, Opioids)

Twelve-step facilitation therapy is an active engagement 

strategy designed to increase the likelihood of a substance 

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12-step self-help groups, thereby promoting abstinence. 

Three key ideas predominate: (1) acceptance, which 

includes the realization that drug addiction is a chronic, 

progressive disease over which one has no control, that 

life has become unmanageable because of drugs, that 

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and that abstinence is the only alternative; (2) surrender, 

which involves giving oneself over to a higher power, 

accepting the fellowship and support structure of other 
58 59

recovering addicted individuals, and following the recovery 

activities laid out by the 12-step program; and (3) active 

involvement in 12-step meetings and related activities. 

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facilitation) in treating alcohol dependence has been 

established, the research on its usefulness for other 

forms of substance abuse is more preliminary, but the 

treatment appears promising for helping drug abusers 

sustain recovery.

Further Reading:

Carroll, K.M.; Nich, C.; Ball, S.A.; McCance, E.; 

Frankforter, T.L.; and Rounsaville, B.J. One-year follow-up 

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Sustained effects of treatment. Addiction 95(9):1335–1349, 

2000. 

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potential role of 12-Step self-help group involvement in 

methamphetamine recovery. Addiction 102(Suppl.1):121–

129, 2007. 

Project MATCH Research Group. Matching alcoholism 

treatments to client heterogeneity: Project MATCH 

posttreatment drinking outcomes. Journal of Studies on 

Alcohol 58(1)7–29, 1997.

Family Behavior Therapy

Family Behavior Therapy (FBT), which has demonstrated 

positive results in both adults and adolescents, is aimed 

at addressing not only substance use problems but other 

co-occurring problems as well, such as conduct disorders, 

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unemployment. FBT combines behavioral contracting 

with contingency management. 

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other such as a cohabiting partner or a parent (in the 

case of adolescents). Therapists seek to engage families in 

applying the behavioral strategies taught in sessions and 

in acquiring new skills to improve the home environment. 

Patients are encouraged to develop behavioral goals 

for preventing substance use and HIV infection, which 

are anchored to a contingency management system. 

Substance-abusing parents are prompted to set goals 

related to effective parenting behaviors. During each 

session, the behavioral goals are reviewed, with rewards 

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8I\QMV\[XIZ\QKQXI\MQV\ZMI\UMV\XTIVVQVOKPWW[QVO[XMKQÅK

interventions from a menu of evidence-based treatment 

options. In a series of comparisons involving adolescents 

with and without conduct disorder, FBT was found to be 

more effective than supportive counseling.

Further Reading:

Azrin, N.H.; Donohue, B.; Besalel, V.A.; Kogan, E.S.; 

and Acierno, R. Youth drug abuse treatment: a controlled 

outcome study. Journal of Child and Adolescent Substance 

Abuse 3:1–16, 1994.

Carroll, K.M.; and Onken, L.S. Behavioral therapies for 

drug abuse. American Journal of Psychiatry 168(8):1452–

1460, 2005. 

Donohue, B.; Azrin, N.; Allen, D.N.; Romero, V.; Hill, 

H.H.; Tracy, K.; Lapota, H.; Gorney, S.; Abdel-al, R.; 

Caldas, D.; Herdzik, K.; Bradshaw, K.; Valdez, R.; and 

Van Hasselt, V.B. Family Behavior Therapy for substance 

abuse: A review of its intervention components and 

applicability. Behavior Modification, 33:495–519, 2009.

LaPota, H.B.; Donohue, B.; Warren, C. S.; and Allen, D.N. 

Integration of a Healthy Living curriculum within Family 

Behavior Therapy: A clinical case example in a woman 

with a history of domestic violence, child neglect, drug 

abuse, and obesity. Journal of Family Violence 26:227–234, 

2011. 
60 61

Behavioral Therapies Primarily 

for Adolescents 

Drug-abusing and addicted adolescents have unique 

treatment needs. Research has shown that treatments 

designed for and tested in adult populations often need 

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involvement is a particularly important component for 

interventions targeting youth. Below are examples of 

behavioral interventions that employ these principles and 

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Multisystemic Therapy

Multisystemic Therapy (MST) addresses the factors 

associated with serious antisocial behavior in children and 

adolescents who abuse alcohol and other drugs. These 

factors include characteristics of the child or adolescent 

(e.g., favorable attitudes toward drug use), the family (poor 

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(positive attitudes toward drug use), school (dropout, poor 

performance), and neighborhood (criminal subculture). 

By participating in intensive treatment in natural 

environments (homes, schools, and neighborhood settings), 

most youths and families complete a full course of 

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during treatment and for at least 6 months after treatment. 

Fewer incarcerations and out-of-home juvenile placements 

offset the cost of providing this intensive service and 

maintaining the clinicians’ low caseloads. 

Further Reading: 

Henggeler, S.W.; Clingempeel, W.G.; Brondino, M.J.; and 

Pickrel, S.G. Four-year follow-up of multisystemic therapy 

with substance-abusing and substance-dependent juvenile 

offenders. Journal of the American Academy of Child and 

Adolescent Psychiatry 41(7):868–874, 2002. 

Henggeler, S.W.; Rowland, M.D.; Randall, J.; Ward, 

D.M.; Pickrel, S.G.; Cunningham, P.B.; Miller, S.L.; 

Edwards, J.; Zealberg, J.J.; Hand, L.D.; and Santos, A.B. 

Home-based multisystemic therapy as an alternative to 

the hospitalization of youths in psychiatric crisis: Clinical 

outcomes. Journal of the American Academy of Child and 

Adolescent Psychiatry 38(11):1331–1339, 1999. 

Henggeler, S.W.; Halliday-Boykins, C.A.; Cunningham, 

P.B.; Randall, J.; Shapiro, S.B.; and Chapman, J.E. 

Juvenile drug court: Enhancing outcomes by integrating 

evidence-based treatments. Journal of Consulting and 

Clinical Psychology 74(1):42–54, 2006. 

Henggeler, S.W.; Pickrel, S.G.; Brondino, M.J.; and 

Crouch, J.L. Eliminating (almost) treatment dropout of 

substance-abusing or dependent delinquents through 

home-based multisystemic therapy. The American Journal 

of Psychiatry 153(3):427–428, 1996. 

Huey, S.J.; Henggeler, S.W.; Brondino, M.J.; and 

Pickrel, S.G. Mechanisms of change in multisystemic 

therapy: Reducing delinquent behavior through therapist 

adherence and improved family functioning. Journal of 

Consulting and Clinical Psychology 68(3):451–467, 2000. 

Multidimensional Family Therapy

Multidimensional Family Therapy (MDFT) for adolescents 

is an outpatient, family-based treatment for teenagers who 

abuse alcohol or other drugs. MDFT views adolescent 

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family, peer, community) and suggests that reducing 

unwanted behavior and increasing desirable behavior 

occur in multiple ways in different settings. Treatment 

includes individual and family sessions held in the clinic, 

in the home, or with family members at the family court, 

school, or other community locations. 

During individual sessions, the therapist and adolescent 

work on important developmental tasks, such as 

developing decision-making, negotiation, and problemsolving skills. Teenagers acquire vocational skills and 
62 63

skills in communicating their thoughts and feelings to 

deal better with life stressors. Parallel sessions are held 

with family members. Parents examine their particular 

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control and to have a positive and developmentally 

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Further Reading: 

Dennis, M.; Godley, S.H.; Diamond, G.; Tims, F.M.; 

Babor, T.; Donaldson, J.; Liddle, H.; Titus, J.C.; Kaminer, 

Y.; Webb, C.; Hamilton, N.; and Funk, R. The Cannabis 

AW]\P<ZMI\UMV\+A<;\]La"5IQVÅVLQVO[NZWU\_W

randomized clinical trials. Journal of Substance Abuse 

Treatment 27(3):197–213, 2004. 

Liddle, H.A.; Dakof, G.A.; Parker, K.; Diamond, 

G.S.; Barrett, K.; and Tejeda, M. Multidimensional 

family therapy for adolescent drug abuse: Results of a 

randomized clinical trial. The American Journal of Drug 

and Alcohol Abuse 27(4):651–688, 2001. 

Liddle, H.A.; and Hogue, A. Multidimensional family 

therapy for adolescent substance abuse. In E.F. Wagner 

and H.B. Waldron (eds.), Innovations in Adolescent 

Substance Abuse Interventions. London: Pergamon/

Elsevier Science, pp. 227–261, 2001. 

Liddle, H.A.; Rowe, C.L.; Dakof, G.A.; Ungaro, R.A.; 

and Henderson, C.E. Early intervention for adolescent 

substance abuse: Pretreatment to posttreatment outcomes 

of a randomized clinical trial comparing multidimensional 

family therapy and peer group treatment. Journal of 

Psychoactive Drugs 36(1):49–63, 2004. 

Schmidt, S.E.; Liddle, H.A.; and Dakof, G.A. Effects of 

multidimensional family therapy: Relationship of changes 

in parenting practices to symptom reduction in adolescent 

substance abuse. Journal of Family Psychology 10(1):1–16, 

1996. 

Brief Strategic Family Therapy

Brief Strategic Family Therapy (BSFT) targets family 

interactions that are thought to maintain or exacerbate 

adolescent drug abuse and other co-occurring problem 

behaviors. Such problem behaviors include conduct 

problems at home and at school, oppositional behavior, 

delinquency, associating with antisocial peers, aggressive 

and violent behavior, and risky sexual behavior. BSFT 

is based on a family systems approach to treatment, in 

which family members’ behaviors are assumed to be 

interdependent such that the symptoms of one member 

(the drug-abusing adolescent, for example) are indicative, 

at least in part, of what else is occurring in the family 

system. The role of the BSFT counselor is to identify the 

patterns of family interaction that are associated with the 

adolescent’s behavior problems and to assist in changing 

those problem-maintaining family patterns. BSFT is 

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broad range of family situations in various settings (mental 

health clinics, drug abuse treatment programs, other 

social service settings, and families’ homes) and in various 

treatment modalities (as a primary outpatient intervention, 

in combination with residential or day treatment, and as 

an aftercare/continuing-care service following residential 

treatment). 

Further Reading: 

Coatsworth, J.D.; Santisteban, D.A.; McBride, C.K.; and 

Szapocznik, J. Brief Strategic Family Therapy versus 

community control: Engagement, retention, and an 

exploration of the moderating role of adolescent severity. 

Family Process 40(3):313–332, 2001. 

3]Z\QVM[?5#5]ZZIa-2#IVL4IXMZZQMZM)-NÅKIKa

of intervention for engaging youth and families into 

treatment and some variables that may contribute to 

differential effectiveness. Journal of Family Psychology

10(1):35–44, 1996. 
64 65

Santisteban, D.A.; Coatsworth, J.D.; Perez-Vidal, A.; 

Mitrani, V.; Jean-Gilles, M.; and Szapocznik, J. Brief 

Structural/Strategic Family Therapy with AfricanAmerican and Hispanic high-risk youth. Journal of 

Community Psychology 25(5):453–471, 1997. 

Santisteban, D.A.; Suarez-Morales, L.; Robbins, M.S.; 

and Szapocznik, J. Brief strategic family therapy: Lessons 

TMIZVMLQVMNÅKIKaZM[MIZKPIVLKPITTMVOM[\WJTMVLQVO

research and practice. Family Process 45(2):259–271, 2006. 

Santisteban, D.A.; Szapocznik, J.; Perez-Vidal, A.; Mitrani, 

V.; Jean-Gilles, M.; and Szapocznik, J. Brief Structural/

Strategic Family Therapy with African-American 

and Hispanic high-risk youth. Journal of Community 

Psychology 25(5):453–471, 1997.

Szapocznik, J.; Perez-Vidal, A.; Brickman, A.L.; Foote, 

F.H.; Santisteban, D.; Hervis, O.; and Kurtines, W.M. 

Engaging adolescent drug abusers and their families in 

treatment: A strategic structural systems approach. Journal 

of Consulting and Clinical Psychology 56(4):552–557, 

1988. 

Functional Family Therapy

Functional Family Therapy (FFT) is another treatment 

based on a family systems approach, in which an 

adolescent’s behavior problems are seen as being created 

or maintained by a family’s dysfunctional interaction 

patterns. FFT aims to reduce problem behaviors by 

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resolution, and parenting skills. The intervention always 

includes the adolescent and at least one family member 

in each session. Principal treatment tactics include (1) 

engaging families in the treatment process and enhancing 

their motivation for change and (2) bringing about 

changes in family members’ behavior using contingency 

management techniques, communication and problemsolving, behavioral contracts, and other behavioral 

interventions.

Further Reading: 

Waldron, H.B.; Slesnick, N.; Brody, J.L.; Turner, C.W.; 

and Peterson, T.R. Treatment outcomes for adolescent 

substance abuse at 4- and 7-month assessments. Journal of 

Consulting and Clinical Psychology 69:802–813, 2001.

Waldron, H.B.; Turner, C. W.; and Ozechowski, T. J. 

8ZWÅTM[WN LZ]O][MJMPI^QWZKPIVOMNWZILWTM[KMV\[QV

treatment. Addictive Behaviors 30:1775–1796, 2005.

Adolescent Community Reinforcement 

Approach and Assertive Continuing Care

The Adolescent Community Reinforcement Approach 

(A-CRA) is another comprehensive substance abuse 

treatment intervention that involves the adolescent and 

his or her family. It seeks to support the individual’s 

recovery by increasing family, social, and educational/

vocational reinforcers. After assessing the adolescent’s 

needs and levels of functioning, the therapist chooses from 

among 17 A-CRA procedures to address problem-solving, 

coping, and communication skills and to encourage active 

participation in positive social and recreational activities. 

A-CRA skills training involves role-playing and behavioral 

rehearsal.

Assertive Continuing Care (ACC) is a home-based 

continuing-care approach to preventing relapse. Weekly 

home visits take place over a 12- to 14-week period after 

an adolescent is discharged from residential, intensive 

outpatient, or regular outpatient treatment. Using positive 

and negative reinforcement to shape behaviors, along with 

training in problem-solving and communication skills, 

ACC combines A-CRA and assertive case management 

services (e.g., use of a multidisciplinary team of 

professionals, round-the-clock coverage, assertive outreach) 

to help adolescents and their caregivers acquire the skills 

to engage in positive social activities. 
66 67

Further Reading: 

Dennis, M.; Godley, S.H.; Diamond, G.; Tims, F.M.; 

Babor, T.; Donaldson, J.; Liddle, H.; Titus, J.C.; Kamier, 

Y.; Webb, C.; Hamilton, N.; and Funk R. The Cannabis 

AW]\P<ZMI\UMV\+A<;\]La"5IQVÅVLQVO[NZWU\_W

randomized trials. Journal of Substance Abuse Treatment

27:197–213, 2004.

Godley, S.H.; Garner, B.R.; Passetti, L.L.; Funk, R.R.; 

Dennis, M.L.; and Godley, M.D. Adolescent outpatient 

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randomized clinical trial. Drug and Alcohol Dependence

Jul 1;110 (1-2):44–54, 2010.

Godley, M.D.; Godley, S.H.; Dennis, M.L.; Funk, R.; and 

Passetti, L.L. Preliminary outcomes from the assertive 

continuing care experiment for adolescents discharged 

from residential treatment. Journal of Substance Abuse 

Treatment 23:21–32, 2002.
68 Resources 69

National Agencies

The National Institute on Drug Abuse (NIDA) leads 

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of drug abuse and addiction. It supports and conducts 

research across a broad range of disciplines, including 

genetics, functional neuroimaging, social neuroscience, 

prevention, medication and behavioral therapies, 

and health services. It then disseminates the results 

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and treatment and to inform policy as it relates to 

drug abuse and addiction. Additional information is 

available at drugabuse.gov or by calling 301-443-1124.

National Institute on Alcohol 

Abuse and Alcoholism (NIAAA)

The National Institute on Alcohol Abuse and Alcoholism 

(NIAAA) provides leadership in the national effort to 

reduce alcohol-related problems by conducting and 

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including genetics, neuroscience, epidemiology, health 

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and treatment; coordinating and collaborating with 

other research institutes and Federal programs on 

alcohol-related issues; collaborating with international, 

national, State, and local institutions, organizations, 

agencies, and programs engaged in alcohol-related work; 

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to healthcare providers, researchers, policymakers, 

and the public. Additional information is available 

at niaaa.nih.gov or by calling 301-443-3860.

69
70 71

Selected Publications and Resources 

for Drug Addiction Treatment

The following are available from the NIDA DrugPubs 

Research Dissemination Center, the National Technical 

Information Service (NTIS), or the Government 

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(877-NIDANIH [643-2644]), NTIS (1-800-553-6847), or 

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Blending products61,)1⁄4[*TMVLQVO1VQ\QI\Q^M ̧I

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drugabuse.gov/blending-initiative

Addiction Severity Index8ZW^QLM[I[\Z]K\]ZMLKTQVQKIT

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visit triweb.tresearch.org/index.php/tools/download-asiinstruments-manuals/

National Institute of Mental Health 

(NIMH)

The mission of the National Institute of Mental Health 

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support of this mission, NIMH generates research 

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behavioral sciences to fuel research on the causes of 

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Center for Substance Abuse 

Treatment (CSAT)

The Center for Substance Abuse Treatment (CSAT), a 

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Treatment Referral Hotline (1-800-662-HELP), which 

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csat.aspx
72 73

Alcohol Alert (published by NIAAA). This is a 

quarterly bulletin that disseminates important research 

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online at niaaa.nih.gov/publications/journals-and-reports/

alcohol-alert.

Helping Patients Who Drink Too Much: A 

Clinician’s Guide (published by NIAAA). This booklet 

is written for primary care and mental health clinicians 

and provides guidance in screening and managing alcoholdependent patients. Available online at pubs.niaaa.nih.gov/

publications/Practitioner/CliniciansGuide2005/clinicians_

guide.htm.

Research Report Series: Therapeutic Community

(2002). This report provides information on the role of 

residential drug-free settings and their role in the treatment 

process. NIH Publication #02-4877. Available online at 

drugabuse.gov/publications/research-reports/therapeuticcommunity.

Drugs, Brains, and Behavior: The Science of 

Addiction (Reprinted 2010). This publication provides an 

overview of the science behind the disease of addiction. 

NIH Publication #10–5605. Available online at drugabuse.

gov/publications/science-addiction.

Seeking Drug Abuse Treatment: Know What To 

Ask (2011). This lay-friendly publication offers guidance in 

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when searching for a treatment program. NIH Publication 

#12-7764. Available online at drugabuse.gov/publications/

seeking-drug-abuse-treatment.

Principles of Drug Abuse Treatment for Criminal 

Justice Populations: A Research-Based Guide

(Revised 2012). Provides 13 essential treatment principles 

and includes resource information and answers to 

frequently asked questions. NIH Publication No.: 11-5316. 

Available online at nida.nih.gov/PODAT_CJ.

NIDA DrugFacts: Treatment Approaches for Drug 

Addiction (Revised 2008). This is a fact sheet covering 

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drug abuse and addiction. Available online at drugabuse.

gov/publications/drugfacts/treatment-approaches-drugaddiction.
74 75

Initiatives Designed to Move 

Treatment Research into Practice

Clinical Trials Network

Assessing the real-world effectiveness of evidence-based 

treatments is a crucial step in bringing research to practice. 

Established in 1999, NIDA’s National Drug Abuse 

Treatment Clinical Trials Network (CTN) uses community 

settings with diverse patient populations and conditions 

to adjust and test protocols to meet the practical needs 

of addiction treatment. Since its inception, the CTN 

has tested pharmacological and behavioral interventions 

for drug abuse and addiction, along with common 

co-occurring conditions (e.g., HIV and PTSD) among 

various target populations, including adolescent drug 

abusers, pregnant drug-abusing women, and Spanishspeaking patients. The CTN has also tested prevention 

strategies in drug-abusing groups at high risk for HCV 

and HIV and has become a key element of NIDA’s 

multipronged approach to move promising science-based 

drug addiction treatments rapidly into community settings. 

For more information on the CTN, please visit drugabuse.

gov/CTN/Index.htm. 

Criminal Justice–Drug Abuse

Treatment Studies

NIDA is taking an approach similar to the CTN to 

enhance treatment for drug-addicted individuals involved 

with the criminal justice system through Criminal 

Justice–Drug Abuse Treatment Studies (CJ-DATS). 

Whereas NIDA’s CTN has as its overriding mission the 

improvement of the quality of drug abuse treatment by 

moving innovative approaches into the larger community, 

research supported through CJ-DATS is designed to 

effect change by bringing new treatment models into the 

criminal justice system and thereby improve outcomes for 

offenders with substance use disorders. It seeks to achieve 

better integration of drug abuse treatment with other 

public health and public safety forums and represents a 

collaboration among NIDA; SAMHSA; the Centers for 

Disease Control and Prevention (CDC); Department of 

Justice agencies; and a host of drug treatment, criminal 

justice, and health and social service professionals.

Blending Teams

Another way in which NIDA is seeking to actively move 

science into practice is through a joint venture with 

SAMHSA and its nationwide network of Addiction 

Technology Transfer Centers (ATTCs). This process 

involves the collaborative efforts of community treatment 

practitioners, SAMHSA trainers, and NIDA researchers, 

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products and devise strategic dissemination plans for 

them. Through the creation of products designed to 

foster adoption of new treatment strategies, Blending 

Teams are instrumental in getting the latest evidencebased tools and practices into the hands of treatment 

professionals. To date, a number of products have been 

completed. Topics have included increasing awareness 

of the value of buprenorphine therapy and enhancing 

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the ASI, motivational interviewing, and motivational 

incentives. For more information on Blending products, 

please visit NIDA’s Web site at nida.nih.gov/blending.
76 77

Other Federal Resources

NIDA DrugPubs Research Dissemination Center. 

NIDA publications and treatment materials are available 

from this information source. Staff provide assistance 

in English and Spanish and have TTY/TDD capability. 

Phone: 877-NIDA-NIH (877-643-2644); TTY/TDD: 240-

645-0228; fax: 240-645-0227; e-mail: drugpubs@nida.nih.

gov; Web site: drugpubs.drugabuse.gov.

The National Registry of Evidence-Based Programs 

and Practices. This database of interventions for the 

prevention and treatment of mental and substance use 

disorders is maintained by SAMHSA and can be accessed 

at nrepp.samhsa.gov.

SAMHSA’s Store has a wide range of products, 

including manuals, brochures, videos, and other 

publications. Phone: 800-487-4889; Web site: 

store.samhsa.gov.

The National Institute of Justice. As the research 

agency of the U.S. Department of Justice, the National 

Institute of Justice (NIJ) supports research, evaluation,

and demonstration programs relating to drug abuse in 

the context of crime and the criminal justice system. 

For information, including a wealth of publications, 

contact the National Criminal Justice Reference Service 

at 800-851-3420 or 301-519-5500; or visit nij.gov.

Clinical Trials. For more information on federally 

and privately supported clinical trials, please visit 

clinicaltrials.gov.
78

NIH Publication No. 12–4180

Printed October 1999;

Reprinted July 2000, February 2008; Revised April; December 2012

U.S. DEPARTMENT OF HEALTH 

AND HUMAN SERVICES