Carla Marienfeld, MD: Evidence-Based Behavioral Therapies in Addiction Treatment

Carla Marienfeld, MD

Medications for substance abuse are both effective and widespread, but the addition of therapy, whether individual or group, may benefit patients with substance abuse to achieve recovery and meet their goals.

In an interview with HCPLive®, Carla Marienfeld, MD, UC San Diego, explained the options for patients with substance abuse, including motivational interviewing and an adaptation of cognitive behavioral therapy.

Marienfeld recently presented a discussion on behavioral and non-opioid therapies for addiction treatment at the "Evolving Approaches in Pain Management" conference in San Diego on August 14.

HCPLive®: Could you give a brief summary of your presentation and any key highlights you think would be important to mention?

Marienfeld: We have a lot of really excellent medications for treating substance use disorders, particularly opioid use disorders, that have wonderful evidence for being helpful.

In addition to providing medications, many patients do benefit from having therapies, whether it's individual or group therapy that helps them also with their goals around substances and to achieve recovery.

The presentation covers some of the main most common evidence-based therapies and approaches that we have towards treating substance use disorders, with a particular focus on motivational interviewing, which is a style or way of facilitating a conversation in order to increase the person's own intrinsic values and desires and likelihood to change.

HCPLive®: Could you talk a little bit more about the specifics of the behavioral therapies and how they work in favor of the patients?

Marienfeld: We take a look at what the patient is presenting with, how effective medications have been in helping with recovery, if they have any co-occurrence, other psychiatric problems related to trauma. We use that to inform what we might offer in a therapy session.

The basic thing that we talk about is called motivational interviewing, which is a general approach to talking to a person that tries to limit their defensiveness, helps to elicit from them what they think is important based on their own values, and what might be most helpful for change.

The most common therapy that we use in most addiction treatment programs that use evidence based medicine is based on an adaptation of cognitive behavioral therapy. Cognitive behavioral therapy was originally started for depression and has been adapted for substance use to focus on triggers and identifying coping skills that we can use to manage our cravings, identifying triggers cravings.

In cognitive behavioral therapy, we really focus on recognizing things like triggers cues that are both external in our environment, as well as internal coming from our own issues going on at that time. We try to anticipate high risk situations and avoid those or have a plan for managing them.

We provide coping skills to help people understand what options they have to try to manage negative emotions or cravings, in order to prevent relapse, and then we connect people with each other, and with meaningful activities to help them in their recovery.

Other approaches include 12 step programs, or what we might call mutual aid programs, that are free and readily available in the community. They often provide a network of support, which is very powerful. Having a good peer cohort, or a good group of peers can be a very powerful agent of change. It's really, you know, an amazing sort of decentralized system that's available anywhere for free.

Community reinforcement approach, which is the idea that substance use, abuse, substance use is more of a learned behavior. If you use natural contingencies that are already operating in our environment, then that helps to modify that learned behavior.

If you give reward for the good choices that you make, and there are natural consequences for the bad choices, those things can then shape our behavior. And we can have some way of modulating those things towards helping the person change.

HCPLive®: How often are these therapies used in conjunction with one another? Are they considered separate or do you often use them together?

Marienfeld: When a person accesses treatment, if they're doing individual therapy, they often will focus on one main modality to kind of organize themselves. But that can shift over time, if it makes sense to shift to something else.

If somebody is in a residential treatment program, or a partial hospital or an intensive outpatient treatment program, they often are having multiple group based therapies per day, in addition to individual therapy.

One might be taking more of a cognitive behavioral therapy approach, one might be coming from something, another one as I was going to mention with the craft approach, which is community reinforcement and family therapy approach, for example.

At any given time, you have different tools, or different ways of approaching it, such that if something seems to work particularly well, for that one person, they can go back and use that skill set.

The idea is we're trying to give people multiple tools in their tool belt, so to speak, so that they can have different things that will work best for them.