PAT (Pharmacological Aversion Treatment) for the People?

       One segment of the population among whom substance abuse and dependence is a particularly salient problem is that of federal prisoners. Indeed, recent figures indicate that some 59.6% of federal prisoners are incarcerated due to drug-related offenses (Schaffer). Their continued upkeep, including exorbitantly high expenditures for security and medical care, comes as an enormous burden upon both the prison system and the wallets of taxpayers. (R.E. Geiselman, class lecture, January 10, 2012). Perhaps one of the most frustrating aspects of the situation is the fact that, following release, some 70% of these individuals reoffend and subsequently find themselves once again incarcerated within the dreary walls of the prison from which they had so recently been discharged (R.E. Geiselman, class lecture, February 2, 2012).
       There are many reasons for this astronomically high rate of recidivism, including the fact that prisoners are freed with little more than the clothes on their backs and $200-something dollars in their pocket, often right back into the community from which they came, complete with the same gang members, drug suppliers, drug customers, drinking buddies, fellow drug users, etc., as before. As if the environmental cues alone were insufficient for catapulting a newly-released offender into relapse, prisoners are also limited in their efforts to better their lives by stringent and unforgiving external constraints, including the fact that they cannot legally apply for a job without notifying a potential employer that they are a convicted felon (failure to do so is a felony in and of itself), and the like (R.E. Geiselman, class lecture, March 8, 2012). It seems that the cards are indeed very much stacked against newly-released convicts- and that is exactly why it is essential to intervene  among members of this group, not only to aid them in breaking their current cycle of dependence, but also to strengthen their resolve and coping skills for when they are released back into society and find themselves once again confronted with all the environmental cues that accompanied and reinforced their previous drug habit.
       A highly effective form of behavioral treatment for substance abuse which might serve this purpose particularly well is that of "Aversion Treatment" or "Aversion Conditioning." This type of therapy relies upon the principles of classical conditioning to cement a relationship (in the mind of a patient undergoing treatment) between the ingestion of a particular drug of abuse and symptoms of nausea and illness (Howard, 2001, p.561). Aversion treatment operates upon the same principles described by Domjan (2009) in relation to taste aversion conditioning, but as applied in a different context. Results of taste aversion conditioning studies performed by Capaldi, Hunter, & Lin, and also by Ramirez [as cited by Domjan (2009)], "A conditioned taste aversion may be learned if ingestion of a novel flavor is followed by an aversive consequence such as indigestion or food poisoning. In contrast, a taste preference may be learned if a flavor is paired with nutritional repletion or other positive consequences" (Domjan, 2009, p. 80-81). The fact that taste aversions found in humans are also the result of Pavlovian conditioning has been established by Scalera (2002) (as cited by Domjan, 2009). Two findings in regard to conditioned taste aversions are particularly significant- first, that "... a flavor-illness experience can produce a conditioned aversion in just one trial, and the learning can occur even if the illness is delayed several hours after ingestion of food" (Domjan, 2009, p. 81) and second, that "... food aversion learning can be independent of rational thought processes and can go against a person's conclusions about the causes of their illness" (Domjan, 2009, p.81). These findings are significant in that they correlate with separate findings more specifically related to the Pharmacological Aversion Treatment for alcohol dependence pioneered by Howard (2001).
       According to Elkins (as cited in Howard, 2001), "taste aversion conditioning, the process by which  alcohol aversions are established, is a phylogenetically old and highly efficient form of learning" (Howard, 2001, p. 562). As Howard goes on to explain, the results of the more than 1300 studies on human taste aversion conditioning performed since 1985 (Riley and Tuck, 1985, as cited by Howard, 2001), indicate that "(a) taste aversions can be established to highly familiar substances through repeated conditioning trials and discrimination training [in the context of classical conditioning, "discrimination" refers to "a procedure in which one stimulus (the CS+) is paired with the unconditioned stimulus on some trials and and another stimulus (the CS-) is presented without the unconditioned stimulus on other trials. As a result of this procedure the CS+ comes to elicit a conditioned response and the CS- comes to inhibit this response," (Domjan, 2009, p. 297)] (b) cognitive mediation is not necessary for the formation of taste aversions and (c) conditioned taste aversions are often highly resistant to extinction," (Howard, 2001, p. 562).
       The fact that Pharmacological Aversion Treatment [an adaptation of taste aversion conditioning used by Howard (2001) to establish an aversion to the taste and smell of alcohol in a group of hospitalized substance abuse patients] can be learned relatively quickly, following as little as one trial (although in Howard's study, five trials were used), and the fact that the results are at least relatively long-lasting, as well as the fact that, since the process of establishing taste aversions seems to be ingrained in the human psyche and  does not seem particularly dependent upon higher cognitive processes (Howard, 2001), makes it a good option for the treatment of alcohol addiction (and perhaps other substance abuse disorders) in the prison setting, where a shorter length of treatment, (and the cost savings that come with this) might make it an appealing choice for lawmakers and taxpayers alike, while the fact that the process can operate relatively independently of higher thought processes allows it to get around the problems with administration of psychotherapy within the prison setting cited by Robert G. Slater (former acting chief psychiatrist of California State Prison, San Quentin), including his assertion that the unbearable stress imposed upon the human psyche by the constant, unrelenting and deafening noise, as well as the constant threat of being severely physically harmed inherent to the prison setting makes effective psychotherapy impossible, and that, in fact, perhaps the best that can be done for people within the system is to provide them with anxiolytics (to lower their anxiety levels) as well as creative outlets for their feelings (such as classes and involvement in arts-and-crafts activities), and to avoid harming them further while they await their date of release (Slater, 1986); since the effectiveness of Pharmacological Aversion Therapy is rooted in human evolution and the ease with which the human brain is hard-wired to make connections between particular evolutionarily-significant pairs of stimuli (i.e., "consumables" and "gastrointestinal distress that results in severe nausea and vomiting" (Howard, 2001, p. 562)). Furthermore, the fact that higher-level thought processes are not deemed essential to the effectiveness of this treatment might make it easier to standardize and administer than the Cognitive Behavioral Therapy traditionally used in such cases, since, because Cognitive Behavioral Therapy generally focuses upon changing maladaptive cognitions, as well as behaviors (Carroll & Onken, 2005), it's effectiveness is more likely to be dependent upon the skill level of the person administering it (and their ability to assist clients with the process of gaining insight into their difficulties) whereas the effectiveness of Pharmacological Aversion Therapy appears to be inherent in its biological bases, with the result that (if proper procedures for its administration are followed) there should be much less inter-therapist variability and variation in its resulting effectiveness.
        In Howard's (2001) study of Pharmacological Aversion Therapy for alcohol abuse, this type of therapy was given to eighty-two hospitalized alcoholics. In this case, treatment consisted of five Pharmacological Aversion Therapy treatments, delivered (following the obtainment of informed consent) over a ten day period. While participants in this study completed numerous physiological as well as psychological tests (measuring everything from heart rate to their current, self-perceived appetite for alcohol and their self-perceived ability to resist ingesting it), the essential "treatment" in this study consisted of the participants being taken to a treatment room in which the shelves were lined with empty containers from a variety of alcoholic beverages, and where there were advertisements featuring various brands of alcohol on the walls. In this setting, one of the medical staff administering the treatment (either a doctor or a nurse) would pour the participant a glass of the type of alcohol they most liked to pursue, mixing it with an equal amount of warm water (the purpose of the warm water was to enhance the smell and taste of the alcoholic beverage). During initial trials, participants were then encouraged to have contact with the alcohol through smelling it and taking it into their mouth and swishing it around, but to stop short of swallowing it; during later trials, participants were encouraged to actually swallow the alcoholic beverage (although, because vomiting was induced soon after the alcohol was consumed, little alcohol was actually absorbed into the bloodstream). After each such session (a "session" generally lasted between 20 and 30 minutes), the participant was allowed to return to their hospital room. Approximately 30 minutes later and in this new location, the participant was served with their preferred alcoholic beverage- but this time, it contained "oral emitine or tartar emitic" (Howard, 2001, p. 567)- drugs specifically designed to make participants vomit between 5 and 8 minutes following their administration  (it was the relationship between the administration of this vomiting-inducing drug and the taste, smell, and consumption of alcohol that the procedure of the study was designed to reinforce). Furthermore, while the initial treatment of participants (during the first trial of the study) involved administering to participants 4 servings of their alcoholic beverage of choice (the specific type of alcohol they had previously been addicted to), later trials involved administering many different types of alcoholic beverages to the participants, in order to enable them to "generalize the conditioned aversion to a range of alcoholic flavors" (Howard, 2001, p. 567). (Howard, 2001).
       The results of the study, particularly given it's short duration and limited number of trials, (as you will remember, Domjan (2009) also stated that "... a flavor-illness experience can produce a conditioned aversion in just one trial" (Domjan, 2009, p. 81)), are impressive. For instance, prior to treatment, participants, (to whom a measure called the "Alcohol Expectancy Questionnaire" (Howard, 2001, p. 567) was administered), "endorsed an average of 65.9 positive alcohol-related outcome expectancies; the mean number of posttreatment positive outcome expectancies was 35.0" (Howard, 2001, p. 574). With t=-12.2 and a p-value of p<.001 (Howard, 2001, p.567) , such results are statistically significant. Furthermore, on another measure, the "Situational Confidence Questionnaire" (Howard, 2001, p. 567), designed to measure participants confidence that they would be able to resist cues that might, if they failed to have enough self-control to resist them, induce participants to return to their previous drug-taking habit, the "mean participant pretreatment SCQ score was 105.5, compared to a posttreatment score of 198.2 (t= 19.8, p<.001)" (Howard, 2001, p. 567). Thus, it is readily apparent that "confidence that abstinence could be maintained in the face of high-risk situations for relapse increased substantially following PAT" (Howard, 2001, p. 567).
       While self-perceived "self-efficacy" in resisting the urge to return to previous patterns of drug abuse might not, at first glance, appear particularly significant in the context of felony drug offenders just getting released from prison and the like, research into the importance of self-efficacy, including Albert Bandura's 1977 paper 'Self-Efficacy: Toward a Unifying Theory of Behavioral Change' (as cited by Cherry, 2012), would indicate otherwise.
       However, as Howard (2009) readily admits, definitive statements about the effectiveness of Pharmacological Aversion Treatment in the treatment of substance abuse disorders cannot be made until larger-scale studies are conducted and the results of the present study are replicated (Howard, 2001).

                                                                      References

1). Carroll, K. M., & Onken, L. S. (2005). Behavioral therapies for drug addiction. The American Journal  of Psychiatry, 162(8), 1452-1460. Retrieved from ajp.psychiatronline.org

2). Cherry, K. (2012). What is self-efficacy?. Retrieved from http://psychology.about.com/od/theoriesofpersonality/a/self_efficacy.htm

3). Domjan, M. (2009). Learning and behavior. (6 ed., pp. 80-81, 297). Belmont, CA: Wadsworth, Cengage Learning.

4). Howard, M. O. (2001). Pharmacological aversion treatment of alcohol dependence.i. production and prediction of conditioned alcohol aversion. The American Journal of Drug and Alcohol Abuse,27(3), 561-585. doi: 10.1081/ADA-100104519

5). Schaffer, C. A. (n.d.). Basic facts about the war on drugs. Retrieved from http://druglibrary.net/schaffer/Library/basicfax.htm


6). Slater, R.  (1986). Psychiatric intervention in an atmosphere of terror. American Journal of Forensic Psychiatry,7(1), 5-12.

Penny for [a significant change in your behavior]?

       The first type of behavioral treatment I am going to compare to cognitive behavioral therapy (the prevailing "gold standard" in the treatment of substance abuse disorders) is that of contingency management. In this type of treatment, patients are challenged to achieve a specific behavioral goal (for example, abstinence from a drug of abuse for a specified period of time, as verified by drug urine drug tests performed according to an agreed-upon schedule). This type of behavior modification is based upon principles of behavioral pharmacology and operant conditioning (a type of conditioning in which an organism acts, or "operates" on its environment in a manner that elicits particular positive or negative results) (Carroll & Onken, 2005). The crucial link between contingency management and operant conditioning is the idea, first publicized by Edward Thorndike, that organisms learn something called the "law of effect"- the idea that certain actions lead to desirable results and others to undesirable ones- and that humans, just as laboratory rats and other animals tend to do "what works"- essentially, whatever it is that might help them to obtain the positive results they desire (Cherry 2012).
In the context of contingency management, the hope is that the law of effect (Cherry 2012) would encourage an individual in need of treatment to abandon the previous, maladaptive behaviors in favor of pursuing the rewards offered by the contingency contract largely because "it works;" the rewards offered are significantly more rewarding than continuing to suffer from one's drug dependence.
       Some might argue that drug addicts aren't actually "suffering" from their addictions, and that perhaps they even find their regular drug use pleasant and enjoyable- and that, thus, contingency management would not be an effective means of combating substance abuse, because substance abuse would already be so rewarding in itself that an alternate reinforcing stimulus would have trouble competing with it (Carroll & Onken, 2005).  This view, however, is contradicted by the evidence. In fact, Solomon and Corbit, in their Opponent Process Theory of Motivation (as cited in Domjan 2009), found, among other things, that "... intense emotional reactions are often biphasic. One emotion occurs during the eliciting stimulus, and the opposite emotion is observed when the stimulus is terminated" (Domjan, 2009, p. 59). The evolutionary function of such rapid reversals between affective states would be to keep the human psyche on an "even keel," (Domjan, 2009, 59) in order to allow for maximal processing of important stimuli and optimal problem-solving (Domjan 2009). In the case of drug use, the authors of the study argued, an initial positive state (dominated by what was called an "a process") (Domjan, 2009, p.60), would inevitably later be followed by a equally-intense negative affective state (called a "b-process") (Domjan, 2009, p.60). Over time, (as, for instance, a casual drug user became a full-fledged drug addict), the initial, pleasurable "a-process" (Domjan, 2009, p. 60) (or "high) is followed more rapidly and overcome more completely by the unpleasant "b-process" (Domjan, 2009, p.60). Over time, the effects of the pleasurable a-process (Domjan, 2009, p.60) would be dulled by the buildup of drug tolerance- while the b-process (Domjan, 2009, p.60) would only become increasingly noxious and pursue the a-process (Domjan, 2009, p.60) ever more closely, dominate over its effects ever more noticeably, and linger for increasingly longer periods after the effects of the a-process will have worn away (Domjan, 2009). The cumulative effect of this, according to Solomon and Corbit's theory, would be that drug addicts would eventually gradually transition from having their motivation for drug use be the pursuit of a pleasurable "high" all the way to seeking to pursue the use of drugs simply as part of an effort to dull the debilitating discomfort the b-process (Domjan, 2009, p.60) (or hangover/ withdrawal effect) was causing them (Domjan, 2009). From this, it becomes clear that using a drug, for a substance abuser with an established habit, quickly becomes less and less enjoyable, and is in fact likely to become more of a compelling physiological need and chore than any sort of pleasure over time (Domjan, 2009). Thus, the offer of a reward or other incentive for abstinence, in combination with the offer of free treatment (an opportunity to rid oneself of a habit that, over time, may have become debilitatingly demanding!) may indeed appear to be a very enticing offer to those motivated to rid themselves of an addiction!
       Such a conclusion is also warranted based on empirical evidence; a study by Miller, Klahr, Gold, Cocores, & Sweeney (as cited by Budney, Higgins, Delaney, Kent & Bickel) which investigated "common reasons given for the use of cannabis by persons presenting for cocaine treatment" (Budney et al., 1991, p. 657) concluded common motivations cited by cocaine addicts for their comorbid use of cannabis included: "(a) to counteract cocaine-induced anxiety (b) to relieve cocaine-induced depression (c) to substitute when cocaine is scarce and (d) to use as a primary drug of choice" (Miller et al., as cited by Budney et. al, 1991). The fact that three out of four of the motivations for the use of an entirely separate drug (with all of the costs and possible legal problems the use of an illicit substance would entail) were simply to counteract the negative effects of another illicit drug provides an all-too-vivid illustration of the previously-mentioned opponent-process theory (Domjan, 2009) in action!
       Furthermore, the fact that these individuals were fully aware of the nature of their motivation for using cannabis (as evidenced by their ability to cite clear reasons for doing so), and the fact that they readily admitted that they weren't using it so much for pleasure it might afford them, but rather to counteract the negative effects of cocaine (an idea that doesn't necessarily make much logical sense- "why create for yourself a whole host of legal and possible financial and health problems by introducing another illegal substance into your body to counteract the effects of a first one, instead of simply quitting them both? Isn't such an action, in real of drug addiction, very similar to the irrational phenomenon, of "robbing Peter to pay Paul" in the financial one, with both making very little rational sense?) in itself serves as evidence (albeit indirect evidence) that they don't need the insight into their own thinking and irrational thoughts that cognitive behavioral therapy might provide; rather, it would appear that such individuals would benefit far more greatly from being a part of an organized, systematic behavior-change system; they already know their reasons for making the decisions that they do, and that, for the moment, these are somewhat irrational; the facts just simply don't add up. What they need is help modifying them.
       A particularly promising means of modifying the maladaptive behavior pattens associated with drug abuse seems to be that of a combination of contingency management and what Higgins, Delaney, Budney, Hughes, Foerg, and Fenwick (1991) called a "community reinforcement approach" (Higgins et al. , 1991, p. 1218), the essential idea being a comparison of treatment outcomes (as measured by retention in the treatment program and abstinence from drug use) between a traditionally-used 12-step program and a new approach which combined contingency management and maximizing the patients' participation in their communities, through such means as obtaining and holding down jobs and socializing with friends and neighbors. Not only did the results of their study indicate that the participants involved in the more community-oriented approach did indeed have a greater rate of staying in the program (Higgins et al. 1991), but such a method of intervention also effectively responds to an important criticism that has to date been fired at contingency management as a method of therapy- that of it being overly focused on material gains, which are expensive for therapists and other service providers to supply, and which can't be provisioned indefinitely (Carroll & Onken, 2005). The community resource approach focuses a patient's attention away from such short-term, material gains, and onto rewards- like forging and sustaining lasting friendships and the independence which having a decently-paying job can afford one- which are "rewards" in and of themselves and can last for a lifetime. (Higgins et al. 1991). 
       Another factor which makes such a "modified contingency-management program"(Higgins et al. 1991) more effective is the fact that it relies upon what is called an "variable ratio schedule of reinforcement"(McIntyre, 2002) that is, a reinforcement schedule where a particular behavior (for instance, abstinence from a particular illegal substance, as evidenced by negative urine test screening results) is rewarded when a particular number of desired responses has been generated- but when the participant has no idea of the exact number required or of when the reinforcing stimulus will occur. This type of reinforcement schedule- an example of operant conditioning in action- is also used by casinos for their slot machines, in the expectation that a participant will continue playing the slots for as long as possible in the hopes that "this draw will be the one" (i.e., that "this" specific response- here, input of money- will be the one to trigger the jackpot reward) (McIntyre, 2002). Such a reinforcement schedule will also eliminate the need for giving rewards for each instance of the desired behavior separately- saving service providers a significant amount of money!
   Thus, given the benefits- specifically, those of focusing in on problem behaviors and their modification, rather spending time focusing on patients' maladaptive thought patterns- which the Budney et al. (1991) case study of two cocaine addicts has shown to be not nearly as crucial for the maintenance of a particular behavior as a desire to eliminate strong, physiologically-rooted cravings, and the effectiveness of contingency management, especially when combined with the community research approach mentioned in the Higgins et al. (1991) study, contingency management combined with a community resource approach seems to be a more effective means of therapy for drug addiction than the cognitive behavioral therapy commonly used at this time.

                                                                      References
Budney, A. J., Higgins, S. T., Delaney, D. D., Kent, L., & Bickel, W. K. (1991). Contingent 
                         reinforcement of abstinence with individuals abusing cocaine and marijuana. Journal of 
                         Applied Behavior Analysis, 24(4), 657-665. doi: 10.1901/jaba.1991.24-657. Retrieved 
                         from http://seab.envmed.rochester.edu/jaba/


Carroll, K. M., & Onken, L. S. (2005). Behavioral therapies for drug addiction. The American Journal   
                      of Psychiatry, 162(8), 1452-1460. Retrieved from ajp.psychiatronline.org


Cherry, K. (2012). What is the law of effect?. Retrieved from 
                       http://psychology.about.com/od/lindex/g/lawofeffect.htm


Domjan, M. (2009). Learning and behavior. (6 ed., pp. 59-60). Belmont, CA: Wadsworth, Cengage 
                     Learning.


Higgins, S. T., Delaney, D. D., Budney, A. J., Bickel, W. K., Hughes, J. R., Foerg, F., & Fenwick, J. 
                        W. (1991). A behavioral approach to achieving initial cocaine abstinence. The American 
                        Journal of Psychiatry, 148(9), 1218-1224. Retrieved from 
                        http://ajp.psychiatryonline.org/journal.aspx?journalid=13


McIntryre, T. (2002, January 4). Schedules of reinforcement. Retrieved from 
                       http://www.behavioradvisor.com/SchedulesOfReinforcement.html

What This Is All About

It is my hypothesis that faulty cognitions (as might be addressed by the cognitive behavioral therapy currently used to treat substance abuse) play at most a minor role in the psychology of substance abuse disorders. Thus, it is really the management of behaviors, through such means as contingency contacts, skills training, motivational interviewing, and family-based treatments, that is really crucial to the treatment of these disorders, and the alleviation of human suffering. To this ends, I am reviewing the relevant literature to determine whether or not this is truly the case. If it is, then patients, as well as treatment providers, could benefit significantly from such findings, as could (if there are significant cost-savings involved) the healthcare system more generally!