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  • Dual Diagnosis in Addiction Medicine (May/June)
  • Cognitive Behavioral Therapy for Substance Use Disorders

Cognitive Behavioral Therapy for Substance Use Disorders

The Carlat Addiction Treatment Report, Volume 7, Number 3&4, May 2019
https://www.thecarlatreport.com/newsletter-issue/catrv7n34/

From The Carlat Addiction Treatment Report, May 2019, Dual Diagnosis in Addiction Medicine

Issue Links: Learning Objectives | Editorial Information | PDF of Issue

Topics: Cognitive Behavioral Therapy | Free Articles | Substance Use Disorder

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Cognitive behavioral therapy (CBT) is one of the most widely used psychotherapies. It was developed in the 1960s by Aaron Beck specifically for the treatment of depression, but its core principles were quickly adapted and applied to a variety of diagnoses. We now have evidence-based CBT interventions not only for depression but also for anxiety, PTSD, bipolar disorder, obesity, insomnia, and substance use disorders (SUDs). Here we’ll go through the basic framework of CBT, how it can be applied to SUDs, and ways to incorporate parts of CBT into your daily addiction treatment practice.

CBT overview
The general treatment approach of CBT is to identify problematic thoughts and behaviors, evaluate what is contributing to those thoughts and behaviors, and then apply new skills to change the outcome of a given situation (Beck JS. Cognitive Behavior Therapy: Basics and Beyond. 2nd ed. New York, NY: Guildford Press; 2011). Through this process, negative or irrational core beliefs are identified and then changed over time to positive or rational beliefs. For example, the thought “I am terrible at everything and others are better than me” may become “I have strengths and weaknesses, just like other people.” CBT is problem-focused, meaning that a patient identifies specific areas of improvement and generally works on one problem or situation at a time. CBT is also present-oriented; it does not focus on past developmental experiences. The therapist can be directive, taking on the role of a teacher for skills training. The classic CBT model of individual or group-based therapy takes place over about 12 structured sessions, but the concepts we’ll discuss here can also be used in brief medication management visits.

CBT applied to SUDs
When CBT is applied for the treatment of SUDs, several common treatment themes usually emerge, no matter which substance is being used (McHugh RK et al, Psychiatr Clin North Am 2010;33(3): 511–525). The key components of CBT that are helpful in treating SUDs are functional analysis, which is identifying triggers and high-risk situations, and skill building. Together the provider and patient can pinpoint maladaptive behavior patterns, barriers to change, and skill deficits. Examples include identifying high-risk situations, like driving by a liquor store; a related skill that can be developed may involve taking a different route (avoiding) or reciting reasons to quit when passing by the store (coping). G. Alan Marlatt’s relapse prevention therapy incorporates these aspects of CBT into initiating and maintaining positive behavior change; it has been used to treat SUDs for decades (Hendershot CS et al, Subst Abuse Treat Prev Policy 2011;6:17). One common method of skill building involves role-playing exercises between the provider and patient. For instance, the patient may identify a high-risk situation at school or work that involves pressure to use substances. The provider can take on the role of the fellow student or coworker while the patient practices different ways of handling the situation.

12-step programs commonly use CBT techniques when dealing with external and internal triggers for substance use (https://sobernation.com). For external triggers, think of people, places, and things: social contacts the patient hung out with, the place the patient was buying or using drugs, and things associated with the drug use like paraphernalia or favorite drinking glasses. External triggers can even be sensory, like sounds or smells the patient associates with drug use. Internal triggers can be explained using the 12-step acronym of HALT: Hunger, Anger, Lonely, and Tired—all common states that can trigger use. When a craving occurs, patients should stop and evaluate whether they are in one of the HALT states, and then take steps to fix the HALT situation instead of turning to substances. This requires using the CBT techniques of identifying the behavior pattern (functional analysis) and then substituting a positive behavior for the negative one (skill building). For instance, carrying around healthy snacks can stop hunger, having go-to meditation exercises can soothe anger, reaching out to a trusted friend or sponsor can address loneliness, and napping or taking time to relax can help deal with feeling tired.

Does it work?
Do these CBT interventions actually work to decrease a patient’s substance use? The evidence for CBT has been mounting since the 1980s, and a 2009 ­meta-analysis looked at 53 studies of CBT specifically for SUDs (Magill M and Ray LA, J Stud Alcohol Drugs 2009;70:516–527). Across all studies, there was a small but significant effect size of 0.144, p < 0.005. When breaking the studies down for type of substance, CBT had a small significant treatment effect for each, except for marijuana use where the effect size was moderate at 0.513, p < 0.005. Effect sizes increased when CBT was combined with other psychosocial treatment (0.305, p < 0.005) or with medication management (0.208, p < 0.005). The largest effect size of 0.796, p < 0.005, was seen with the studies that compared CBT to no treatment at all.

Incorporating CBT into your practice
While many of your patients may not have the time or resources to attend a course of structured CBT sessions, there are many ways to incorporate CBT concepts into your daily practice. When patients are in the early stages of change, motivational interviewing can bring them closer to the action stage, and then CBT techniques can be used to learn and practice specific skills to promote and maintain recovery. This can be as simple as asking about triggers for their substance use (functional analysis), then thinking about ways of avoiding or coping with those triggers (skill building). Other skills that can be improved upon in a brief clinical visit include communication skills with friends and family, coping skills for emotional regulation, identifying pleasurable sober activities to replace substance use, and ­goal-setting (eg, deciding on a quit date). Also, know when to refer a patient for a full CBT course. If you have someone who is ready to learn new skills, capitalize upon that motivation by connecting the patient with group or individual therapy providers.

To learn more about structured CBT sessions and how to incorporate the basics of functional analysis and skill building into your practice, there are some free resources available online. While CBT skills can be applied to recovery from any substance, the National Institute on Alcohol Abuse and Alcoholism has a guide specifically for alcohol use disorder treatment (https://archives.drugabuse.gov/sites/default/files/cbt.pdf). The National Institute on Drug Abuse has a similar guide for cocaine use disorder (https://pubs.niaaa.nih.gov/publications/projectmatch/match03.pdf). Finally, for other ideas on how to incorporate CBT techniques into a medication management visit, the APA offers a book worth checking out (Wright JH, Sudak DM, Turkington D, Thase ME, eds. High-Yield Cognitive-Behavior Therapy for Brief Sessions: An Illustrated Guide. Arlington, VA: American Psychiatric Association Publishing; 2010).

CATR Verdict: CBT skills are easy to learn and evidence-based to promote recovery from addiction. It’s definitely worth the time to familiarize yourself with the core concepts of functional analysis and skill building. Learn a few CBT exercises that are high-yield for your patient population as part of your clinical arsenal. These CBT interventions can easily be incorporated into the time frame of medication management visits.

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Medication Fact Book for Psychiatric Practice, Sixth Edition (2022)
2022 Carlat Psychiatry Report Self-Assessment Course
Prescribing Psychotropics: From Drug Interactions to Genetics
The Child Medication Fact Book for Psychiatric Practice (2018)
Issues Archives

2022

  • Alcohol Use Disorder (March/April)
  • Smoking Cessation (January/February)

2021

  • Opioid Epidemic Update (November/December)
  • Designer Drugs (September/October)
  • Addiction in Pregnancy (July/August)
  • Stimulant Use Disorder (May/June)
  • Integrating Pharmacotherapy and Psychotherapy (March/April)
  • Pain and Addiction (January/February)

2020

  • Esketamine (January)
  • Telepsychiatry (May)
  • Mind-Gut Connection (January)
  • Practical Psychotherapy (November/December)
  • Mood and Menopause (October)
  • When to Use Lithium (September)
  • Traumatic Brain Injury (August)
  • Borderline Personality Disorder (June/July)
  • Psychopharmacology Algorithms (April)
  • Bipolar II (March)
  • Inflammation and Depression (February)

2020

  • Mood Disorders in Children and Adolescents (Oct/Nov/Dec)
  • Identity & Culture in Children and Adolescents (July/August/September)
  • Psychosis in Children and Adolescents (April/May/June)
  • ADHD in Children and Adolescents (Jan/Feb/Mar)

2020

  • Harm Reduction (January/February)
  • Substance Use in Health Professionals (March/April)
  • Alternative Treatment in Addiction (November/December)
  • Social Aspects of Addiction (September/October)
  • Opioid Use Disorder Treatment (July/August)
  • Emerging Risks for Old Medications (May/June)

2019

  • Depression (May)
  • Adult ADHD (November/December)
  • Mental Health Apps (October)
  • How to Talk about Medication (September)
  • Side Effects Part II (August)
  • Side Effects Part I (June/July)
  • Sleep (April)
  • Parenting, Pregnancy, and Prevention (March)
  • Dark and Light Therapy (February)
  • Deprescribing (January)

2018

  • Drug Metabolism (November/December)
  • Working With Transgender Patients (October)
  • Emergency Psychiatry (September)
  • Treatment-Resistant Depression (July/August)
  • Neurobiology (June)
  • Anxiety (May)
  • Neurofeedback (April)
  • Antipsychotics Update (March)
  • Working With Families (February)
  • Bipolar Disorder (January)

2017

  • PTSD (December)
  • Retirement (November)
  • Intellectual Disability (September/October)
  • Antidepressants (July/August)
  • Personality Disorders (June)
  • Dementia (May)
  • Cognitive Behavior Therapy Techniques (April)
  • Pharmacogenetics (March)
  • Treating Psychosis (February)
  • Adult ADHD (January)

2016

  • Complementary and Alternative Medicine in Psychiatry (November/December)
  • Side Effects (October)
  • Pain Management (September)
  • Medication in Pregnancy (July/August)
  • Psychoanalysis in Modern Psychiatry (June)
  • Correctional Psychiatry (May)
  • Antidepressant Roundup (April)
  • Burnout (March)
  • Private Practice (February)
  • Bipolar Disorder (January)

2015

  • Psychiatry and General Medicine (November/December)
  • Biomarkers in Psychiatry (May)
  • Telepsychiatry (October)
  • Sleep Disorders (September)
  • Interventional Psychiatry (July/August)
  • Eating Disorders (June)
  • Psychotherapy Updates (April)
  • Topics in Geriatric Psychiatry (March)
  • Antipsychotics Update (February)
  • Risk Management (January)

2014

  • Bipolar Disorder (November/December)
  • Pharmacogenetics (October)
  • Keeping up in Psychiatry (September)
  • Research in Psychiatry (July/August)
  • Marijuana (June)
  • Psychiatric Diagnosis (May)
  • Issues in Psychopharmacology (April)
  • Schizophrenia (March)
  • Women’s Psychiatry (February)
  • Ethics in Psychiatry (January)

2013

  • Military Psychiatry (December)
  • Depression (November)
  • Treatment of Dementia (October)
  • Anxiety Disorders (September)
  • Natural and Alternative Treatments in Psychiatry (July/August)
  • Autism Spectrum Disorder (June)
  • Practice Tips (May)
  • Substance Abuse (April)
  • Medicolegal Topics (March)
  • End of Life Care (February)
  • Antipsychotic Update (January)

2012

  • Screening Tools and Tips (December)
  • Medical Comorbidities (November)
  • Devices in Psychiatry (October)
  • Eating Disorders (September)
  • Bipolar Disorder (July/August)
  • Risk Management (June)
  • Antidepressant Roundup 2012 (May)
  • Gender and Sexuality (April)
  • Personality Disorders (March)
  • ADHD (February)
  • Natural Treatments in Psychiatry (January)

2011

  • Electronic Medical Records (December)
  • Insomnia (November)
  • Psychotherapy (October)
  • Alcoholism (September)
  • Anxiety Disorders (July/August)
  • Schizophrenia (June)
  • Managing Side Effects (May)
  • Antidepressant Roundup 2011 (April)
  • DSM-5 and Diagnostic Issues (March)
  • Drug-Drug Interactions (February)
  • Bipolar Disorder (January)

2010

  • Hospital Psychiatry (December)
  • Psychiatric Medication in Pregnancy (November)
  • Maintenance of Certification (October)
  • The Neuroscience of Psychotherapy (September)
  • Treatment of Depression (July/August)
  • Email and the Internet in Psychiatry (June)
  • Substance Abuse (May)
  • The Diagnosis and Treatment of Dementia (April)
  • Ethics in Psychiatry (March)
  • Natural Treatments in Psychiatry (February)
  • ADHD (January)

2009

  • Treating Schizophrenia (December)
  • Treatment for Anxiety Disorders (November)
  • The Latest on Antidepressants (October)
  • Topics in Neuropsychiatry (September)
  • The Interface of Medicine and Psychiatry (July/August)
  • Generic Medications in Psychiatry (June)
  • The Treatment of Eating Disorders (May)
  • Healthcare Policy and Psychiatry (April)
  • Antipsychotic Roundup 2009 (March)
  • Psychiatric Medication in Pregnancy and Lactation (February)
  • Transcranial Magnetic Stimulation (January)

2008

  • Treating Fibromyalgia and Pain in Psychiatry (December)
  • Issues in Child Psychiatry (November)
  • Improving Psychiatric Practice (October)
  • Treating Personality Disorders (September)
  • Bipolar Disorder (July/August)
  • Antipsychotic Roundup 2008 (June)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Neuropsychological Testing (May)
  • Psychiatric Medications: Effects and Side Effects (April)
  • Update on Substance Abuse (March)
  • Anticonvulsants in Psychiatry (February)
  • Brain Devices in Psychiatry (January)

2007

  • The Treatment of Insomnia (December)
  • Avoiding Malpractice in Psychiatry (November)
  • Update on Eating Disorders (October)
  • Complex Psychopharmacology (September)
  • Laboratory Testing in Psychiatry (August)
  • Psychotherapy in Psychiatry (July)
  • Posttraumatic Stress Disorder (June)
  • Topics in Geriatric Psychiatry 2007 (May)
  • Pregnancy and Menopause in Psychiatry (Apil)
  • Antipsychotic Roundup 2007 (March)
  • Understanding Psychiatric Research (February)
  • Antidepressant Round-up 2007 (January)

2006

  • Technology and Psychiatric Practice (December)
  • The Use of MAOIs (November)
  • Medication Treatment of Depression (January)
  • Seasonal Affective Disorder (October)
  • Treatment of ADHD (September)
  • Topics in Bipolar Disorder (August)
  • Neurotransmitters in Psychiatry (July)
  • Treating Substance Abuse (June)
  • The STAR*D Antidepressant Trial (May)
  • Natural Treatments in Psychiatry (April)
  • Medication Treatment of Anxiety (March)
  • Panic Disorder: Making Treatment Work (March)
  • Antipsychotic Roundup 2006 (February)
  • Antidepressant Roundup 2006 (January)

2005

  • Self-Help Books and Psychiatry (December)
  • Genetics and Psychiatry (November)
  • Pregnancy and Psychiatric Treatment (October)
  • Benzodiazepines and Hypnotics in Psychiatry (September)
  • Geriatric Psychiatry Update (August)
  • Chart Documentation in Psychiatry (July)
  • The Treatment of Bipolar Disorder (June)
  • Weight Loss and Smoking Cessation in Psychiatry (May)
  • Treating ADHD (April)
  • Drug Industry Influence in Psychiatry (March)
  • Atypical Antipsychotics 2005 (February)
  • Antidepressant Roundup 2005 (January)

2004

  • Sexual Dysfunction (December)
  • Suicide Prevention (November)
  • To Sleep, To Awake (October)
  • Women’s Issues in Psychiatry (September)
  • OCD: An Update (August)
  • Chronic Pain and Psychiatry (July)
  • Neuroimaging in Psychiatry (June)
  • Natural Medications in Psychiatry (May)
  • Posttraumatic Stress Disorder (April)
  • Treatment of Alcoholism (March)
  • Battle of the Atypicals (February)
  • Antidepressant Roundup, 2004 (January)

2003

  • Research Methods in Psychiatry (December)
  • Antidepressants in Children (November)
  • The Treatment of Dementia (October)
  • Bipolar Disorder, Part II: The Novel Anticonvulsants (September)
  • Bipolar Disorder: The Basics (August)
  • Drug-Drug Interactions in Psychiatry (July)
  • Managing Antidepressant Side Effects (June)
  • Antidepressants in Pregnancy and Lactation (May)
  • ADHD: Medication Options (April)
  • Panic Disorder: Making Treatment Work (March)
  • Atypical Antipsychotics in Clinical Practice (February)
  • Medication Treatment of Depression (January)

2019

  • Autism in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (May/June/July/August)
  • Substance Use in Children and Adolescents (September/October)
  • Trauma in Children and Adolescents (March/April)
  • Anxiety in Children and Adolescents (January/February)

2018

  • Psychotropic Risks in Children and Adolescents (May/June)
  • ADHD in Children and Adolescents (November/December)
  • Depression in Children and Adolescents (September/October)
  • Autism in Children and Adolescents (July/August)
  • Anxiety in Children and Adolescents (March/April)
  • Suicide in Children and Adolescents (January/February)

2017

  • Adolescents (November/December)
  • ADHD in Children and Adolescents (September/October)
  • Psychosis in Children and Adolescents (August)
  • PANDAS, PANS, and Related Disorders (June/July)
  • Marijuana in Children and Adolescents (May)
  • Tourette’s and Other Tic Disorders in Children and Adolescents (March/April)
  • Autism in Children and Adolescents (January/February)

2016

  • Gender Dysphoria in Children and Adolescents (November/December)
  • Technology Issues With Children and Adolescents (September/October)
  • Mood Dysregulation in Children and Adolescents (July/August)
  • Eating Disorders in Children and Adolescents (May/June)
  • Conduct Disorder in Children and Adolescents (April)
  • Sleep Disorders in Children and Adolescents (March)
  • ADHD in Children and Adolescents (January/February)

2015

  • Antidepressant Use in Children (November/December)
  • Foster Care and Child Psychiatry (September/October)
  • Autism (July/August)
  • Trauma (May/June)
  • Anxiety Disorders (April)
  • Schools and Psychiatry (March)
  • Emergency Psychiatry in Children (January/February)

2014

  • Antipsychotics in Children (December)
  • ADHD (November)
  • Gender and Sexuality (September/October)
  • Psychotic Symptoms (Summer)
  • Medication Side Effects (May)
  • Food and Mood (April)
  • Learning and Developmental Disabilities (February)

2013

  • Complex Practice Issues (December)
  • Diet and Nutrition (November)
  • Child Psychiatry in DSM-5 (August/September)
  • Medication Side Effects and Interactions (June/July)
  • Problematic Technology (March/April)
  • Autism Spectrum Disorders (January/February)

2012

  • Bipolar Disorder (December)
  • Substance Abuse (October/November)
  • Transitional Age Youth (July/August)
  • Rating Scales (May/June)
  • Eating Disorders (March/April)
  • Behavioral Disorders (February)

2011

  • Treatment of Anxiety Disorders (December)
  • Trauma (November)
  • Bullying and School Issues (October)
  • Hidden Medical Disorders (August)
  • OCD and Tic Disorders (June)
  • Suicide and Non-Suicidal Self Injury (April)
  • Sleep Disorders (March)
  • ADHD (January)

2010

  • Use of Antipsychotics in Children and Adolescents (December)
  • Learning and Developmental Disabilities (October)
  • Major Depression (September)
  • Treating Children and Families (July)
  • The Explosive Child (May)

2019

  • Dual Diagnosis in Addiction Medicine (May/June)
  • Medical Issues in Addiction Practice (November/December)
  • Alcohol Addiction (September/October)
  • Legal Issues in Addiction Medicine (July/August)
  • Traumatic Brain Injury and Addiction (March/April)
  • Board Certification in Addiction Medicine (January/February)

2018

  • Opioid Addiction (November/December)
  • Addiction in Older Adults (October)
  • Sleep Disorders and Addiction (September)
  • Adolescent Addiction (July/August)
  • Pain and Addiction (May/June)
  • Cannabis and Addiction (March/April)
  • Stigma and Addiction (January/February)

2017

  • Pregnancy and Addiction (November/December)
  • Detox (Sepember/October)
  • Dual Diagnosis (August)
  • Alternatives to 12-Step Programs (June/July)
  • Recovery (May)
  • Psychiatric Uses of Street Drugs (March/April)
  • Sex Addiction (January/February)

2016

  • Prescription Drug Monitoring Programs (PDMPs) (November/December)
  • Addiction in Health Care Professionals (September/October)
  • Dialectical Behavior Therapy in Addiction (August)
  • Motivational Interviewing (June/July)
  • Benzodiazepines (May)
  • Opioid Addiction (March/April)
  • Families and Substance Abuse (January/February)

2015

  • The Twelve Steps (November/December)
  • Designer Drugs (September/October)
  • Residential Treatment Programs Decoded (July/August)
  • Nicotine and E-Cigarettes (June)
  • Drug Screening (April/May)
  • Integrating Therapy and Medications for Alcoholism (March)
  • Detoxification Protocols (January/February)

2014

  • Behavioral Addictions (December)
  • Risk and Reimbursement (November)
  • Stimulant Abuse (September/October)
  • Self-Help Programs (June)
  • Opioid Addiction (May)
  • Coping with Bad Outcomes (March)
  • Change Management in Addiction Treatment (January/February)

2013

  • Cocaine Addiction (December)
  • Relapse Prevention (November)
  • Cannabis Addiction (August/September)
  • Addiction in DSM-5 (June/July)
Editor-in-Chief

Noah Capurso, MD, MHS

Dr. Capurso is an assistant professor of psychiatry at the Yale University School of Medicine and practices clinically at the West Haven Veterans Administration Hospital. He attended medical school at Yale, where he received his MD, and where he conducted research in the Department of Biomedical Engineering. He stayed at Yale for residency and addiction psychiatry fellowship training. As an educator, Dr. Capurso teaches medical students about addiction treatment and develops the psychiatric curriculum for residents. As a clinician, Dr. Capurso is the medical director of the VA’s Detoxification & Addiction Stabilization Service and the Psychosocial Residential Rehabilitation Program.

Full Editorial Information

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