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Library of Congress Cataloging-in-Publication Data
Addictive behaviors: new readings on etiology, prevention, and treatment / edited by G. Alan
Marlatt and Katie Witkiewitz. 1st ed.
p.; cm.
"Reprinted from American Psychological Association joumals."
Includes bibliographical references and index.
ISBN-13:978-1-4338-0402-1
ISBN-10:1-4338-0402-6
1. Substance abuse. 2. Compulsive behavior. I. Marlatt, G. Alan. II. Witkiewitz, Katie.
III. American Psychological Association.
[DNLM: 1. Substance-Related DisordersetiologyCollected Works. 2. Behavior,
AddictiveCollected Works. 3. Substance-Related Disordersprevention & control
Collected Works. 4- Substance-Related DisorderstherapyCollected Works. WM 270
A22473 2009]
RC564.A314 2009
362.29^Ic22
2008014394
British Library Cataloguing-in-Publication Data
A CIP record is available from the British Library.
Printed in the United States of America
First Edition
CONTENTS
Contributors
xi
Introduction
G. Alan Marlatt and Katie Witkiewitz
Chapter 2.
17
19
33
Chapter 4.
Chapter 5.
57
59
89
117
135
Chapter 6.
137
Chapter 7.
Chapter 8.
VI
CONTENTS
159
187
197
199
Chapter 10.
Chapter 12.
VI.
257
Chapter 13.
Chapter 14.
Chapter 15.
225
259
287
321
CONTENTS
323
343
367
vn
Chapter 17.
Chapter 18.
Chapter 19.
Chapter 20.
Chapter 21.
Chapter 22.
vm
401
403
429
459
CONTENTS
497
515
537
559
Chapter 24.
Chapter 25.
Chapter 26.
573
575
623
657
677
Author Index
713
Subject Index
751
777
CONTENTS
IX
CONTRIBUTORS
Sally O. Cressler
Lillian H. Cummins
Thomas J. Dishion
Brad Donohue
Elizabeth Egan
William Fals-Stewart
Charles B. Fleming
Stephen J. Glatt
Maryann Gnys
Enoch Gordis
Chad J. Gwaltney
Kevin P. Haggerty
Elizabeth H. Hawkins
Mary Hickcox
Brian M. Hicks
William G. lacono
Kristina M. Jackson
Jon D. Kassel
Kevin M. King
Robert D. Abbott
David B. Abrams
John S. Baer
Mark H. Balabanis
Danielle Barry
Marsha E. Bates
Jack Blaine
Eric C. Brown
Sandra A. Brown
Jennifer F. Buckman
S. Alexandra Burt
Scott R. Carlson
Richard F. Catalano
Laurie Chassin
Howard D. Chilcoat
Richard Clayton
Allan Cohen
Judith L. Cooney
Ned L. Cooney
XI
Serena M. King
Kimberly Kirby
Ken Kolodner
Joseph Krasnansky
Robert F. Krueger
Erich W. Labouvie
William W. Latimer
Noelle L. Lefforge
Carl Leukefeld
Rui Li
Mark D. Litt
Kenneth S. Liu
TK Logan
Susan E. Luczak
Donald R. Lynam
Robert J. MacCoun
Stephen M. Malone
The Marijuana Treatment Project
Research Group
G. Alan Marlatt
Catherine Martin
Silvia S. Martins
Guido Mazzotti
Matt McGue
Jane Metrik
Richard Milich
Elizabeth T. Miller
William R. Miller
Rudolf H. Moos
Dan J. Neal
XH
CONTRIBUTORS
Raymond Niaura
Scott P. Novak
Cheryl A. Oncken
Lee D. Owen
Christopher J. Patrick
Jean A. Paty
Jessica Peirce
Nancy M. Petry
David T. Pilkey
Lisa J. Roberts
John Roll
James M. Sandy
John E. Schulenberg
Kenneth J. Sher
Saul Shiffman
Ori Shinar
Howard R. Steinberg
Randy D. Stinchfield
Maxine L. Stitzer
Marilyn J. Strada
Ryan Vandrey
Gerald Voelbel
Tamara L. Wall
Thomas Ashby Wills
Ken C. Winters
Katie Witkiewitz
Alison Yaeger
Qing Zhou
Rick Zimmerman
Addictive Behaviors
INTRODUCTION
G. ALAN MARLATT AND KATIE WITKIEWITZ
The expansion of available treatment goals is also a noteworthy development of the past decade. Traditional abstinence-only or "high-threshold"
intervention programs are typically based on the disease model of addiction
and a 12-step program for recovery. More recently, clients who are unwilling
or unable to make a commitment to abstinence have been offered altemative
treatment goals (an approach known as h^irm reduction). Originally associated
with interventions for IV dmg users such as needle exchange (to reduce the
potential harm of HIV infection) or methadone maintenance (to reduce the
risk of overdose or other problems associated with illegal drug use), harm
reduction strategies have been applied to other high-risk addictive behaviors
such as problem drinking (e.g., moderation management, brief alcohol
screening and intervention for college students). Harm reduction therapy is
a low-threshold approach that is willing to "meet people where they are at"
instead of a confrontational top-down approach that mandates treatment
goals that require total abstinence for successful recovery.
The addictive behaviors treatment field is also working to develop an
integrated treatment approach for working with clients who are experiencing
co-occurring substance abuse and mental health problems. Many clients that
we see in our clinical programs are using alcohol and/or other dmgs to selfmedicate other personal problems such as anxiety, depression, or personality
disorders. Typically, such clients are referred back and forth between mental
health professionals ("You are drinking excessively because you are trying to
reduce the intensity of your depression symptoms") and substance abuse treatment professionals ("Your depression is caused by your alcoholism"). Such
clients often fall between the cracks of these frequently opposing professional
perspectives and may give up and drop out of treatment altogether. As a
result, there is a strong need to provide an integrated treatment approach, one
that ties together both sides of the presenting problem, and offers a flexible
approach to choosing treatment goals (including both harm reduction and
abstinence).
INTRODUCTION
in adolescence (Part IV); (e) the role of familial factors, including family
history of addiction (Part V); (f) the screening and assessment of addictive
behaviors (Part VI); (g) treatment approaches and models of addiction
(Part VII); and (h) addictive behaviors in specific populations (Part Vlll).
We started with abstracts from every article published in APA journals since 1997 that were related to the topic of addictive behaviors. This
voluminous list was then reduced to 86 articles that were deemed "exceptional" by the editors, three advanced graduate students (Sharon Hsu,
Diane Logan, and Joel Grow), and one postdoctoral fellow (Susan Collins)
at the University of Washington, Seattle. A final selection of 26 articles
was chosen for this collection. Because of space limitations and to avoid
overlap of topic areas, many excellent and ground-breaking articles were
left out of the final selection.
Role of Psychology and Behavioral Science
in Addiction Research and Treatment
Part I of the book contains two chapters written by top researchers in
the field of addictive behaviors. Enoch Gordis (chap. 1), former director of
the National Institute of Alcohol Abuse and Alcoholism, provides a thorough overview of the role of behavioral science in the prevention and treatment of alcohol use disorders. He highlights genetics research, gaining
knowledge of neural systems, and medications development as important for
elucidating the relationship between biology and behavior as well as how
advances in these areas will improve the efficacy and effectiveness of alcohol
prevention and intervention methods. Gordis also describes fiiture challenges
for behavioral scientists, all of which are still relevant today: diagnostic issues,
adolescent drinking, the role of stress hormones, and increasing biobehavioral
(including neural systems) and etiology research.
The chapter by W. R. Miller and Brown (chap. 2) makes a compelling
case for how and why psychologists, who may or may not have formal addictions training, can and should provide assessment and treatment of addictive
behaviors. The chapter focuses on the qualities and special expertise of
psychologists that make them suited for working with individuals who have
alcohol and/or drug problems. Substance use disorders are the most prevalent
form of mental health problem and frequently co-occur with other mental
health disorders. Thus, psychologists who treat other psychological problems
will likely have several clients who are also struggling with an addictive
behavior. Fortunately, many studies have shown that basic clinical skills
(e.g., empathy, reflection) are predictors of favorable treatment outcomes.
W. R. Miller and Brown also address some of the barriers for psychologists in
the routine treatment of substance use disorders and provide several recommendations for future training and research.
INTRODUCTION
MacCoun (chap. 6) addresses the American dmg policy and a framework for
integrating strategies to reduce harmful consequences of substance use and
other behaviors. The strategies described in the articleprevalence reduction, quantity reduction, and harm reductionhave been evaluated quite
differently in the domain of drug control, where the primary strategy has
traditionally been "use reduction" via strict prohibition and enforcement. As
of 2006, the Department of Justice had reported that 53% of federal prison
inmates were drug offenders, and the trend of increased prison populations
due to dmg-related convictions continues. MacCoun takes a "frank look" at
opposition to harm reduction and provides hypotheses for making harm
reduction more successful and palatable.
The most effective and cost-saving way to reduce harm from substance use is through prevention. In the 1990s there was a flurry of largescale preventive interventions targeting youth development and substance
use. One such intervention, the Raising Healthy Children project, was
designed to target developmentally appropriate risk and protective factors
by implementing, school-, student-, and family-level intervention strategies that were targeted to the developmental stage of the child. Brown,
Catalano, Fleming, Haggerty, and Abbott (chap. 7) examined the developmental trajectories of substance use from Grades 6 through 10 in 959
participants in this project. Using an innovative growth modeling strategy,
the authors report that the intervention was effective in reducing the
frequency of both alcohol and marijuana use during these years but not
eliminating use entirely. Returning to the idea of harm reduction. Brown
et al. conclude that although the intervention did not prevent use, it did
potentially reduce the harm that has been associated with frequent substance use in adolescence.
In the final chapter of this section, Lynam et al. (chap. 8) examine
10-year outcomes of the most widely disseminated and ineffective drugprevention program in the United States, Project Drug Abuse Resistance
Education (DARE). DARE is a federally funded, school-based education
program, which is delivered by uniformed police officers over 17 weekly sessions. Despite the widespread popularity ofthe program and the federal cost
of implementing it, several outcomes studies have concluded that DARE
has no short-term effects on actual drug use. Lynam et al. examine the
affects of DARE (compared with a standard drug-education curriculum) on
drug use in 1,002 individuals 10 years after they received the DARE
curriculum. As in nearly all studies to date, the chapter concludes that
DARE is not effective at reducing drug use or changing attitudes toward
drug use. The authors provide some potential reasons why DARE advocates
persist in promoting the program despite the overwhelming evidence that
the program is not efficacious.
INTRODUCTION
alcohol on offspring substance use dependence and family harmony as a protective factor related to decreased dmg dependence during young adulthood.
In addition, the authors show that family harmony during adolescence partially mediated the direct effect of family history on young adult development
of substance use dependence.
In the second chapter. Wills, Sandy, Yaeger, and Shinar (chap. 12) provide a slightly different slant by examining potential moderators of adolescent
substance use, including family risk factors and a variety of temperament characteristics. The application of latent growth modeling to test moderation
effects, a large sample size (N = 1,810), and obtaining information from multiple reporters (adolescents and teachers) are particular strengths of the study.
The chapter reports that family relationships and family stress are significant
and unique predictors of adolescent and peer substance use. In addition, several
temperament factors were found to moderate this association. For adolescents
with positive emotionality and task attention, the relationship was weakened,
whereas for those adolescents with high negative emotionality and high activity level the impact of family risk factors was heightened. The chapter concludes by examining these opposing resiliency and vulnerability effects within
a broad theoretical context.
Screening and Assessment
As described above, one of the most notable changes since the publication of the Addictive Behaviors Reader in 1997 is the advances in computing
technology and an exponential increase in the number of Internet users.
Since the early 1990s, researchers have been incorporating Web-based computer technology and handheld computers as useful research tools, and the
applications of computing to research questions have greatly expanded our
ability to gather large amounts of data from a wide variety of people. The first
and third chapters in Part VI describe two such applications. E. T. Miller et al.
(chap. 13) conducted the first test-retest reliability study comparing Internetbased assessment and traditional paper-based methods of assessment. The
authors conducted two assessments within 1 week in which 255 participants
were randomized to complete either Intemet or paper-based assessments.
The results strongly support the test-retest reliability of Internet-based assessment and show no differences between assessment techniques, suggesting that
Internet-based methods are a suitable and cost-efficient altemative to traditional paper-based measures.
Advances in statistical software are evident in the second study in Part
VI. Fals-Stewart and Bates (chap. 14) examine the neuropsychological functioning of 587 participants recruited from substance use treatment programs
using a multimethod approach and latent variable modeling. The authors
describe four cognitive factors (executive, verbal, speed, and memory) that
J0
INTRODUCTION
JI
participants did not lapse to alcohol use during the monitoring period, but
the abstinence rates for smoking were 5.8% and 24.0% for brief and intensive
treatments, respectively. Momentary predictors of thefirstdrink andfirstcigarette included urges to smoke and drink, self-efficacy, and mood. The data
also provided evidence that alcohol urges increased following smoking
episodes, supporting a cross-substance cue reactivity model. These are exciting data and future research needs to be conducted to extend the EMA
follow-up period fiirther.
In the next chapter in this section. Moos (chap. 21) ponders the seven
principles and unresolved puzzles of effective addictive behavior treatment
and recovery processes. He provides a detailed review of research studies that
have either provided support or refuted the prevailing wisdom in addiction
treatment. In conclusion. Moos provides a brief discussion of the concems
commonly voiced by clinical providers who are often least familiar and most
suspicious of "evidence-based" treatments. In many ways, this chapter is
essential reading for all psychologists who are practitioners treating or
researchers researching addictive behavior.
In the final treatment approach chapter, Stitzer et al. (chap. 22) describe
an innovative and evidence-based treatment for stimulant abuse and dependence. The introduction of incentives as part of addiction treatment was based
on a basic behavioral principle: If a behavior is reinforced, it is more likely to
occur in the fiiture. Starting in the early 1990s, researchers began to systematically evaluate whether providing incentives, a treatment called contingency
management, would result in lasting changes beyond the period when incentives for behavior were stopped. According to behavioral theory, there will be
decay of the behavior after reinforcement ceases, and this has commonly
been found to be the case in addiction treatment. Stitzer et al. look at a specific aspect of contingency management within a sample of 386 methadone
maintenance patients. The question they address is whether intake stimulant
test results (i.e., providing stimulant negative or positive urine tests at the
initiation of treatment) would mediate the relationship between incentives
and treatment outcomes. Analyses reveal that both groups of individuals
(stimulant positive and stimulant negative at intake) reported reduced duringtreatment dmg use relative to a non-incentive-based control condition. The
results from this particular study mn contrary to a commonly held belief that
incentives should only be offered for individuals with less severe dmg abuse.
Issues in Specific Populations
In Part VIII, the final section of the book, four chapters examine issues for
specific populations with substance abuse problems. As identified by Gordis in
the first chapter of this collection, understanding and preventing adolescent
substance use is an enormous challenge for addictive behaviors researchers and
INTRODUCTION
13
clinicians. Thus, for the first three chapters in this section, we included articles
that focused on adolescent populations. In thefirstchapter of Part VIII, Hawkins,
Cummins, and Marlatt (chap. 23) provide a thorough literature review on preventing substance use in American Indian and Alaskan Native adolescents. In
thefirstsection ofthe chapter, the authors provide an introduction to substance
use prevalence rates as well as risk and protective factors for abusing specific
substances among Native populations. In the last two sections Hawkins et al. provide a review of prevention efforts and offer recommendations for fiiture research
and preventive strategies that are most promising for substance abuse prevention
among Native adolescents. The chapter concludes with a description of a
program that was codeveloped by researchers at the University of Washington
and Native eldersfi-omthe Seattle Indian Health Board. The "Canoe Joumey"
is a culturally congment prevention program that is unique to the cultural experiences of tribes in the Pacific Northwest. Drawing on the Northwest Native
tradition of the canoe joumey, a metaphor was constmcted in which the canoe
joumey, as well as other Native symbols, served as a metaphor to teach skills such
as communication, decision making, and goal setting as well as providing information about alcohol and dmg use and its consequences.
The Hawkins et al. chapter provides a convincing example of how
ethnicity and cultural values should be incorporated into treatment of substance use as well as how an existing prevention program can be successfiilly
modified to accommodate culturally relevant variables. In counterpoint to the
Hawkins chapter, Strada, Donohue, and Lefforge (chap. 24) provide a comprehensive review of how poorly the field has responded to this need. The
authors reviewed 18 adolescent dmg treatment outcome studies to examine
whether ethnicity was systematically incorporated into the analysis or interpretation of findings across all studies. In total, 94% ofthe studies mentioned
ethnicity to some extent and 28% incorporated ethnicity into their design, but
only 6% of studies included specific analyses to examine ethnicity as a potential moderator of treatment responding. The authors conclude that the addictive behaviors research community needs to invest energy in the examination
of ethnicity in existing controlled outcome studies and the development or
adaptation of treatments to accommodate culture-relevant variables.
Winters, Latimer, Stinchfield, and Egan (chap. 25) focus specifically on
the validation of a multiscale assessment tool for adolescent dmg abusers called
the Personal Experience Inventory, which was primarily developed in White
samples. The authors sampled 3,191 adolescent boys (13 to 18 years old) fi'om
30 different adolescent dmg abuse programs, representing four groups: White,
African American, Native American, and Hispanic. Although the results
do provide strong support for the validity and commonality of the Personal
Experience Inventory across ethnic groups, there were discrepancies across all
ethnic groups on test-retest reliability in which some scales had inadequate reliability and some had discrepancies on response probabilities and distortions.
14
In the final chapter of this collection, Luczak et al. (chap. 26) provide
an update and meta-analysis of two genes, ALDH2 (aldehyde dehydrogenase) and ADH IB (alcohol dehydrogenase), which have been shown to
offer protection from alcohol dependence, particularly among Northeast
Asian populations. The chapter reviews the genetic influence and the
potential mediators and moderators for the effects of these genes on alcohol dependence. In general, the authors conclude that an additive model of
genetic influence (in which one gene allele is good and possession of two
gene alleles is even better) provides an appropriate means for modeling
the relationship between ALDH2 and alcohol dependence, whereas a partial dominant or dominant model explains the influence of ADHIB. The
article also describes several moderators of these effects, including being
Japanese, recruiting samples from treatment settings, and gender (with men
showing greater protection from ADHIB). It is interesting that this finding
is consistent with the results from King et al. (chap. 4) presented in Part II
of this volume.
REFERENCES
Shiffman, S., Balabanis, M. H., Paty, J. A., Engberg, J., Gwaltney, C. J., Liu, K. S.,
et al. (2000). Dynamic effects of self-efficacy on smoking lapse and relapse.
Health Psychology, 19, 315-323.
INTRODUCTION
15
Shiffman, S., Engberg, J., Paty, J. A., Perz, W., Gnys, M., Kassel, J. D., & Hickcox,
M. (1997). A day at a time: Predicting smoking lapse from daily urge. Joumal of
Abnormal Psychology, 106, 104-116.
Shiffman, S., Paty, J. A., Gnys, M., Kassel, J. D., & Hickcox, M. (1996). First lapses
to smoking: Within-subjects analyses of real-time reports. Joumal of Consulting
and CUnical Psychology, 64, 366-379.
Stone, A. A., & Shiffman, S. (1994). Ecological momentary assessment in behavioral medicine. Annals of Behavioral Medicine, 16, 199-202.
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ROLE OF PSYCHOLOGY
AND BEHAVIORAL SCIENCE
IN ADDICTION RESEARCH
AND TREATMENT