Kontingenzmanagement in der Substitutionsbehandlung Opiatabhängiger

Zusammenfassung

Die Mehrheit der Opiatabhängigen in Substitutionsbehandlung leidet unter weiteren suchtmittelbezogenen Störungen. Der Beikonsum von Heroin, Alkohol, Benzodiazepinen oder Kokain gefährdet den Erfolg der Substitutionsbehandlung. Eine Intervention zur Behandlung des Beikonsums ist das auf lerntheoretischen Prinzipien basierende Kontingenzmanagement (KM). Im KM wird Drogenabstinenz – verifiziert durch Urintests – kontingent und zeitnah verstärkt. Bei Substitutionspatienten wurden u. a. geldwerte Gutscheine oder Mitgabeprivilegien als Verstärker für suchtmittelfreie Drogen-Urinscreenings eingesetzt. Zahlreiche kontrollierte Studien in den USA belegen einen mittelstarken durchschnittlichen Effekt auf Beikonsum- bzw. Abstinenzraten der Substitutionspatienten. Der Effekt lässt nach Beendigung der Intervention allerdings deutlich nach. Es wird diskutiert, wie sich KM in der deutschen Substitutionspraxis umsetzen und mit anderen Maßnahmen zur Beikonsumreduktion wie selektiven Entgiftungen oder kognitiv-verhaltenstherapeutischen Programmen kombinieren lässt.

Abstract

The majority of opiate-dependent patients in substitution treatment show additional substance-related disorders. Concomitant use of heroin, alcohol, benzodiazepines or cocaine compromises treatment success. Concomitant drug use may be treated by using contingency management (CM) which is based on learning theory. In CM, abstinence from drugs, as verified by drug screenings, is reinforced directly and contingently. Reinforcers used in CM studies with substituted patients were, amongst others, vouchers and take-home privileges. Studies in the USA show a medium average effect of CM on drug consumption rates and abstinence. The effects decrease markedly after the end of the intervention. We discuss whether CM is applicable within the German substitution treatment system and how it can be combined with other interventions such as selective detoxification treatments or cognitive-behavioural programmes.

Opiatabhängigkeit - Kontingenzmanagement - komorbide substanzbezogene Störungen - Psychotherapie

opiate dependence - contingency management - comorbid substance-related disorders - psychotherapy

Literatur

• 1 Kunstmann W, Hessenauer F. Substitution Opiatabhängiger: Versorgung wird schwieriger.  Dtsch Arztebl. 2009;  106 A-1508 /B-1289 /C-1257
• 2 Senay E C. Opioids: Methadone maintenance. Galanter M, Kleber H D, (ed.) Textbook of Substance Abuse Treatment.. Washington: American Psychiatric Press; 2005: 271-279
• 3 Wittchen H U, Apelt S M, Soyka M et al. Feasibility and outcome of substitution treatment of heroin-dependent patients in specialized substitution centers and primary care facilities in Germany: a naturalistic study in 2694 patients.  Drug Alcohol Depend. 2008;  95 245-257
• 4 Verthein U, Haasen C, Prinzleve M et al. Cocaine use and the utilisation of drug help services by consumers of the open drug scene in Hamburg.  Eur Addict Res. 2001;  7 176-183
• 5 Backmund M, Schütz C G, Meyer K et al. Alcohol consumption in heroin users, methadone-substituted and codeine-substituted patients – frequency and correlates of use.  Eur Addict Res. 2003;  9 45-50
• 6 Backmund M, Meyer K, Henkel C et al. Co-consumption of benzodiazepines in heroin users, methadone-substituted and codeine-substituted patients.  J Addict Dis. 2005;  24 17-29
• 7 Raschke P. Substitutionstherapie. Ergebnisse langfristiger Behandlung von Opiatabhängigen. Freiburg i. Br: Lambertus; 2005
• 8 Stitzer M, Petry N. Contingency management for treatment of substance abuse.  Annu Rev Clin Psychol. 2006;  2 411-434
• 9 Perrez M, Zbinden M. Lernen. Ehlers A, Hahlweg K, (Hrsg.) Grundlagen der Klinischen Psychologie.. Göttingen: Hogrefe; 1996: 301-349
• 10 Silverman K, Higgins S T, Brooner R K et al. Sustained cocaine abstinence in methadone maintenance patients through voucher-based reinforcement therapy.  Arch Gen Psychiatry. 1996;  53 409-415
• 11 Cohen J. Statistical Power Analysis for the Behavioral Sciences. 2nd. ed. Hillsdale, NJ: Lawrence Erlbaum Associates; 1988
• 12 Griffith G A, Rowan-Szal R R, Roark D D. Contingency management in outpatient methadone treatment: Meta-Analysis.  Drug Alcohol Depend. 2000;  58 55-66
• 13 Prendergast M, Podus D, Finney J et al. Contingency management for treatment of substance use disorder: a meta-analysis.  Addiction. 2006;  101 1546-1560
• 14 Lussier J P, Heil S H, Mongeon J A et al. A meta-analysis of voucher-based reinforcement therapy for substance use disorders.  Addiction. 2006;  101 192-203
• 15 Dutra L, Stathopoulou G, Basden S L et al. A meta-analytic review of psychosocial interventions for substance use disorders.  Am J Psychiatry. 2008;  165 179-187
• 16 Sofuoglu M, Gonzalez G, Poling J et al. Prediction of treatment outcome by baseline urine cocaine results and self-reported cocaine use for cocaine and opioid dependence.  Am J Drug Alcohol Abuse. 2003;  29 713-727
• 17 Stitzer M L, Iguchi M Y, Felch L J. Contingent take-home incentive: effects on drug use of methadone maintenance patients.  J Consult Clin Psychol. 1992;  60 927-934
• 18 Preston K L, Silverman K, Higgins S T et al. Cocaine use early in treatment predicts outcome in a behavioral treatment program.  J Consult Clin Psychol. 1998;  66 691-696
• 19 Chutuape M A, Silverman K, Stitzer M. Use of methadone take-home contingencies with persistent opiate and cocaine abusers.  J Subst Abuse Treat. 1999;  16 23-30
• 20 Stitzer M L, Peirce J, Petry N M et al. Abstinence-based incentives in methadone maintenance: interaction with intake stimulant test results.  Exp Clin Psychopharmacol. 2007;  15 344-350
• 21 Dallery J, Silverman K, Chutuape M A et al. Voucher-based reinforcement of opiate plus cocaine abstinence in treatment-resistant methadone patients: effects of reinforcer magnitude.  Exp Clin Psychopharmacol. 2001;  9 317-325
• 22 Preston K L, Umbricht A, Wong C J et al. Shaping cocaine abstinence by successive approximation.  J Consult Clin Psychol. 2001;  69 643-654
• 23 Piotrowski N A, Tusel D J, Sees K L et al. Contingency contracting with monetary reinforcers for abstinence from multiple drugs in a methadone program.  Exp Clin Psychopharmacol. 1999;  7 399-411
• 24 Stitzer M L, Bigelow G E, Liebson I A et al. Contingent reinforcement for benzodiazepine-free urines: evaluation of a drug abuse treatment intervention.  J Appl Behav Anal. 1982;  15 493-503
• 25 Iguchi M Y, Stitzer M L, Bigelow G E et al. Contingency management in methadone maintenance: effects of reinforcing and aversive consequences on illicit polydrug use.  Drug Alcohol Depend. 1988;  22 1-7
• 26 Silverman K, Robles E, Mudric T et al. A randomized trial of long-term reinforcement of cocaine abstinence in methadone-maintained patients who inject drugs.  J Consult Clin Psychol. 2004;  72 839-854
• 27 Petry N M, Martin B. Low-cost contingency management for treating cocaine-abusing methadone patients.  J Consult Clin Psych. 2002;  70 398-405
• 28 Peirce J M, Petry N M, Stitzer M L et al. Effects of lower-cost incentives on stimulant abstinence in methadone maintenance treatment: a National Drug Abuse Treatment Clinical Trials Network study.  Arch Gen Psychiatry. 2006;  63 201-208
• 29 Kidorf M, Brooner R K, King V L et al. Concurrent validity of cocaine and sedative dependence diagnosis in opioid-dependent outpatients.  Drug Alcohol Depend. 1996;  42 117-123
• 30 Rhodes G L, Saules K K, Helmus T C et al. Improving on-time counseling attendance in a methadone treatment program: a contingency management approach.  Am J Drug Alcohol Abuse. 2003;  29 759-773
• 31 Villano C L, Rosenblum A, Magura S et al. Improving treatment engagement and outcomes for cocaine-using methadone patients.  Am J Drug Alcohol Abuse. 2002;  28 213-230
• 32 Kidorf M, Stitzer M L, Brooner R K et al. Contingent methadone take-home doses reinforce adjunct therapy attendance of methadone maintenance patients.  Drug Alcohol Depend. 1994;  36 221-226
• 33 Iguchi M Y, Belding M A, Morral A R et al. Reinforcing operants other than abstinence in drug abuse treatment: an effective alternative for reducing drug use.  J Consult Clin Psychol. 1997;  65 421-428
• 34 Petry N M, Martin B, Cooney J L et al. Give them prizes and they will come: contingency management for the treatment of alcohol dependence.  J Consult Clin Psychol. 2000;  68 250-257
• 35 Petry N M, Tedford J, Austin M et al. Prize reinforcement contingency management for treating cocaine user: how low can we go, and with whom?.  Addiction. 2004;  99 349-360
• 36 Petry N M, Peirce J M, Stitzer M L et al. Effect of prize-based incentives on outcomes in stimulant abusers in outpatient psychosocial treatment programs: a national drug abuse treatment clinical trials network study.  Arch Gen Psychiatry. 2005;  62 1148-1156
• 37 Petry N M, Martin B, Simcic F. Prize reinforcement contingency management for cocaine dependence: integration with group therapy in a methadone clinic.  J Consult Clin Psychol. 2005;  73 354-359
• 38 Rogers R E, Higgins S T, Silverman K et al. Abstinence-contingent reinforcement and engagement in non-drug-related activities among illicit drug abusers.  Psychol Addict Behav. 2008;  22 544-550
• 39 Ferster C B, Skinner B F. Schedules of reinforcement. Englewood Cliffs, NJ: Prentice Hall; 1957
• 40 Chutuape M A, Silverman K, Stitzer M. Effects of urine testing frequency on outcome in a methadone take-home contingency program.  Drug Alcohol Depend. 2001;  62 69-76
• 41 Preston K L, Ghitza U E, Schmittner J P et al. Randomized trial comparing two treatment strategies using prize-based reinforcement of abstinence in cocaine and opiate users.  J Appl Behav Anal. 2008;  41 551-563
• 42 Ghitza U E, Epstein D H, Schmittner J et al. Effect of Reinforcement Probability and Prize Size on Cocaine and Heroin Abstinence in Prize-Based Contingency Management.  J Appl Behav Anal. 2008;  41 539-549
• 43 Roll J M, Huber A, Sodano A R et al. A comparison of five reinforcement schedules for use in contingency management-based treatment of methamphetamine abuse.  Psychol Rec. 2006;  56 67-81
• 44 Silverman K, Wong C J, Umbricht-Schneiter A et al. Broad beneficial effects of cocaine abstinence reinforcement among methadone patients.  J Consult Clin Psychol. 1998;  66 811-824
• 45 Bundesärztekammer . Richtlinien der Bundesärztekammer zur Durchführung der substitutionsgestützten Behandlung Opiatabhängiger.  Dtsch Arztebl. 2002;  99 B1218-1221 ; novellierte Version: Deutsches Ärzteblatt 2010; 107: A511–A516
• 46 Havemann-Reinecke U, Küfner H, Schneider U et al. AWMF-Leitlinien: Postakutbehandlung bei Störungen durch Opioide.  Sucht. 2004;  50 226-257
• 47 Kirby K C, Benishek L A, Dugosh K L et al. Substance abuse treatment providers’ beliefs and objections regarding contingency management: Implications for dissemination.  Drug Alcohol Depend. 2006;  85 19-27
• 48 Scherbaum N, Kluwig J, Meiering C et al. Use of illegally acquired medical opioids by opiate-dependent patients in detoxification treatment.  Eur Addict Res. 2005;  11 193-196
• 49 Bechara A, Damasio H. Decision-making in addiction (part I): impaired activation of somatic states in substance-dependent individuals when pondering decisions with negative future consequences.  Neuropsychologia. 2002;  40 1675-1689
• 50 Rosenblum A, Foote J, Magura S et al. Follow-up of inpatient cocaine withdrawal for cocaine-using methadone patients.  J Subst Abuse Treat. 1996;  13 467-470
• 51 Specka M, Scherbaum N. Ergebnisse der stationären Entzugsbehandlung von Benzodiazepinen bei Methadonsubstituierten.  Sucht. 2005;  51 329-338
• 52 Chutuape M A, Silverman K, Stitzer M. Contingent reinforcement sustains post-detoxification abstinence from multiple drugs: a preliminary study with methadone patients.  Drug Alcohol Depend. 1999;  54 69-81
• 53 Wurst F M, Dürsteler-MacFarland K M, Auwaerter V et al. Assessment of alcohol use among methadone maintenance patients by direct ethanol metabolites and self-reports.  Alcohol Clin Exp Res. 2008;  32 1552-1557
• 54 Broers B, Giner F, Dumont P et al. Inpatient opiate detoxification in Geneva: follow-up at 1 and 6 months.  Drug Alcohol Depend. 2000;  58 85-92
• 55 Rosenblum A, Magura S, Foote J et al. Treatment intensity and reduction in drug use for cocaine-dependent methadone patients: a dose-response relationship.  J Psychoactive Drugs. 1995;  27 151-159
• 56 Rawson R A, Huber A, McCann M J et al. A comparison of contingency management and cognitive-behavioral approaches during methadone maintenance treatment for cocaine dependence.  Arch Gen Psychiatry. 2002;  59 817-824
• 57 Scherbaum N, Kluwig J, Specka M et al. Group Psychotherapy for Opiate Addicts in Methadone Maintenance Treatment – A Controlled Trial.  Eur Addict Res. 2005;  11 163-171