Principal Investigator: William R. Miller, Ph.D.
Co Investigator: Robert J. Meyers, Ph.D.
Funding Agency: National Institute on Alcohol Abuse and Alcoholism (NIAAA)
The Community Reinforcement Approach (CRA) is a broad-spectrum alcoholism treatment strategy introduced by Dr. Nathan Azrin in 1973. In three well-designed clinical trials by Azrin's group, the CRA was reported to yield results far superior to those from standard treatment methods. Yet 15 years after its initial publication, the CRA remained unreplicated and rarely used in alcoholism treatment.
We conducted a randomized clinical trial to assess the efficacy of CRA in outpatient treatment for alcohol dependence (Miller, Meyers, Tonigan & Grant, 2001). The project replicated and extended Azrin's research, studying a culturally diverse population treated in a metropolitan public outpatient treatment facility. Disulfiram-eligible patients were assigned randomly to one of four groups: traditional alcoholism treatment with or without Azrin's disulfiram compliance procedure (one component or the CRA), or the full CRA program with or without disulfiram. In a separate randomization, disulfiram-ineligible patients were assigned to either traditional treatment or CRA (without disulfiram). Methodological improvements of the present study over prior CRA research include: (1) extension of follow-up to 2 years; (2) specification of traditional treatment components; (3) delivery of traditional treatment by therapists committed to this approach; (4) double-blind intake assessment and single-blind follow-up assessment; (5) inclusion of a broader range of pretreatment assessment to enable the development of treatment matching schemas, (6) inclusion of a disulfiram-ineligible population and greater cultural diversity, and (7) separate evaluation of the contribution of disulfiram to the CRA program.
Treatment retention was similar for all groups (average of 9 of 12 sessions completed), except for a high rate of early drop-out (41%) from traditional treatment among disulfiram-ineligible clients (the comparable drop-out rate for CRA was 9%). Follow-up was completed with 83% of clients who were not known to be deceased or institutionalized.
In the disulfiram-eligible sample, percent days abstinent (PDA) was significantly higher during the first six months for clients treated by CRA, as compared with traditional treatment (97% vs. 81% days abstinent, p<.0001). When monitored disulfiram was added to traditional treatment, along with CRA-based training for a significant other in how to help the client with disulfiram adherence, outcomes were similar to those for CRA (96% days abstinent). Among groups receiving CRA, however, outcomes were similar whether or not disulfiram was included in treatment. Finally, among disulfiram-ineligible clients, outcomes were similar for CRA and traditional treatment.
When total abstinence was the outcome criterion, the highest percentage of completely abstinent clients for the first six months was found in the disulfiram-eligible group receiving traditional treatment plus SO-monitored disulfiram (59%). When clients in traditional treatment did drink, however, their drinking was significantly heavier than in the CRA group. No between-group outcome differences remained at 2-year follow-up.
References:
Co Investigator: Robert J. Meyers, Ph.D.
Funding Agency: National Institute on Alcohol Abuse and Alcoholism (NIAAA)
The Community Reinforcement Approach (CRA) is a broad-spectrum alcoholism treatment strategy introduced by Dr. Nathan Azrin in 1973. In three well-designed clinical trials by Azrin's group, the CRA was reported to yield results far superior to those from standard treatment methods. Yet 15 years after its initial publication, the CRA remained unreplicated and rarely used in alcoholism treatment.
We conducted a randomized clinical trial to assess the efficacy of CRA in outpatient treatment for alcohol dependence (Miller, Meyers, Tonigan & Grant, 2001). The project replicated and extended Azrin's research, studying a culturally diverse population treated in a metropolitan public outpatient treatment facility. Disulfiram-eligible patients were assigned randomly to one of four groups: traditional alcoholism treatment with or without Azrin's disulfiram compliance procedure (one component or the CRA), or the full CRA program with or without disulfiram. In a separate randomization, disulfiram-ineligible patients were assigned to either traditional treatment or CRA (without disulfiram). Methodological improvements of the present study over prior CRA research include: (1) extension of follow-up to 2 years; (2) specification of traditional treatment components; (3) delivery of traditional treatment by therapists committed to this approach; (4) double-blind intake assessment and single-blind follow-up assessment; (5) inclusion of a broader range of pretreatment assessment to enable the development of treatment matching schemas, (6) inclusion of a disulfiram-ineligible population and greater cultural diversity, and (7) separate evaluation of the contribution of disulfiram to the CRA program.
Treatment retention was similar for all groups (average of 9 of 12 sessions completed), except for a high rate of early drop-out (41%) from traditional treatment among disulfiram-ineligible clients (the comparable drop-out rate for CRA was 9%). Follow-up was completed with 83% of clients who were not known to be deceased or institutionalized.
In the disulfiram-eligible sample, percent days abstinent (PDA) was significantly higher during the first six months for clients treated by CRA, as compared with traditional treatment (97% vs. 81% days abstinent, p<.0001). When monitored disulfiram was added to traditional treatment, along with CRA-based training for a significant other in how to help the client with disulfiram adherence, outcomes were similar to those for CRA (96% days abstinent). Among groups receiving CRA, however, outcomes were similar whether or not disulfiram was included in treatment. Finally, among disulfiram-ineligible clients, outcomes were similar for CRA and traditional treatment.
When total abstinence was the outcome criterion, the highest percentage of completely abstinent clients for the first six months was found in the disulfiram-eligible group receiving traditional treatment plus SO-monitored disulfiram (59%). When clients in traditional treatment did drink, however, their drinking was significantly heavier than in the CRA group. No between-group outcome differences remained at 2-year follow-up.
References:
- Meyers, R. J., & Miller, W. R. (Eds.) (2001). A community reinforcement approach to addiction treatment. Cambridge, UK: Cambridge University Press.
- Miller, W. R., Meyers, R. J., & Hiller-Sturmhöfel, S. (1999). The community-reinforcement approach. Alcohol Health & Research World, 22, 116-121.
- Miller, W. R., Meyers, R. J., Tonigan, J. S., & Grant, K. A. (2001). Community reinforcement and traditional approaches: Findings of a controlled trial. In R. J. Meyers & W. R. Miller (Eds.), A community reinforcement approach to addiction treatment (pp. 79-103). Cambridge, UK: Cambridge University Press.
- Smith, J. E., Meyers, R. J., & Miller, W. R. (2001). The community reinforcement approach to the treatment of substance use disorders. American Journal on Addictions, 10 (Suppl.), 51-59.
