The integration of naltrexone and Community Reinforcement Approach in patients with substance use disorders: findings from the Netherlands

The Community Reinforcement Approach (CRA) is a comprehensive cost-effective treatment, which innovatively integrates psychosocial and pharmacological approaches. Nathan Azrin and George Hunt devised CRA in the early seventies and based it on Skinner’s operant learning paradigm. CRA focuses on the replacement of an alternative lifestyle that is more rewarding than a substance using one. Indeed, it has been shown that individuals with substance use disorders reported a reduced level of engagement in pleasant activities as compared to healthy controls, especially on the social domain. Consequently, CRA attempts to increase natural positive reinforcement from different life-areas such as vocational, recreational and social, by sampling rewarding resources contingent on non-substance related behaviors.

An important characteristic of CRA is the inclusion of pharmacological options to attenuate the reinforcing effects of alcohol and drugs. Several studies have demonstrated that CRA combined with pharmacological agents such as methadone, buprenorphine and disulfiram is efficacious. However, there is lack of evidence of CRA integrated with the opioid antagonist naltrexone (NTX). NTX has been approved for the treatment of opioid and alcohol use disorders in both Europe and the US. NTX blocks the intrinsic reinforcing effects of alcohol and opioids, which act on the opioid receptor sites by competitively occupying these. It appears that NTX is an effective agent only under the condition that patients are compliant.

But most patients without supervision and monitoring discontinue their NTX-intake often rapidly. Several strategies have been developed to overcome these compliance problems such as extended-release injectable NTX (Vivitrol), NTX implants and contingency management aimed at oral NTX intake. In addition, the social network can be employed to improve compliance with the medication regimen. The involvement of families and other individuals in the treatment process is a central concept of CRA. CRA has demonstrated that family members are capable to monitor and assist the intake of daily doses of medication successfully. The medication-procedure is practiced during sessions by means of communication skill-trainings and role-plays with the patient and family member, to establish a medication-intake habit.

The combinations of the various CRA components, including pharmacological options such as NTX, may contribute to a successful outcome in the treatment of substance use disorders. In Europe research on ways to bolster the therapeutic efficacy of CRA is negligible. The presentation is focused on several studies conducted in the Netherlands investigating the feasibility and effectiveness of the combination of CRA and NTX in the treatment of patients with substance use disorders.