AVERSlON THERAPY AS PART OF A MULTIMODALITY TREATMENT PROGRAM

Addicts have been conditioned by their drug of choice. Studies have shown that alcoholics increase the
number of swallows and amount of salivation in response to the sight of alcohol, as compared to non
alcoholics. Studies of smokers seeking to quit show that those who are least likely to quit have a muc
h larger conditioned drop in pulse (presumably to compensate for the increase in pulse rate caused by
smoking) when presented with a cigarette. Cocaine-dependent addicts experience progressively steeper dr
ops in skin temperature and increased galvanic skin response (a sign of arousal) when viewing pro- gr
essively more intense and explicit pictures ol cocaine use. These responses can be shown to decay in s
trength as time away from the drug increases .

The presence of these phenomena suggests that one of the consequences of addiction is that the body
becomes conditioned to drink or use drugs in the presence of certain stimuli. T his may contribute to
the sensation of physical craving experienced by addicts.

Aversion thetap}: or eountereonditionino. is a powerful tool in the treatment of alcohol and other drug
addietion. Its goal is to reduce or eliminate the “hedonie memory" or craving for a drug and to simul
taneously develop a dis.. taste and avoidance response to the substance. Unlike punishments. which ofte
n are delayed in time from the use episode, aversion therapy relies on the immediate association of th
e sight. smell. tasteand act of using the substance with an unpleasant or “aversive” experience. Also. w
ith punishment, it is the individual who

receives the negative consequences, whereas in " aversion therapy it is the behavior-thc nega. the conse
quence is only paired with the act of using a drug. This has a very important benefit to self-esteem.
While the patient is engaging in positive recovery activities, he or she is receiving immediate positive
support for a new way of behaving and‘thinking. it is only when the patient is engaging in an old heh
avior---alcohol or drug use--that he or she experienCes immediate and consistent discomfort. Hence, sel
L esteem is rebuilt by separating the drug from the self.

The development of an aversion can be very Specific; for example, inadequate treatment can occur wh
en aversion is developed only to one type of alcoholic beverage. Also, repetition is an essential part of
training and conditioning; adequate trials are needed to develop an aver. sion and to maintain and rei
nforce it to prevent extinction.

Contrary to pOpular belief. disulfiram is not a classic aversion treatment. In aversion therapy for alcoh
ol addiction, alcohol is not absorbed into the system. W'ith disulftram, alcohol must be absorbed and
metabolism begun for it to produce its toxic effect. Aversion relies on safe but uncomfortable experien
ces that can be repeated, whereas disulhram induces a profoundly uncomfortable reaction. For this reas
on, patients undergoing formulized aversion treatments are not given alcohol at the same time that they
are prescribed disulhram; as a result, they have not actually experienced a disulftram reaction. Thus. d
isulfiram does not change the way the addict feels about alcohol He or she may fear the consequence
of drinking, just as he or she fears being arrested for thinking and drivinoz nexer~ thcless, he or she
still retains the euphoric recall

01pm! cplsudc‘s uf drinkmg .duvhul and hence the (mung for the alcuhul itaclf. Ax crsmn work: m ch
mmatc or reduce euphoric recall h} recording new negatixc experiences with the drug.
USES OF AVERSION THERAPY

AverSton Therapy for Alcohol E‘Addiction

:Nattsca Aversion

E Studies in rats suggest that humans and Other

g :organisms may be biologically predisposed

E to form long~lasting conditioned aVersions to

it; consumables such as alcohol and foodstulfs

.whose consumption is followed by nausea and vomiting.

The usual treatment session involves having the patient take nothing except clear liquids by mouth for
6 hours prior to treatment, in order [0 reduce the likelihood of aspiration. After receiving a full explan
ation of the treatment procedure, the patient is taken to the treatment room, which

hours prior to treatment, in order [0 reduce the likelihood of aspiration. After receiving a full explanati
on of the treatment procedure, the patient is taken to the treatment room, which

The usual treatment session involves having the patient take nothing except clear liquids by mouth for
6 hours prior to treatment, in order IO reduce the likelihood of aspiration. After receii“ ing a full expl
anation of the treatment procedure. the patient is taken to the treatment room, which

has shelves containing all types of alcoholic be“ erages along the walls, as well as cutouts of vari‘

u 4’
the patient is taken to the treatment room. which

has shelves containing all types of alcoholic bev' erages along the walls, as well as cutouts of various
liquor ads on the walls: The intent is to have the majority of the patient’s visual stimuli associated w
ith visual cues for drinking. The patient receives an oral dose of emetine and is given water and electr
olytes to provide a volume of easily vomited material. Shortly before the expected onset of nausea, the
nurse administering the treatment pours a drink of the patients preferred alcoholic beverage. The patie
nt is instructed to smell the beverage, take a small mouthful, swish it around in the mouth. to get the
full flavor of it, and then to spit it out into the basin. This ensures that the patient has well-defined
visual. olfactory. and gustatory sensations associated with the preferred beverage prior to the onset of t
he nausea. The nausea and vomiting ensue shortlv there

receives an oral dose of emetinc and is given water and electrolytes to provide a volume of easily vo
mited material. Shortly before the expected onset of nausea, the nurse administering the treatment pours
a drink of the patients preferred alcoholic beverage. The patient is instructed to smell the beverage, ta
ke a small mouthful, swish it around in the mouth to get the full flavor of it, and then to spit it out
into the basin. This ensures that the patient has well-defined visual, olfactory. and gustatory sensations
associated with the pre~ ferred beverage prior to the onset of the nausea. The nausea and vomiting en
sue shortly thereafter, and the “sniff, swish, and Spit” procedure described above is altered to "sniff, s
wish. and swallow,” with the swallowed alcoholic bever~ age being returned shortly as emesis so that
no significant amount of alcohol is retained to be absorbed. After a session, the patient is returned to
the hospital room, where another drink of alcoholic beverage is given containing an oral dose of em‘et
ine and tartar emetic, which induces a slower-acting residual nausea lasting up to 3 hours. The average
patient receives five treatment

sessions which are given ever}~ other day over a [0-day period. In the private sector, Smith and Fraw
ley compared 2+9 inpatients receiving aver. sion therapy as part of a multitnodality treatment program
with .249 inpatients from a large (>9,000 patients) treatment registry of patients receiving multimodality
treatment, but without aversion therapy. All were matched on 17 baseline characteristics. Of the patien
ts receiving aversion therapy, 84.7% had total abstinence from alcohol at 6 months, compared with 72.
2% in the control group (p < 0.01); at 1 year‘ 79% of those treated with aversion had maintained abst
inence versus 67% of those without such treatment (p < 0.05).

The group showing the greatest benefit from aversion therapy was the daily drinkers (84% vs

67%, p < 0.001).

Fnrndic Aversion This treatment paradigm consists of pairing an aversive level of electrostiinulation wit
h the sight, smell, and taste of alcoholic beverages. At the direction of the therapist (forced choice tria
l), the patient reaches for a bottle of alcoholic beverage, pours some of it in a glass, and tastes it wit
hout swallowing. Electrostimulus onset occurs randomly throughout the entire behavior continuum, from
reaching for the bottle through tasting the alcoholic beverage. The number of electrostimuli with each
trial varies. An additional 10 free choice trials are designed so that the patient is negatively reinforce
d, with removal of the aversive stimulus if he or she selects a nonalcoholic choice such as fruit juice.
The patient is instructed not to swallow

any alcohol at any time throughout the faradic

session, and this behavior is closely monitored by the therapi

Covert Sensitization

Conditioned'nausea responses can be trained in some alcoholic patients through the use of imagination
and verbal suggestion without the use of an emetic drug. in covert sensitization. patients are helped to
imagine personally relevant drinking scenes that emphasize the motivational. sensory. and behavioral p
recursors and concomitants of alcohol ingestion. The thinking scenes then are paired repeatedly with ve
rbally induced nausea. Most cooperative participants can learn to experience genuine and intense nausea
reactions by focusing on the therapist‘s noxious

verbal suggestions: these suggestions prompt recipients to remember and recreate prior feelings and tho
ughts that have been prominent in their former nausea experiences. Such verbally induced nausea is de
signated as demand nausea. Repeated presentations of the drinking scenes (i.e., conditioned stimulus) fo
llowed by episodes of verbally induced demand nausea (i.e., unconditioned stimulus) can, over extended
conditioning trials, produce conditioned aversions to alcohol in many of the participants. The goal of t
reatment is for a patient’s demand nau~ sea to transition to conditioned nausea, an automatic conseque
nce of the patient’s focusing on a drinking scene without any attempted therapist ‘ or self-induction of
nausea.

In one study of 52 patients, 33 were able to develop verbally induced nausea after imagined drinking
scenes; of these, 23 were able to develop conditioned nausea to either the desire for alcohol or other a
lcohol-related physical stimuli. Those who developed conditioned nausea had an average of 13.74 mont
hs of total abstinence as compared to 4.52 months for those who failed to progress beyond the deman
d nausea stage.

Aversion Therapy in Smoking Cessation

A review of modern smoking cessation treatments concluded that programs that use rapid smoking aver
sion or satiation had superior outcomes. Rapid smoking involves smoking cigarcttes with inhalations ev
ery 6 seconds; though nicotine is taken into the system during rapid smoking, the aversion developed t
o smoking is adequate to prevent relapse. Sessions last an average of 15 minutes, during which the su
bject smokes an average of live cigarettes. The treatment sessions are usually daily for 5 days with a t
apering frequency of booster treatments after that. When compared to the physical effects of normally
paced smoking, clients undergoing rapid smoking experience increased burning in the lungs. palpitations
, facial flush, headache, and feeling faint or weak. The best results have been reported by programs in
which aversion was combined with several other modalities, including relapse prevention, relaxation tra
ining, written exercises, contract management,
booster sessions of 'AVL‘I‘SlOlL and group support, A study of patients it ith cardiopulmonary disease
who underwent satiation treatment found no myocardial ischemia or significant arrhyth. mia in this gr
oup; live patients with ischemic , changes on the treadmill did not experience the 'changes during the
satiation treatment. .

Faradic aversion has also been used for " smoking cessation: Each time a patient bring§ a cigarette to
ward his or her lips, a mild electrical stimulus is administered automatically by a 9-V battery. With la
radic aversion, the smoke is not inhaled but merely pulled; inhaling may lead to early relapse because
of maintenance of the nicotine dependence. One advantage of this form of treatment is that less medic
ally sophisticated staff can supervise the administration of the treatment.

in both forms of treatment, patients personally administer the aversive agent to themselves, while the t
herapist serves as a coach.

Aversion Therapy for Marijuana I “ Dependence

in clinical practice, aversion therapy for marijuana uses faradic aversiomhe protocol for faradic aversion
is similar to tlTac of the treat

ment for alcohol, except that it uses a VM'IEIY 0‘ bongs, drug paraphernalia and visual imagery. An
artificial marijuana substitute and marijuana aroma are used in treatment. A 1-year abstinence rate of 8
400 was reported after 5 days of treatment, combined with three weekly group sessions on self-manage
ment techniques. .

Aversion Therapy for CocaineAmphetamine Dependence

In a study of the use of chemical aversion for the treatment of cocaine dependence, an artificial cocain
e substitute called articaine was developed from tetracaine‘ mannitol, and quinine. Patients snorted this
substance and paired it with nausea induced by emetine. Of those so treated, 56% were continuously a
bstinent and 7800 currently abstinent (i.e.. [or the prior 30 days) at 6 months after treatment: at 18 m
onths 3800 were continuously abstincnt and 7390 currently abstinent. For those treated for both alcohol
and cocaine, 70% were continuously and currently abstinent from comment 6 months.

and 5001. were continuously absunent and 803‘’ currently abstinent at 18 months after treatmenL A we
ll designed experimental evaluation of “aversion lllClapV neatments for cocaine depenidence enlisted vo
lunteer participants from the igugusta \A Medical Center Substance Abuse sqreatment Program The abst
inence rate at 6 :months posttreatment follow-up was reported teas :37 9% for participants who had re
ceived ’ emetic theiam significantlt exceeding the _~ 26 5.0 6-month abstinence hnding for control grO
UP participants Covert sensitization also ipmduced a significant therapeutic benefit but ’_ its effect did
not extend beyond 3 months post3‘ treatment. A result unique to participants who ”received emetic ther
apy was a total loss of craviings for cocaine by the end of treatment.
Aversion Therapy for Heroin and Other Opioid Addiction

'One study employed a unique approach to aversion therapy by pairing aversive stimuli with ‘cognitive
images of heroin use. Patients were éasked to V'erbalize only after they had conjured * up a strong m
ental image. In the second part of i the treatment, addicts were asked to conjure up images of socially
appropriate behavior. including employment, education, or nondrug entertainment. Latency to verbalizati
on was measured: At baseline. addicts could rapidly conjure up positive thoughts about heroin use but
had signilicant

tive thoughts about heroin use but had signilicant delays in conjuring up thoughts about rewarding non
drug activities. Subjects were in a halfway house for heroin addicts and received group therapy in conj
unction with relaxation therapy. along with aversion treatment. A faradic stimulator was used; once add
icts had conjured up drug images, faradic aversion was applied. At other times. addicts were given 15
seconds to conjure up images of nondrug. socially appropriate behavior to prevent aversion from being
applied. With this training in an average of 15 sessions. latency [or drug-related images increased. wh
ile that for socially appropriate images decreased. Thirtv of fifty patients completed the treatment. and.
at 2+ months. 80% of these were reported to be drug free. Since 3012, a new approach to aversion th
erapy for heroin has been developed. This heroin treatment combines hnmoticallv guided covert sensitiz
ation with the programs well-established

medical (emetic) counterconditinning. Seven heroin counterconditioning sessions are provided \xithin the
traditional 10-day inpatient multimodal treatment format that is used for alcohol and other drug depen
dencies. The first three sessions provide training in hypnotically induced nausea followed by four sessio
ns where emetine is added to enhance the nausea.

A novel treatment for prescription opioid dependence has been developed in the Schick Shadel Hospital
. This treatment capitalizes on the use of naltrexone to negate the psychotropic effects of prescription
opioids. Prescription Opioid-dependent recipients first are detoxifted; they then are started on a daily na
ltrexone regimen that begins in the morning of the Erst treatment day. The recipients then use prescrip
tion opioids in their customary manner during emetic therapy sessions. The, treatment has been well re
ceived and is being requested by an increasing number of patients.

USE OF REINFORCEMENT (BOOSTER) AVERSION TREATMENTS

Researchers followed up at 1 year on 437 of 600 patients treated with chemical and faradic aversion f
or alcohol, marijuana, or cocaine. One-year complete abstinence rate for alcohol for those who did not
return for any reinforcements was 29.4%; for one booster aversion treatment, the abstinence rate was
30.5%; the two booster aversions abstinence rate was 68.5%; and for more than two aversions, the abs
tinence rate was 80%.

USE OF SUPPORT PROGRAMS AND TWELVE-STEP MEETINGS AFTER RECEIVING AVERSIO

N THERAPY

Follow-up studies found that those who used

some form ol~ support groups after aversion treatment did better than those who did not use
such support, with an additive effect of the use of reinforcement (booster) aversion treatments and supp
ort and/or Twelve-Step meetings after completion of a hospital aversion program. Though total abstinen
ce was associated with use of support groups after treatment for those with urges to drink. increased s
upport use was negatively associated with abstinence. A similar pattern was found for patients going to
Schick Sliadcl Hospital-sponsored support groups.

SAFETY OF AVERSION THERAPY

lerzttllc aversion has virtttall} no unsafe side effects and has been found to be safe for patients with p
acemakers and pregnant women (because the current only travels between two electrodes on the arm).
To be eligible for chemical aversion therapy, patients must be free of medical contraindications such as
esophageal varices, serious coronary artery disease, or active GI pathology. There was no increased in
cidence ol‘ medical utilization or hospitalization in the 6 months after treatment in a group treated with
aversion therapy, as compared to matched controls treated without aversion.

The contraindications to covert sensitization are similar to those for chemical aversion; however, with t
his therapy, emesis can be prevented in most cases. The drawback to covert aversion therapy is that th
e induction of nausea or other aversive state is not as predictable as with medication and requires mor
e patient preparation.

AVERSION THERAPY AS PART OF ESTABLISHED CARE FOR ADDICTIVE DISEASE

Selecting the appropriate treatment for a particular patient involves the patient having full informed con
sent. The practitioner needs to counsel the patient about the risks of continuing the addiction and the r
isks, benefits, and expected outcomes of various methods of treatment. Studies of patients who voluntar
ily received aversion therapy do not show higher rates of leaving against medical advice than is found
in patients in Minnesota Model programs. Patients seeking aversion therapy in clinical settings comple
te treatment at the same rate as patients seeking alternative established treatments. Aversion therapy has
been recognized by both governmental and private agencies as appropriate treatment for patients with
addictive disease.

NEED FOR FURTHER RESE3QR£H

A study Of emetic therapy for cocaine dcpendence, funded by the National Institute on Drug Abuse: d
emonstrated that recipients not only lost their cravings for cocaine but also dcx'eloped strong active rev
ulsions lot" the placebo cocaine materials and for. cocaine-related cues.

Howex er. the re\ ttlsitms \\ ere not measurable by the t) to it) cravings scale that “as used in the Stu
dy. Future studies should incorporate bidi» rectional scales that measure maximum craving at one extre
me and maximum revulsion at the other extreme with a neutral zero-craving mid scale region.

Future research should better characterize the physiologic changes that coincide with the transition from
cue-induced cravings to cue~ induced revulsion within a course of emetic aversion treatments. The dy
namically expanding held of brain imaging research is likely to provide the greatest near-term advance
ments in our basic understanding and possible clini~ cal applications of cue-induced brain changes that
occur during the emetic therapy-induced transition from cocaine cravings to revulsions. Recent studies
have reported activations of spe~ cific brain regions during cue-induced cravings for cocaine. Reliable
change in brain activa~ tion patterns may be revealed by comparisons of the initial episodes of cue-ind
uced cravings that typify the beginning of treatment with those that accompany the late-treatment cue~
induced revulsions of successfully conditioned participants. The landmarlwpositron emission

l tomography (PET) scan findings obtained from

tomography (PET) scan findings obtained from cocaine~addicted human volunteers have shown that dop
amine in the dorsal striatum is involved in cocaine craving and addiction. The dorsal striatum is a regi
on that has been implicated in habit learning and in action initiation. The dorsal striatum is therefore a
high-interest area for studies of possible transitions from cravings to revulsions. Cue-induced craving t
o revulsion changes are also likely to be found in brain regions that include the amygdala, the nucleus
accumbens, the dorsal anterior cingulate cortex. the ventral anterior cingulate cortex, and the frontal c
ortex. An Ul)\'lDLlS clinical application of such information would be to assess the strength of the att
ained aversion at the end of treatment. Additionally the findings could sup~ port Propitious individually
tailored timings of booster treatments.

Functional magnetic r ‘sonance imaging (MRI) also may be well suited to studies of emetic ther~ apy-
induced changes of cue-induced craxings ’to revulsions. The lMRl technology unlike PET scan technolo
gy does not involve the injection of

radioactive compounds. Therefore, it can be safely used during repeated measures of the same panici~
pants across different time periods.

A variety of researchers have reported that some patients do not seem to develop aversions‘ leading re
searchers to develop and study lines of selectively bred taste aversion~prone and

staste aversion-resistant rats. Such studies {live “promise of leading to identifications of biologic ‘indice
s to separate conditionable and nonconditionable potential emetic therapy recipients. Additionally, studie
s of the two lines may support the development of pharmacologic or nutritional interventions to increas
e the nausea-based 'conditionability oi TAR substance abusers.

KEY POINTS

1. Aversion therapy has its best outcomes with daily drinkers compared to periodic drinkers.

2. Aversion therapy is retraining the emotional memory through repetitive negative immediate associatio
ns with the substance.

3. Aversion therapy can be a part of a multimodal treatment program.

4. Aversion therapy has been successfully applied to multiple types of addictions.