- Aversion Therapy
- Alcohol Addiction
- Gambling addiction
- Critical Evaluation
- APA Style References
- How to reference this article:
- History of Aversion Therapy
- Use in Therapy
- Find a Therapist
- Controversy Surrounding Conversion Therapy
- How It Works & What to Expect
- What Is Aversion Therapy and How Does it Work?
- What Can Aversion Therapy Help With?
- Aversion Therapy Examples
- Aversion Therapy For Alcohol Use Disorder
- Aversion Therapy For Obesity
- Aversion Therapy For Nail Biting
- Cost of Aversion Therapy
- How To Find Aversion Therapy
- What to Expect At Your First Appointment
- Is Aversion Therapy Effective?
- Controversy & Criticism of Aversion Therapy
- What Is Aversion Therapy?
- Uses of Aversion Therapy
- Criticisms of Aversion Therapy
- Chemical Aversive Conditioning for Alcoholism
- The above policy is the following references:
By Dr. Saul McLeod, published March 04, 2021
Aversion therapy is a behavioral therapy technique with the aim of reducing unwanted behavior.
Aversion therapy works by pairing together the stimulus that can causes deviant behavior (such as an acholic drink or cigarette) with some form of unpleasant (aversive) stimulus such as an electric show or nausea-inducing drug.
With repeated presentations, the two stimuli become associated and the person develops an aversion towards the stimuli which initially caused the deviant behavior.
Aversion therapy is classical conditioning. According to learning theory, two stimuli become associated when they occur frequently together (pairing). For example, in addiction, the drug, alcohol or behavior in the case of gambling becomes associated with pleasure and high arousal.
Aversion therapy uses the same principle but changes the association and replaces the pleasure with an unpleasant state (counterconditioning).
Aversion therapy has been used effectively for years in the treatment of alcoholism (Davidson, 1974;Elkins, 1991; Streeton & Whelan, 2001).
Patients are given an aversive drug which causes vomiting-emetic drug. They start experiencing nausea at this point they are given a drink smelling strongly of alcohol, they start vomiting almost immediately. The treatment is repeated with a higher dose of the drug.
Another treatment involves the use of disulfiram (e.g. Antabuse). This drug interferes with the metabolism of alcohol. Normally alcohol is broken down into acetaldehyde and then into acetic acid (vinegar).
Disulfiram prevents the second stage from occurring leading to very high level of acetaldehyde which is the main component of hangovers. This results in severe throbbing headache, increased heart rate, palpitations, nausea, and vomiting.
For behavioral addiction such as gambling aversion therapy involves associating such stimuli and behavior with a very unpleasant unconditioned stimulus, such as an electric shock. These shocks are painful but do not cause damage.
The gambler creates cue cards with key phrases they associate with their gambling and then similar cards for neutral statements.
As they read through the statements they administer a two-second electric shock for each gambling related statement. The patient set the intensity of the shock themselves aiming to make the shock painful but distressing.
The client thus learns to associate the undesirable behavior with the electric shock, and a link is formed between the undesirable behavior and the reflex response to an electric shock.
There are ethical issues associated with the use of aversion therapy such as physical harm (vomiting can lead to electrolyte unbalance) and loss of dignity for this reason covert sensitization is now preferred to aversion therapy.
Compliance with the treatment is low due to the unpleasant nature of the stimuli used e.g. inducing violent vomiting.
Apart from ethical considerations, there are two other issues relating to the use of aversion therapy.
First, it is not very clear how the shocks or drugs have their effects. It may be that they make the previously attractive stimulus (e.g. sight/smell/taste of alcohol) aversive, or it may be that they inhibit (i.e. reduce) the behavior of drinking.
Second, there are doubts about the long-term effectiveness of aversion therapy. It can have dramatic effects in the therapist’s office. However, it is often much less effective in the outside world, where no nausea-inducing drug has been taken and it is obvious that no shocks will be given.
Also, relapse rates are very high – the success of the therapy depends of whether the patient can avoid the stimulus they have been conditioned against.
Away from the controlled environment where the associations between behavior/drug and unpleasant stimuli are formed, it is common for addictions to return.
Chesser (1976) found that with aversion therapy 50% of alcoholics abstained for at least a year and that the treatment was more successful than no treatment. This supports the effectiveness of interventions classical conditioning.
However, Hajek and Stead (2013) reviewed 25 studies of the effectiveness of aversion therapy and found that all but one had significant methodological flaws which mean that their results have to be treated with caution.
Behavioral therapies are mostly used in combination with other therapies [(CBT) or biological (drugs)] it is therefore difficult to evaluate their effectiveness.
Behavioral interventions focus on the behavior but do not address the underlying cause of addiction such as biological factors, cognitive bias or social environment (i.e. the thing that is leading them to addictive behavior in the first place) a more holistic approach might be more effective to achieve a lasting improvement.
APA Style References
Chesser, E. S. (1976). Behaviour therapy: Recent trends and current practice. The British Journal of Psychiatry, 129(4), 289-307.
Davidson, W. S. (1974). Studies of aversive conditioning for alcoholics: A critical review of theory and research methodology. Psychological bulletin, 81(9), 571.
Elkins, R. L. (1991). An appraisal of chemical aversion (emetic therapy) approaches to alcoholism treatment. Behavior research and therapy, 29(5), 387-413.
Hajek, P., Stead, L. F., West, R., Jarvis, M., Hartmann‐Boyce, J., & Lancaster, T. (2013). Relapse prevention interventions for smoking cessation. Cochrane database of systematic reviews, (8).
Streeton, C., & Whelan, G. (2001). Naltrexone, a relapse prevention maintenance treatment of alcohol dependence: a meta-analysis of randomized controlled trials. Alcohol and Alcoholism, 36(6), 544-552.
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How to reference this article:
McLeod, S. A. (2021, March 04). Aversion Therapy. Retrieved https://www.simplypsychology.org/aversion-therapy.html
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History of Aversion Therapy
Aversion therapy was built upon behaviorist research, which suggests that conditioning is a highly effective form of learning, even in otherwise uncooperative people.
Chemical and electrical aversion have been the most commonly employed techniques, although these techniques have seen a decline in recent decades.
Visual imagery has become a more acceptable and sometimes more effective form of aversion therapy, in which a person focuses on the target behavior while visualizing an undesirable consequence.
Use in Therapy
A variety of aversive techniques are used in a therapeutic setting.
A therapist trying to help someone eliminate a problematic behavior might show a person photos of something associated with the problematic behavior—cigarettes, drugs, and so on—and then administer a shock or pinch.
In other cases, a therapist might suggest that a person self-administer aversive techniques, such as visualizing something unpleasant or snapping an elastic band on one’s wrist or to help deter cravings or disrupt negative or compulsive thought processes.
Find a Therapist
Drug and alcohol treatment programs have traditionally used aversion therapy techniques, such as electrical shocks or nausea-inducing medications, to help people reduce or eliminate cravings for the substances.
For example, some medications can cause people with addiction problems to feel ill when they consume alcohol or drugs.
Although these techniques have largely fallen favor across the mental health community and are often regarded as less successful than other methods, many treatment facilities still use them in conjunction with other therapeutic interventions.
There is significant controversy about the ethics of aversion therapy, particularly when practitioners are administering painful stimuli to patients. Most mental health professionals oppose aversion therapy techniques except for those where the person is self-administering the aversive stimulus.
Some practitioners find the practice to be an ineffective long-term strategy, because a person can easily revert back to undesirable behaviors and habits in the absence of the unpleasant stimulus, and, other behavioral techniques, aversion therapy may not take into account deeper emotional needs that are driving the undesired behavior.
Controversy Surrounding Conversion Therapy
Aversion therapy techniques have also been used in reparative therapy or conversion therapy, which is designed to convert gay people to heterosexuality.
Aversive techniques have included administering shocks to a person’s genitals or inducing a person to vomit when he or she is stimulated by sexualized images of members of the same sex.
Numerous groups have spoken out against this practice, and people who have been subjected to it have lambasted it as both abusive and ineffective.
Conversion therapy has also been used to «treat» people who identify as transgender, the intent being to force them to adopt the gender expression that matches their biological sex. In some cases, minors are sent to conversion camps or treatment facilities by their parents, thus eliminating any option to consent to the therapy. Some states, including California and New Jersey, have banned conversion therapy for minors. Many other states are moving to follow suit.
Nevertheless, several prominent religious people have spoken out in favor of the process, claiming to be “ex-gays.
” Conversion therapy may affect a person’s sexual expression, perhaps by making the person feel guilt or shame for his or her feelings, but the process is unly to create heterosexual urges or to change a person’s sexual orientation.
In fact, the American Psychological Association's (APA) Task Force on the Appropriate Therapeutic Responses to Sexual Orientation determined that “efforts to change sexual orientation are unly to be successful and involve some risk of harm.
” The process of conversion therapy can lead to “loss of sexual feeling, depression, suicidality, and anxiety,” according to the APA. Conversion therapy’s use to “cure homosexuality” also helps contribute to the idea that gays and lesbians are fundamentally flawed, which can contribute to a culture of bullying and discrimination.
- American Psychological Association. (2009). Report of the American Psychological Association Task Force on the Appropriate Therapeutic Responses to Sexual Orientation. Retrieved from http://www.apa.org/pi/lgbt/resources/therapeutic-response.pdf?utm_source=LifeSiteNews.com+Daily+Newsletter&utm_campaign=635da942bd-LifeSiteNews_com_Intl_Full_Text_02_26_2013&utm_medium=email
- Bull, C. (1998, Nov 24). Peddling the cure: An examination from both the inside and outside of the religious right's movement to eliminate homosexuality. The Advocate, 42. Retrieved from http://search.proquest.com/docview/215759572?accountid=1229
- Colman, A. M. (2006). Oxford dictionary of psychology. New York, NY: Oxford University Press.
How It Works & What to Expect
Aversion therapy motivates behavior change through the formation of negative associations with a behavior.
Medication, unpleasant smells or tastes and even electrical shocks are some of the methods used to create negative associations that discourage unwanted behaviors.
While controversial, research suggests certain types of aversion therapy can be effective in the treatment of addiction and diseases related to lifestyle.
What Is Aversion Therapy and How Does it Work?
Aversion therapy is a psychological or medical treatment that uses negative physical and emotional associations to encourage behavior change.
By pairing a problem behavior with something that creates physical or emotional discomfort, the positive association with the behavior is broken and a new, negative association is developed.
This process is also referred to as “counterconditioning,” and is designed to encourage behavior change.7
Some of the methods used in aversion therapy to create unpleasant associations include:8
- Emetic methods: use of medication to induce nausea and vomiting
- Electrical methods: administering electric shocks
- Imaginal methods: use of unpleasant or upsetting mental images or thoughts
- Sensory methods: use of something with an unpleasant sensation (touch, taste or smell)
- Pharmacological methods: use of a medication which creates illness or discomfort when it interacts with a certain substance
Aversion therapy operates off of the principles of behaviorism, which encourages positive behaviors through rewards and discourages unwanted behaviors through punishments.
Essentially, behaviorism is the idea that human behavior is motivated by natural urges to seek pleasure and avoid pain.
Counterconditioning involves pairing behaviors or behavioral cues with painful, unpleasant or uncomfortable experiences to encourage future avoidance.1
Drugs and certain compulsive behaviors sex, gambling or stealing are believed to activate reward centers in the brain, causing the release of dopamine and causing a pleasurable “high”.
Over time, repeating the behavior causes reward or “addiction” pathways to form in the brain, resulting in strong urges to repeat the behavior and making it much harder to stop.
Aversion therapy aims to reverse this process by interrupting the reward process and punishing the behavior to create a negative association.2,6,7
Aversion therapy is an umbrella term that actually includes a variety of different treatment methods. Some of these have more evidence to support their use and are more commonly used. For example, the use of pharmacological aversion treatments Antabuse for alcoholism or orlistat for obesity are much more common than methods using electrical shock or sensory methods.
What Can Aversion Therapy Help With?
Aversion therapy can be used to treat a number of behavioral issues, lifestyle diseases, and addictions. In recent years, aversion therapy techniques are most commonly used to treat:1,5
Less commonly, aversion therapy has a history of being used to treat:1,8
- Self-harming behavior (i.e. cutting)
- Nail biting or thumb sucking
- Trichotillomania (hair pulling)
- Excoriation (skin picking)
- Problem sexual behaviors
Aversion therapy is usually recommended only when other frontline treatments have been ineffective or when there are other factors complicating treatment.
For example, aversion therapy has been used to help reduce self-harming and compulsive sexual behaviors in people who have an underlying brain injury or developmental disorder.
2,8 In another example, a person with a history of serious drug use and multiple failed treatments is more ly to be recommended for aversion therapy than a person seeking treatment for the first time.
Aversion Therapy Examples
Aversion therapy has been a controversial treatment and there were many documented instances where its use was unethical and even inhumane. Because of this complicated history, aversion therapy is often misunderstood. The following are examples of aversion therapy as it is most commonly used today.
Aversion Therapy For Alcohol Use Disorder
The FDA-approved medication disulfiram (or Antabuse) is often prescribed to people with alcohol use disorders. Disulfiram is a medication that, when taken daily, causes an adverse response to alcohol by blocking enzymes in the liver.
When people on this medication drink alcohol, they will develop uncomfortable symptoms nausea and vomiting, headaches, changes in blood pressure, sweating, anxiety, and trouble breathing.
Some people choose to take the medication to help safeguard against a relapse.3,9
Aversion Therapy For Obesity
Another FDA-approved medication used as a form of aversion therapy for obesity is the drug orlistat (brand names are Xenical and Alli).
Orlistat reduces the amount of fat metabolized by the body by approximately 30% but the side effects of the drug are what classify it as a form of aversion therapy.
When a person taking orlistat eats foods that are high in fat, they will experience diarrhea, gas, and even an inability to control the bowels. These unpleasant and embarrassing side effects are intentionally designed to create a negative association with eating fatty foods.4
Aversion Therapy For Nail Biting
Aversion therapy for nail biting is also relatively common. This technique is usually accomplished by painting the nails with a bitter substance neem oil or a formula using a spicy ingredient cayenne pepper.
This at-home technique can be accomplished using products easily bought online or at a drugstore, and has two main functions.
The first function is to help nail biters become more aware of the behavior and the second is to create a negative taste association.10
Cost of Aversion Therapy
The cost of aversion therapy varies greatly depending on the type of aversion therapy, whether it is being self-administered or professionally administered, and individual factors the length of treatment. The most common types of professional aversion therapy are medications which can be prescribed by a primary care doctor or a specialist.
Costs for these pharmacological aversion treatments vary considerably. According to Good RX, the generic version of the drug Antabuse averages around $35 for a 30 day supply. Additional to this cost would be the cost of the actual visit or consultation with the prescribing professional.
Aversion therapy is often recommended in combination with other treatments. For example, those taking the drug Antabuse for alcohol dependence are also recommended to see a professional counselor or addiction specialist.
Often, prescribed medications and office visits are at least partially covered by health insurance.
Visiting the insurers website or calling the number on the back of the insurance card is a good way to get detailed information about the cost of covered services and medications.
How To Find Aversion Therapy
Where to begin your search for aversion therapy greatly depends on the type of aversion therapy you are seeking, and the particular issue being addressed.
Those who are seeking aversion therapy for health-related issues weight loss or even smoking cessation can sometimes set up an appointment with their primary care doctor.
Those who are looking for aversion therapy for addiction or compulsive gambling should search for an addiction counselor.
Many people begin their search for an addiction counselor by doing a google search or by using an online directory. Those with health insurance can often save money by selecting an in-network therapist.
Reaching out to the insurance company or using their online portal can help identify a list of in-network therapists.
Those who need addiction treatment should look for providers with secondary licenses or credentials to prove they are experienced in treating addiction.
Because aversion therapy is not very common, it may be difficult to find a counselor who specializes in this approach.
There is not a formal designation or credential for aversion therapists, but calling around can sometimes lead to finding a counselor with specialized training in this area.
Because of their education and training, most professional counselors are not able to prescribe medication, so those interested in pharmacological treatments should find a doctor or other prescribing professional.
What to Expect At Your First Appointment
Those who begin aversion therapy with a licensed counselor can expect to spend 60-90 minutes completing a detailed intake and assessment.
During this appointment, clients are asked to fill out paperwork and are also asked a number of questions designed to help determine a clinical diagnosis.
At the end of the appointment, the counselor will review the diagnosis and discuss options for further treatment.
If the first appointment is with a prescribing professional ( a doctor, physician’s assistant, or nurse practitioner), the first appointment will involve a less formal discussion of the issue. Those seeking pharmacological aversion therapy can expect for the practitioner to provide detailed information about the medication, purpose, and potential side effects.
When any medication is prescribed, a follow-up appointment is usually scheduled to determine whether the medication is having the desired effects after 2-6 weeks. If a person has adverse reactions or side effects prior to their follow-up, they are recommended to contact the doctor for advice on whether to continue the medication.
Is Aversion Therapy Effective?
Certain types of aversion therapy have more research to support their efficacy. Much of the research on aversion therapy is outdated, and was conducted when standards for research were less rigorous.
More current research on aversion therapy has proven it can be effective in treating the following issues:1,2,5,6,7,9,10,11
- Addictions to alcohol, cocaine, methamphetamines
- Obesity and weight loss (Orlistat)
- Self-harming behaviors (i.e. cutting)
- Nail biting
- Compulsive gambling
Brain imaging studies have provided evidence that counterconditioning does interrupt reward activity, suggesting that it can be effective in counteracting addiction pathways in the brain.
6 It is also well documented that aversion therapy can reduce cravings but what is less clear is whether these results are lasting, as research on the topic has been mixed.2,11 Many of the medications used in aversion therapy will not have lasting impact.
So if a patient decides to stop taking the prescription there will no longer be the negative “consequences” to the behavior being addressed.
Insufficient research exists on the use of aversion therapy for the following issues:1,8
- Excoriation disorder (skin picking)
- Trichotillomania (hair pulling)
- Sexually compulsive behaviors (pedophilia, exhibitionism)
- Smoking cessation (specifically aversive smoking which involves rapid chain smoking)
- Compulsive gambling
Controversy & Criticism of Aversion Therapy
Today, there are many ethical codes, laws, and safeguards that protect people seeking treatment for a physical or psychological problem. Unfortunately, this was not always the case.
Much of the controversy surrounding aversion therapy stemmed from experimental psychological treatments done in the ’50s, ’60s, and ’70s.
At this time, electric shock treatment was the most commonly used technique, and un modern methods of electrical treatment, was painful and inhumane.8
Because of the controversy surrounding these techniques, aversion therapy was rarely used between the years of 1980-2000, and has only recently reemerged as a viable treatment option for addiction, lifestyle, and behavioral disorders.
Still, some continue to raise ethical concerns about certain aversion techniques the use of electrical shocks.
There is also some research which suggests that counterconditioning in aversion therapy provides only short-term results as opposed to the more lasting results seen in other types of treatment.11
It should be pointed out that shock treatments for aversion therapy are different than elecroconvulsive therapy, which is still used for cases of treatment resistant depression.
What Is Aversion Therapy?
Aversion therapy is the psychological principle of classical (or Pavlovian) conditioning.
Classical conditioning is when you pair two different stimuli together to create an associative memory. For example, you can pair an auditory tone with an electric shock to create an association.
Then, when you play the tone later by itself, the tone alone will elicit a stress or fear response because it has been associated with the shock.
Aversion therapy takes advantage of the same basic principles to change behavior.
Uses of Aversion Therapy
Aversion therapy has been used to treat conditions in which a person engages in unhealthy behaviors. While modern psychologists will ly use other treatment methods, aversion therapy can be used for the following challenges:
- Bad habits: Some people may seek to address bad habits, such as nail biting, with aversion therapy. For example, a greater proportion of people who went through aversion therapy had either ceased biting their nails or were biting less frequently three months later compared to people who experienced no aversion therapy.
- Smoking: Aversion therapy has been used for smoking cessation purposes.
- Gambling: Research has shown the use of aversion therapy in attempts to stop people from gambling.
- Alcoholism: In the past, alcoholism has been treated using aversion therapy procedures that either involved electrical, chemical or verbal imagery as the negative stimulus, which served to reduce drinking behavior amongst people struggling with alcohol use.
- Violence: Aversion therapy was also used to reduce violent behavior. Historically, this method has most often been utilized in correctional facilities.
Aversion therapy effectiveness has been a matter of contention. Many factors come into play when it comes to the effectiveness of aversion therapy, such as the treatment methods, aversive conditions that are used and whether the client continues to practice setback-prevention techniques after treatment finishes.
Usually, aversion therapy may be effective while a person is still undergoing treatment and in a clinical setting. The biggest problem is the high rate of setbacks that occur once the patient is back in real-world settings without the aversive stimulus (usually an electric shock) present.
Criticisms of Aversion Therapy
There has been much criticism of aversion therapy. The primary criticism is the lack of scientific rigor in the studies conducted. The studies that do exist on aversion therapy are mainly from the 1960s and 1970s and often their conclusions were drawn from very small samples. Sometimes these published studies included only one person.
Another major criticism of aversion therapy involves its use in the “treatment” of homosexuality. This issue wasn’t officially addressed by the American Psychological Association until 1994.
Today, there are more widely used, evidence-based therapies and treatment options available for addiction and other conditions. If you or a loved one struggle with a substance use disorder, contact The Recovery Village to speak with a representative about how evidence-based treatment helps people live healthier lives.
- SourcesMcGuire, Ralph J; Maelor, Vallance. “Aversion therapy by electric shock: A simple technique.” British Medical Journal, 1964. Accessed September 22, 2019.Vargas, John; Vincent J. Adesso. “A comparison of aversion therapies for nailbiting behavior.” Behavior Therapy, 1976. Accessed September 22, 2019.Hajek, Peter; Lindsay F. Stead. “Aversive smoking for smoking cessation.” Cochrane Database of Systematic Reviews, 2001. Accessed September 22, 2019.Barker, J. C.; Mabel Miller. “Aversion therapy for compulsive gambling.” British Medical Journal, 1966. Accessed September 22, 2019.Elkins, Ralph L. “Aversion therapy for alcoholism: Chemical, electrical, or verbal imaginary?” International Journal of the Addictions, 1975. Accessed September 22, 2019.Gaylin, Willard; Helen Blatte. “Behavior modification in prisons.” Am. Crim. L. Rev., 1975. Accessed September 22, 2019.Witkiewitz, Katie; Marlatt, Alan. “Behavioral Therapy Across the Spectrum.” Alcohol Research and Health. Accessed November 4, 2019.
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Chemical Aversive Conditioning for Alcoholism
Aetna considers aversive conditioning for alcoholism experimental and investigational due to insufficient evidence in the peer-reviewed literature.
Chemical aversion therapy is a behavior modification technique that is used in the treatment of alcoholism by facilitating alcohol abstinence through the development of conditioned aversions to the taste, smell, and sight of alcohol beverages. Aversive conditioning involves pairing alcohol with unpleasant symptoms (e.g.
, nausea) which have been induced by one of several chemical agents. While a number of drugs have been employed in chemical aversion therapy, the three most commonly used are emetine, apomorphine, and lithium.
However, it should be noted that these agents are not FDA approved specifically for chemical aversive conditioning for alcoholism (CMS, 2015).
Smith et al (1990) conducted a study of a multimodal inpatient program that used aversion therapy as a treatment component. A sample of 200 patients who had been completed treatment for alcoholism were recruited and a final sample of one hundred sixty (80%) were located. A minimum of 13 months had elapsed since treatment (mean 20.
5 months) and abstinence status was determined for the first 12 months since treatment, the entire elapsed time since treatment (range 13 to 25 months, mean 20.5 months), and «current abstinence» (last 6 months). Results showed an abstinence rate for the first 12 months of 71.3%; 65% for the total period since treatment (mean 20.
5 months), and the current abstinence rate was 78.1The authors suggested that a multimodal alcoholism treatment program utilizing aversion conditioning is at least as acceptable to patients as counseling centered programs and can be expected to yield favorable abstinence rates.
However, replication of these findings in a controlled clinical trial would strengthen the weight of evidence.
Smith et al (1991) evaluated 249 patients who were treated for alcoholism in an inpatient multimodal treatment program that included aversion therapy.
They were matched on 17 baseline variables post hoc with patients from a national treatment outcome registry who received inpatient treatment that emphasized individual and group counseling as the primary therapeutic elements but did not include aversion therapy for alcohol.
Data on 6- and 12-month abstinence rates from alcohol and all mood-altering chemicals was collected. The authors reported results including a statistically significant difference in the patients treated with aversion therapy compared with the matched patients.
The patients treated with aversion therapy for alcohol had higher alcohol abstinence rates at 6 and 12 months (p less than 0.01) and abstinence rates from all mood-altering chemicals were higher in the aversion group at 6 months (p less than 0.05) but not at 12 months.
Treatment groups in 6-month alcohol abstinence rates were found to have the largest differences for males (p less than 0.001), those over 35 (p less than 0.001), daily drinkers (p less than 0.001), and those with alcohol-related work performance problems (p less than 0.05). Again, while encouraging, this study design is not a randomized controlled clinical trial to evaluate the effectiveness of chemical aversive conditioning for alcoholism.
Frawley et al (1992) studied 214 randomly selected patients treated with aversion therapy for cocaine dependence in four chemical dependency units operated by Schick Shadel Hospitals. Of these, 156 were followed up 12 to 20 months post-treatment (average 15.2 months).
One-year total abstinence from alcohol was 54% for those receiving aversion for both alcohol and cocaine and 77% for those receiving aversion for alcohol, cocaine, and marijuana. Current abstinence from alcohol at follow-up was 68% and 81%, respectively.
Results showed that 1 year total abstinence from marijuana was 42% for those treated with aversion for cocaine and marijuana and 64% for those treated with aversion for alcohol, cocaine, and marijuana while current abstinence at follow-up from marijuana was 61% and 81%, respectively.
The results illustrated that total abstinence from cocaine for the group overall was 53% at one year post-treatment, current abstinence of at least 6 months at follow-up was 68.6%, while those treated with aversion for cocaine alone had a one-year abstinence of 39% and a current abstinence of 62.4%.
Study participants treated with aversion for alcohol and cocaine had a one-year total abstinence from cocaine of 69% and a current abstinence of 76%. Those treating with aversion for cocaine and marijuana had a one-year total abstinence from cocaine of 50% and a current abstinence of 65%.
Those treating with aversion for alcohol, cocaine, and marijuana had a one-year total abstinence from cocaine of 73% and a current abstinence of 73%. The authors noted that the use of aversion therapy for both alcohol and cocaine in alcoholics who were also using cocaine was associated with higher total abstinence rates (88% vs.
55%) from cocaine when compared with alcoholics who used cocaine but received no aversion as part of their program. They further noted that the conclusion is tentative since the follow-up rate in this study was lower than that of the previous study (64% vs.
84%) and that being around other users accounted for 49% of relapse situations while family/work stress was associated with relapse in 33% of cases and unpleasant feelings in 24% of cases. The use of both reinforcement treatments and the use of support following treatment were associated with improved abstinence rates from cocaine while those patients who reported losing all urges for cocaine after treatment had a total abstinence from cocaine of 90%, those who reported losing all the uncontrollable urges had a total abstinence of 64%, and those who reported still having the urge reported only 33% total abstinence from cocaine.
Smith et al (1997) reported on 249 patients who were treated for alcoholism in an inpatient multimodal treatment program that included aversion therapy and were matched post hoc on 17 baseline variables with patients from a national treatment outcome registry.
The latter patients received inpatient treatment that emphasized individual and group counseling as the primary therapeutic elements but did not include aversion therapy for alcohol.
Six- and 12-month abstinence rates from alcohol and all mood-altering chemicals were reported and the patients treated with aversion therapy for alcohol had higher alcohol abstinence rates at 6 and 12 months (p < 0.01). The abstinence rates from all mood-altering chemicals were significantly higher in the aversion group at 6 months (p < 0.05) but not at 12 months.
It should be noted that these comparisons pooled faradic aversion and chemical aversion results. In order to determine whether or not the faradic aversion gave comparable results to the chemical aversion, the two groups were separately analyzed and no significant differences in outcome was found.
Diana et al (2008) reported that ethyl alcohol (EtOH), the main psychoactive ingredient of alcoholic drinks, is widely considered responsible for alcohol abuse and alcoholism through its positive motivational properties, which depend at least partially on the activation of the mesolimbic dopaminergic system.
They further noted that acetaldehyde (ACD), EtOH's first metabolite, has been classically considered aversive and useful in the pharmacologic therapy of alcoholics.
The authors illustrated that EtOH-derived ACD is necessary for EtOH-induced place preference, a preclinical test with high predictive validity for reward liability and that ACD is essential for EtOH-increased microdialysate dopamine (DA) levels in the nucleus accumbens (NAcc), and that this effect is mimicked by ACD administration to the intraventral tegmental area (VTA). The authors state that these results provide in vivo and in vitro evidence for a key role of ACD in EtOH motivational properties and its activation of the mesolimbic DA system. They further note that these observations suggest that ACD would oppose its well-known peripherally originating aversive properties by increasing VTA DA neuronal activity. These findings could help in devising new effective pharmacologic therapies in alcoholism.
Cassiaglia et al (2013) reported that people at high risk for alcoholism show deficits in aversive learning, as indicated by impaired electrodermal responses during fear conditioning, a basic form of associative learning that depends on the amygdala.
They also state that positive family history of alcohol dependence has been related to decreased amygdala responses during emotional processing.
This study reported that reduced amygdala activity during the acquisition of conditioned fear in healthy carriers of a risk variant for alcoholism (rs2072450) in the NR2A subunit-containing N-methyl-d-aspartate (NMDA)-receptor.
The authors note that results indicate that rs2072450 might confer risk for alcohol dependence through deficient fear acquisition indexed by a diminished amygdala response during aversive learning, and provide a neural basis for a weak behavioral inhibition previously documented in individuals at high risk for alcohol dependence.
Kim et al (2014) noted that episodes of alcohol consumption produce use-limiting aversive effects as well as use-promoting euphoric effects and that the brain regions associated with the reward circuit in patients with alcohol dependence show signs of conditioning for alcohol craving.
Kim et al (2014) also note that brain structures in the medial temporal region are known to be crucial for aversive conditioning.
This study was conducted to compare differences in patterns of brain activation in response to cues that induce cravings versus aversion in alcohol dependence in 38 alcohol dependent and 26 healthy volunteers who were administered cue reactivity tasks while undergoing functional magnetic resonance imaging (fMRI) to examine brain response to craving-inducing cues (CIC) and aversion-inducing cues (AIC). The authors found that the right medial frontal gyrus (right orbitofrontal cortex) during CIC was greater in alcohol dependent study participants than in healthy volunteers. Participants in the alcohol dependence group displayed less activation in the right amygdala and the right middle temporal gyrus during AIC than did the healthy volunteers and brain reactivity within the right medial frontal gyrus in response to CIC was positively correlated with the scores of alcohol dependent participants on the Korean Alcohol Urge Questionnaire (AUQ-K) and the Michigan Alcohol Screening Test (MAST). Reactivity within the amygdala in response to AIC was negatively correlated with AUQ-K scores among alcohol dependent patients. The authors concluded that the dysfunction of the orbitofrontal cortex that results from repeated exposure to alcohol accounts for craving and relapse in alcohol dependent subjects. Additionally, alcohol dependent subjects seem to be less sensitive to cues related to aversive consequences of alcohol overuse in comparison with healthy individuals.
Centers for Medicare and Medicaid Services (CMS) have published a National Coverage Determination (NCD) stating that chemical aversion therapy for alcoholism may be an effective component of certain alcoholism treatment programs, particularly as part of multi-modality treatment programs which include other behavioral techniques and therapies, such as psychotherapy and thus do cover chemical aversion therapy. However, the NCD also notes that «[h]owever, since chemical aversion therapy is a demanding therapy which may not be appropriate for all Medicare beneficiaries needing treatment for alcoholism, a physician should certify to the appropriateness of chemical aversion therapy in the individual case.»
|F10.10 — F10.19||Alcohol abuse|
|F10.20 — F10.29||Alcohol dependence|
The above policy is the following references:
- Cacciaglia R, Nees F, Pohlack ST, et al. A risk variant for alcoholism in the NMDA receptor affects amygdala activity during fear conditioning in humans. Biol Psychol. 2013;94(1):74-81.
- Centers for Medicare & Medicaid Services (CMS).
National Coverage Determination (NCD) for Chemical Aversion Therapy for Treatment of Alcoholism (130.3). Baltimore, MD: CMS; undated.
- Diana M, Peana AT, Sirca D, et al. Crucial role of acetaldehyde in alcohol activation of the mesolimbic dopamine system. Ann N Y Acad Sci. 2008;1139:307-317.
- Frawley PJ, Smith JW.
One-year follow-up after multimodal inpatient treatment for cocaine and methamphetamine dependencies. J Subst Abuse Treat. 1992;9(4):271-286.
- Kim SM, Han DH, Min KJ, et al. Brain activation in response to craving- and aversion-inducing cues related to alcohol in patients with alcohol dependence. Drug Alcohol Depend.
- Smith JW, Frawley J, Polissar L. Six- and twelve-month abstinence rates in inpatient alcohoics treated with aversion therapy compared with matched inpatients from a treatment registry. Alcoholism: Clinical and experimental research. 1991;15(5): 862-870.
- Smith JW, Frawley PJ, Polissar NL.
Six- and twelve-month abstinence rates in inpatient alcoholics treated with either faradic aversion or chemical aversion compared with matched inpatients from a treatment registry. J Addict Dis. 1997;16(1):5-24.
- Smith JW, Frawley PJ.
Long-term abstinence from alcohol in patients receiving aversion therapy as part of a multimodal inpatient program. J Subst Abuse Treat. 1990;7(2):77-82.