Resumen:

El abuso crónico de sustancias adictivas es un problema de salud pública, debido a la gravedad de sus consecuencias: accidentes automovilísticos mortales, urgencias traumáticas, enfermedades físicas severas: cirrosis hepática, alteraciones cardiovasculares, problemas cerebrovasculares, pancreatitis; pérdidas en diferentes áreas del funcionamiento de vida cotidiana: social, psicológica, legal, personal, familiar, económica y laboral; depresión, ansiedad, alteraciones en el sueño, pérdida de redes de apoyo, suicidio, violencia, homicidios, divorcio, pérdida de empleo, hospitalizaciones, encarcelamientos, etc.

En México, es necesario desarrollar más modelos de intervención para usuarios crónicos de sustancias adictivas, que incluyan la instrumentación y evaluación sistematizadas con mediciones a mediano y largo plazo para constatar su efectividad. El diseño de modelos de intervención requiere la inclusión de antecedentes de otros modelos con solidez y efectividad en su evidencia empírica.

El modelo de intervención: Commun ity Reinforcement Approach "CRA", es reconocido por la literatura científica y por instancias internacionales (Nacional Institute of Drug Addiction y el National Institute of Alcoholism and Alcohol Abuse) como uno de los de mayor efectividad para disminuir el patrón de consumo en usuarios crónicos de sustancias adictivas.

El objetivo en esta investigación preliminar fue adaptar, sistematizar, instrumentar y evaluar el impacto del modelo de intervención Community Reinforcement Approach en la disminución del patrón de consumo en usuarios dependientes de alcohol y otras drogas en población mexicana.

Se instrumentó un Modelo de Intervención cognoscitivo-conductual en nueve usuarios crónicos; los criterios de inclusión fueron: ser mayor de 18 años, saber leer y escribir, tener un nivel de dependencia media y severa al alcohol y/o un nivel de dependencia sustancial y severa a otras drogas, uno o más tratamientos o internamientos previos, y pérdidas asociadas al consumo en diferentes áreas de vida cotidiana. La duración del tratamiento fue de 15 a 24 sesiones; y la duración de la sesión: 1 Hora Vi, dos veces por semana. Se utilizó un Diseño de Caso Unico con Réplicas y Seguimiento. El Modelo incluyó los siguientes componentes de intervención: Análisis funcional, muestra de no consumo, metas de vida cotidiana, comunicación, solución de problemas, rehusarse al consumo, consejo marital, búsqueda de empleo, habilidades recreativas y sociales, y prevención de recaídas. La adaptación del modelo original (CRA), incorporó cambios: 1) Inclusión de otras habilidades de comunicación, 2) Evaluación de variables predictoras de recaídas: autoeficacia y precipitadores, 3) Se añadieron habilidades de rehusarse al consumo de acuerdo al contexto ambiental de los usuarios mexicanos. Los instrumentos de evaluación pre-postest fueron: línea base retrospectiva (LIBARE), autoregistro, escala de confianza situacional y/o escala de autoconfianza en el consumo de drogas, escala de satisfacción de vida cotidiana, inventario de situaciones de consumo de drogas y/o inventario de situaciones de consumo de alcohol.

Los cambios significativos identificados en esta investigación preliminar constatan la efectividad del modelo en los nueve usuarios dependientes de sustancias adictivas: decremento en el patrón de consumo durante y al año después de terminado el tratamiento, incremento en el nivel de satisfacción de vida cotidiana y en el nivel de autoeficacia después del tratamiento y en seguimiento; y disminución de la cantidad de precipitadores al consumo después del tratamiento y en seguimiento. Los usuarios aprendieron a generarse un estilo de vida cotidiano más satisfactorio, al incluir actividades incompatibles con el consumo. Se recomienda en réplicas de la instrumentación de este modelo incluir un componente de entrenamiento para el autocontrol de emociones (depresión, ansiedad y enojo), evaluar el funcionamiento cognitivo como variable predictora de recaídas, incluir a usuarios egresados en un grupo de actividades social-recreativas para reforzar el mantenimiento de la abstinencia a largo plazo.

Palabras clave: Consumo crónico; intervención cognoscitivo-conductual; sustancias adictivas

Abstract:

The chronical abuse of addictive substances is a major public health problem, due to the seriousness of the consequences: fatal automobile accidents or others involving traumatic injury and emergency medical care, chronic physical diseases such as cirrhosis of the liver, cardiovascular complaints, cerebrovascular problems and pancreatitis, as well as disability and disruption in different functional areas of daily life, whether social, psychological, legal, personal, family, economic or professional. These factors include: depression, anxiety, loss of sleep, loss of support networks, suicide, violence, injury in fights, homicide, financial debt, divorce, loss of employment, hospitalization, crime and imprisonment, among others.

It is therefore required to establish multidisciplinary intervention models that respond to the seriousness of the problem. In Mexico, reports show that there is a need for the development of more intervention models for chronic users of addictive substances, which include systematic implementation and evaluation as well as medium- and long-term measurements to assess effectiveness. Intervention services often do not go beyond support for the initial detoxification. Additionally, the high cost of most treatment schemes makes them inaccessible to the majority of the people affected by these problems.

Intervention models must be designed and developed to include elements from other models that have proven to be reliable and effective on the basis of empirical evidence.

The Community Reinforcement Approach or "CRA" intervention model has gained recognition in scientific literature and from international institutions (the National Institute of Drug Addiction, NIDA, and the National Institute of Alcoholism and Alcohol Abuse, NIAAA) as one of the most effective means in reducing consumption by chronic users of addictive substances.

Consequently, the objective of this research was to use a pilot project to adapt, systemize, implement and assess the impact of the Community Reinforcement Approach intervention model in reducing consumption patterns among chronic dependent users of alcohol and other drugs within the Mexican population.

A cognitive-behavioral intervention model was applied to 9 chronic users who had requested psychological help at the

Psychological Service Centers of the Faculty of Psychology. The average age of the users was 35. Seven of them were male and two female. The most commonly consumed addictive substance was alcohol by six users, with other drugs accounting for three (benzodiazepine, marihuana, cocaine, solvents and amphetamines). On average, the subjects had spent 14 years in schooling. Five of them were single, one was married, one cohabiting and two divorced. With regard to the occupations of the sample, one was a student, two had abandoned a course of study, four were employed before treatment and two were unemployed.

The criteria that the users had to meet for inclusion in the study were: to be aged 18 or over; to be able to read and write; to have a medium-to-severe level of alcohol dependence corresponding to a range between 22 and 47 points on the Alcohol Dependence Scale (ADS) and/or a substantial-to-severe level of dependence on other drugs of between 11 and 20 points according to the Drug Abuse Questionnaire (DAQ); to consume a quantity of 14 or more measures of alcohol per occasion and/ or 20 or more measures per week for men, and 10 or more per occasion or 15 or more per week for women; to have been treated or interned on at least one previous occasion; to suffer consumption-related difficulties in different areas of daily life.

The duration of the treatment period was from 15 to 24 sessions, depending on the specific training needs of each user. Sessions lasted 1% hours, and were given twice a week. The methodology used was single case with repetitions and follow-up.

The cognitive-behavioral model included the following intervention components: Functional Analysis, Demonstration of Non-Consumption, Daily Life Goals, Communication, Problem Solving, Consumption Refusal, Marriage Guidance, Employment Searches, Recreational and Social Skills and Prevention of Relapses. The didactic techniques used in the training for each of the aforementioned components were: verbal instruction, modeling, behavioral trials and feedback.

The original model (CRA) was adapted to include the following changes: 1) More communication skills were integrated, including listening, starting conversations, giving and receiving criticism, giving and receiving recognition, and sharing positive and negative feelings; 2) Relapse prediction variables were assessed: self-effectiveness and triggers; 3) New skills for refusing consumption were added: interrupting interaction, justification for non-consumption.

Occurrence records were kept for the application in natural settings of the skills taught. In addition, teaching materials were prepared, along with information brochures on different addictive substances and the different training components, lists of community resources and therapist checklists to guarantee the systematic implementation of the model.

The pre-post-test evaluation methods were: Retrospective Baseline (RETBAS), Self-Recording, Situational Confidence Scale and/or Drug Consumption Self-Confidence Scale, Daily Life General Satisfaction Scale, Inventories of Drug Consumption Situations and/or Inventories of Alcohol Consumption Situations.

The significant changes identified in this preliminary research were: decreases in consumption patterns during and after treatment, since in the pre-post-test statistical analysis for paired samples the results t= 4.75 p = .001 were obtained in the comparison of baseline and treatment, and t= 4.28 p=.002 in the comparison of the baseline and follow-up; increases in the levels of general satisfaction in daily life following treatment and during follow-up, since in the pre-post-test statistical analysis for paired samples the results t=-3.94 and p=.004 were obtained, and t=-4.03 and p=.004 in the pre-follow-up comparison; increases in levels of self-effectiveness after treatment and during follow-up, since in the pre-post-test statistical analysis for paired samples the results t= -5.08 and p=.001 were obtained, and t= 4.37 and p=.002 in the pre-follow-up comparison; decrease in the number of consumption triggers after treatment and during follow-up, since in the pre-post-test statistical analysis for paired samples the results t= 5.80 and p=.000 were obtained, and t= 5.3 and p=.001 in the pre-follow-up comparison.

As a result of the foregoing, the researchers were able to verify the effectiveness of this intervention model in significantly reducing consumption patterns in nine chronic dependent users of addictive substances. Similarly, the model had a significant impact on consumption prediction variables, as well as increasing self-effectiveness levels and eliminating triggers to avoid relapses. Users learnt how to create a more satisfying day-to-day lifestyle, by including activities incompatible with consumption.

Finally, in repetitions of the implementation of this intervention model, it is recommended that a training component be introduced for emotion management (depression, anxiety and anger), as well as an assessment of cognitive functioning as a relapse prediction variable, and the participation of users that have been part of a social-recreational activity group to reinforce sustained abstinence in the long term.

Key words: Chronic consumption; cognitive behavioral intervention; addictive substances