Mental Health Section - Aversion Therapy for Chemical Dependency

IMPORTANT REMINDER

This Medical Policy has been developed through consideration of medical necessity, generally accepted standards of medical practice, and review of medical literature and government approval status.

Benefit determinations should be based in all cases on the applicable contract language. To the extent there are any conflicts between these guidelines and the contract language, the contract language will control.

The purpose of medical policy is to provide a guide to coverage. Medical Policy is not intended to dictate to providers how to practice medicine. Providers are expected to exercise their medical judgment in providing the most appropriate care.

Description
Aversion therapy is an in-patient substance abuse treatment strategy that has been used for many years for alcohol and cocaine dependence at the Shick Shadel Hospitals. The treatment generally includes a ten day in-patient stay during which the patient receives aversion counter-conditioning designed to make the sight, smell, taste and thought of the alcohol and/or cocaine unpalatable. Narcotherapy (pentothal interview) is a component of the aversion therapy program designed to gather initial psychological diagnostic information and to monitor the development of aversion to the addictive substances. Under light anesthesia, patients are queried about the level of desire for each type of substance. Aversion therapy with pentothal interview is provided within a comprehensive treatment program that includes detoxification, counseling, addiction education, and introduction to a 12 step program for follow-up care.

Policy/Criteria
Aversion therapy and pentothal interviews are considered investigational in the treatment of chemical dependency.

Scientific Background

The components of standard outpatient substance abuse therapy consist of individual, group and family psychotherapy, relapse prevention therapy, and introduction to a 12-step program for follow-up. Agonist substitution therapy (methadone or LAAM) and medications to decrease the reinforcing effects of abused substances, also known as withdrawal drugs (eg, naltrexone, clonidine/naltrexone, buprenorphine), may also be included as a component of standard therapy.

Long term outcomes from randomized trials comparing aversion therapy to standard substance abuse therapy are needed to demonstrate the independent contribution of aversion therapy in the overall treatment program. No randomized trials were identified in the published literature.  The only available published evidence consists of outcomes from two series of patients treated at Schick Shadel Hospitals:

• Smith and Frawley reported outcomes for 200 patients randomly selected from a group of patients that completed an initial10 days of treatment at a Schick Shadel Hospital in 1983. (2) During the initial 10-day hospitalization, patients received five days of aversion therapy and 5 days of narcotherapy, given on alternating days. This was followed at 30-day and 90-day intervals with 2-day inpatient admissions for reinforcement treatment consisting of one day each of aversion therapy and narcotherapy. Follow-up was by telephone interview at 12-months. Of the 200 patients, 20% were lost to follow-up. In addition, 22 patients were known to have relapsed prior to the 12-month telephone interview.
• The same authors followed 156 of 214 patients for 12 months post-aversion therapy. (1)  Patients in this cohort were addicted to cocaine alone, cocaine and alcohol, or cocaine and marijuana. As with the first study, there was significant loss to follow-up in this study (36%).

Conclusions concerning the impact of aversion therapy and narcotherapy on health outcomes cannot be reached from the above two studies.  Data from these studies are unreliable due to a lack of treatment randomization, selection bias, significant loss to follow-up, and inability to isolate the independent contribution of aversion therapy and pentothal interview from the overall substance abuse treatment program.

References

1. Smith JW, Frawley PJ. Long-term abstinence from alcohol in patients receiving aversion therapy as part of a multimodal inpatient program. J Substance Abuse Treat 1990;7:77-82
2. Frawley PJ, Smith JW. One-year follow-up after multimodal inpatient treatment for cocaine and methamphetamine dependencies. J Substance Abuse Treat 1992 Fall;9:271-286

Cross References
None

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