Chapter 15 Tx Of Subtance Use Disorders

Treatment of Substance-Use

Disorders

Chapter 15

Introduction

Some people whose substance use becomes abuse or dependence seek treatment.

Treatment – Planned activities designed to change some pattern of behavior (s) of individuals or their families

Figure 15.1 provides a model of what might occur during the course of treatment, from the time an alcohol or drug problem is recognized to the outcome, or the result that is attributed to treatment

For any treatment to happen there must be recognition of a problem and the person must be motivated to change

If change is initiated, it typically happens in one of three ways: Spontaneous Remission – Resolution of a problem

without the help of formal treatment. As with nicotine dependence, people with substance abuse disorders change these problem behaviors on their own quite frequently.

Use of self-help groups such as Alcoholics Anonymous and Narcotics Anonymous.

Individuals go into some kind of professional treatment Frequently self-help groups and professional

treatment are combined

Motivation to Change

Readiness or commitment to change is often considered essential for treatment to be effective.

Denial is a major barrier to change One model of the change process is the stages of

change model. The five stages are precontemplation, contemplation,

preparation, action, and maintenance A person may cycle through the stages to various points

several times before problem resolution is reached Rate of progression and the amount of recycling differ

from person to person and from problem to problem for a given person, but going through the stages applies generally

Precontemplation – Not aware of the problem or no interest in change. They are said to be in “denial”

Contemplation - Vacillate between the pros and cons of the behavior and the pros and cons of changing it. They have taken no steps toward change

Preparation – On the edge of taking action to change and may have made a try in the recent past. In order to progress, a commitment to take action and to set goals is needed

Action - Already engaged in explicit activities to change Maintenance – Continued use of behavior-change

activities for as long as three years after the action stage began

Change Without Formal Treatment

More people resolve their substance abuse problems on their own than any other way

Some report their change resulted from weighing the benefits and costs of continuing their current use

Some report change was immediate, and they either could not recall what triggered the change or said it was a major event, such as a serious alcohol-related health problem

Self-Help Groups

Peer self-help groups are a major part of the treatment of substance-use disorders

Peer self-help groups are distinguished from those in which therapeutic agents, such as the group leader, are not identified as having the same problem as the clients. Peer self-help group participants both give and receive help with their problems

The self-help groups Alcoholics Anonymous and Narcotics Anonymous are major resources in helping people who have alcohol and drug use disorders

AA is the prototype self-help group because it is the oldest, established in 1935 by Dr. Bob and Bill W.

Alcohol self-help groups derived from AA include Alateen for teenagers with an alcoholic parent and Alanon aimed at spouses and others close to the alcoholic

The basis of the AA program are self-help through following the Twelve Steps ( See Table 15.1) and group participation

The Twelve Steps recovery program is oriented toward action, both in self-examination and change and in behavior toward others

Recovery – In the addictions field, changes back to health in physical, psychological, spiritual, and social functioning. It generally is believed that recovery is a lifetime process that requires total abstinence from alcohol and nonprescribed drugs

Women for Sobriety (WFS) is similar to AA, yet focuses on the special psychological and social needs and concerns that women face in achieving and maintaining sobriety

Peer self-help has been a popular treatment of choice for other addictive behaviors: Weight Watchers and TOPS (Taking Off Pounds Sensibly), Smokers Anonymous, and Gamblers Anonymous

Self-help groups, presented as alternatives to AA, also are becoming more popular. Two examples are SMART and Secular Organizations for Sobriety (SOS).

SMART stresses self-management and recovery training, while SOS deemphasizes spirituality or higher powers in staying sober

Models of Substance-Use Disorders

The model of etiology (cause) of alcohol and drug use disorders that a treatment is based on affects its design.

The five models reviewed are: Moral, American Disease, Biological, Social Learning, and Sociocultural

Moral model – Substance abuse viewed as the result of personal decisions and choices and thus the individual is responsible. Treatment consists of either legal or spiritual intervention

American Disease model – Prevalent in the U.S. and the foundation of A.A., alcohol and drug dependence is viewed as the product of a progressive, irreversible disease. Treatment is to identify people who have the disease, confront them with it, help them to accept they have it, and persuade them to abstain

Biological model – Dependence is the result of genetic or physiological processes. Treatment is to advise biologically at-risk people of their risk and counsel them to avoid drugs/alcohol altogether

Social Learning model – Result of complex learning from an interaction of the person with his or her environment. Situations and psychological processes are most important. Harmful substance use patterns

The Biopsychosocial model of etiology addresses the inadequacy of single-factor models by combining the major types of factors that seem to influence the development of alcohol and drug use disorders

Professional Treatment: Assessment and Goals

Treatments have aims or goals that typically follow from a thorough assessment and refer to a person’s use of alcohol and drugs and to other areas of life functioning

It has been standard practice to specify abstinence from alcohol or other drugs as the major outcome goal for a treatment. However, some argue that moderate, nonproblem use of alcohol is a reasonable outcome goal for some patients.

Harm Reduction models seek to reduce the negative consequences of using rather than reducing the quantity or frequency of consumption. Examples include designated driver programs and syringe distribution to addicts

Alcohol Treatment Settings and Services

Alcohol treatment can be classified broadly into three categories of settings: hospital, intermediate, and outpatient. Within each setting a wide variety of services may be offered. Types of treatments include:

Psychological Treatment – Treatment geared to changing emotions, thoughts, or behavior without the use of medications or other physical or biological means (Common in hospital-based and inpatient “free-standing” alcohol programs)

Milieu Treatment – Treatment in which the organization and structure of a setting are designed to change behavior. Counseling and psychotherapy are usually available and there is a strong emphasis on the use of self-help groups such as A.A. (Halfway Houses)

Counseling – In alcohol and drug treatment, counselors are specially trained professionals who perform a variety of treatment activities, including assessment, education, and individual, marital, and family counseling

Psychotherapy – Typically, conversation between a specially trained individual (Therapist) and another person (or family) that is intended to change patterns of behavior, thoughts, or feelings in that person

Outpatient services may include both individual and group counseling with professionals and/or “paraprofessionals”, people working in direct patient care yet not possessing a formal degree

Pharmacological Treatment

Pharmacological treatment of alcohol problems includes medication to manage withdrawal from alcohol, alcohol-sensitizing drugs, drugs that alter the reinforcing properties of alcohol, and drugs that manage alcohol craving.

Several pharmacological agents have shown promise as treatments for alcohol use disorders

There is little controversy regarding the use of drugs to manage acute withdrawal. This is not the case with using drugs in treatment subsequent to detoxification

Antabuse is an alcohol-sensitizing drug in use in the United Sates since 1948. It interferes with the metabolism of alcohol so a person feels very ill if he or she drinks

Several types of drugs are thought to affect the neurochemical bases of alcohol use among people with alcohol use disorder (Table 15.3):

Naltrexone – Opiate antagonist that affects the incentive to use alcohol

Buspirone – Antianxiety drug that affects serotonin and other neurotransmitters, and alleviates longer-term symptoms of alcohol withdrawal such as high anxiety and worry and difficulties coping with stress

Acamprosate – Acts on GABA receptors just as alcohol is hypothesized to do

Zoloft, Prozac and other SSRIs retard the reuptake of serotonin

Effectiveness of Pharmacological Treatments

Research on pharmacotherapy for alcohol-use disorders is still in its very early stages

However, it is believed all pharmacotherapies should be accompanied by psychological and social treatments if they are to have longer-term effectiveness

Medications may need to be matched to the needs of the individual, i.e, Disulfiram implants for patients with poor compliance, Naltrexone for patients prone to relapse, Buspirone for patients with high anxiety, and antidepressants for those with a depressive disorder

Simultaneous use of more than one medication may be needed to help some people

Effectiveness of Alcohol Treatment

Overall, no one treatment for alcohol problems seems to be superior to others, but staying in treatment is associated with better outcomes

Individual treatments may be more effective if they are matched to patients characteristics

It has proved difficult to conduct controlled outcome research on self-help groups, yet what research has been done suggests that A.A. helps some people but not everybody

Research on pharmacotherapy for alcohol use disorders is still in its very early stages. However, it is generally believed pharmacotherapies should be accompanied by psychological and social treatments if they are to have longer-term effectiveness

Other Drug Treatment Settings and Services

Settings of drug treatment traditionally have been defined by treatment of heroin abuse, but abusers of other drugs now also appear in most of these settings.

In fact, since the 1980s there has been an upsurge in the treatment of nonopiate drug abusers, though such treatments have not been specified well

Traditionally drug treatment settings include detoxification, methadone maintenance, residential, and outpatient

As with alcohol treatment, a wide variety of treatment services may be offered in a given setting

Pharmacotherapy of Other Drug Problems

Pharmacotherapy of drug problems includes managing drug withdrawal, replacing one opiate (e.g., heroin) with another that is less addictive (methadone), using antagonist drugs (e.g., naltrexone), and prescribing compounds to reduce drug craving

Several effective pharmacotherapies for opioid dependence have been developed. The best known of these is methadone.

Methadone treatment is associated with reduced drug use and criminal behavior, is effective in bringing reluctant addicts into treatment and keeping them there, and is cost-effective

Levo-Alpha-Acetylmethadol (LAAM) – A drug used in treating heroin addiction that is similar in action to methadone but has longer-lasting effects

Attempts to develop effective pharmacotherapies for cocaine dependence have been less successful than for opioid dependence

Antidepressants have been used in an attempt to address the reduction in the production of dopamine in the brain during cocaine withdrawal, which appears to be related to cocaine cravings and depression which are major factors in relapse

CONTEMPORARY ISSUE BOX 15.5 “Treatment Research and Clinical Practice”

Though there is a considerable amount of high-quality treatment research on substance-use disorders, the drug treatment most people receive is not always “empirically supported”

Certain barriers must be overcome before the foundation of knowledge that has accumulated can be applied to enhance the quality of care that patients receive.

Barriers may include factors related to the provider of the service (clinician), the recipient of the service (patient), or to the system in which treatment is delivered.

This knowledge-practice gap has resulted in studies concerning ways the barriers to dissemination of treatment research can be overcome.

Special Topics in Alcohol and Drug Treatment

Increasing numbers of drug treatment patients are polysubstance abusers, people who use more than one drug. Therefore, there is increasing recognition of the need for settings that can accommodate multiple substance users and for understanding common aspects of the addictive behaviors

Individuals who show up for alcohol or drug treatment may also have major psychiatric disorders. Such patients are called dual-diagnosis patients.

There is a relationship between alcohol or drug disorders characterized by a high degree of anxiety and the personality disorders, particularly what is commonly called sociopathy.

Personality Disorders – Long-standing patterns of behavior that frequently create distress for the individual due to his or her personal or social consequences; usually recognizable from adolescence or earlier

Sociopathy – Personality disorder characterized by a lack of concern for social obligations or rules, a lack of feelings for others, and a tendency toward violence

Self-Medication – The idea that some people prescribe their own medication, in the form of alcohol or illicit drugs, to alleviate psychological difficulties such as anxiety or depression

Psychotropic medication thus may be used in treatment in combination with nonmedical techniques

Relapse

The challenging problem of relapse has received a lot of research attention in the last 25 years.

Relapse is a medical concept which means the reappearance of some problem after a period of its remission

Many have referred to alcohol and other drug abuse and dependence as “chronic relapsing conditions” based on the research that 70% of individuals treated for alcohol, tobacco, or heroin abuse in abstinence-oriented programs had returned to using their primary substance by the time they were out of treatment for three months

As no one theory of relapse has emerged as superior to others, it may be more important to focus on the ingredients of relapse

Internal (e.g., mood) and external (e.g., drinking setting) stimulus conditions that precede relapse, cravings to use drugs, expectations about the utility of drugs and alcohol in a given situation, and one’s ability to cope with the situation without substance use are all important factors

This work has resulted in treatment applications called relapse prevention where the focus is on assessing “high-risk” situations or situations associated with the use of alcohol or drugs in the past

Treatment approaches then focus on teaching alternative coping skills, improving self-efficacy, or educating the person about the actual effects of alcohol and drugs

Economic Factors in Alcohol and Drug Treatment

Financial factors, especially health insurance coverage, have had and are having great influence on the type and accessibility of alcohol and drug treatment

The current trend is to less inpatient and more outpatient care in an effort to control the costs of health care

There is concern that this prescription for care is based too much on money and not enough on proven differences in treatment benefits

Another serious concern is individuals who do not have health insurance – a major problem on the United States. Because of decreased availability of publicly funded treatment, getting any professional care at all may be impossible

The Stepped Care Approach

This approach to professional treatment selection is an alternative to the “one size fits all” approach

It integrates the current knowledge about alcohol and drug treatment effectiveness and the conditions under which it is delivered

In the Stepped Care Approach, selection of treatment is guided by three principles: Treatment should be individualized with regard to the

client’s needs and problems Treatment should be consistent with the current knowledge

about effectiveness Treatment should be least restrictive (considering the

physical effects of treatment on the client and the client’s lifestyle and resources)

Summary

Change may occur in many different ways and may or may not involve the use of professional treatment resources

Treatment consists of several different ways to help people reach different goals that relate to how they function in different parts of their lives, and it occurs in several different settings

Some treatment approaches or techniques have more scientific support than others, and some seem better suited to the needs and goals of any given person

What professional treatment is accessible to individuals depends partly on their personal income and insurance coverage