SUBSTANCE USE DISORDERS GENERAL METHODS OF TREATMENT Inpatient Detoxification and Rehabilitation Outpatient Individual, Couple, or Family Counseling Self-help Groups (Alcoholics Anonymous; NA, CA, OA, GA, Al-Anon etc.) Residential Facilities & Therapeutic Communities Medications

Early identification Education about diagnosis Acceptance of disease and overcoming “denial” Abstinence 12-steps essential for real recovery Disease Model - Treatment

12 Steps of Alcoholics Anonymous

TREATMENT OF SUBSTANCE USE DISORDERS Addictive Behavior Meds ETOH: antabuse, naltrexone, acomprosate; benzodiazepines Opiates: Methadone; LAAM narcan/naltrexone; depot naltrexone buprenophine Nicotine: Nicotine Replacement Therapies Zyban, Wellbutrin (bupropion) Effexor (venlafaxine)

Strength of Evidence of Pharmacotherapies for Alcohol Dependence Naltrexone – Acomprosate – Disulfiram – Serotonergic drugs – Lithium –

TREATMENT OF SUBSTANCE USE DISORDERS TX myths 1. Nothing works 2. One approach is superior to all others (“one true light” tradition) 3. All treatment approaches work equally well for everyone - measuring outcomes - good studies use:________________________

TREATMENT OF SUBSTANCE USE DISORDERS Outcome Studies Hazeldon study: Drug Abuse Treatment Outcome Study (DATOS) – natural tx in 4 settings: outpt. methadone clinics, outpatient drug-free, short-term inpatient, long-term residential: 1 year f/u data for outpt. methadone group Pre F/U N = 727 / 1, %  27.8 heroin use (60 %) 41.9%  21.7 cocaine use *weekly or more drug use 17.1%  13.9 marijuana use 14.8%  16.3 alcohol use, 5+ drinks 28.6%  13.7 predatory illegal activity 25.2%  12.9 sexual behavior risk

4 sessions in 12 weeks Therapist applies motivational psychology to examine effect of drinking on patient’s life, and develop and implement a plan to stop drinking Mobilize the person’s own commitment and motivation to change MET (Motivational Enhancement Therapy) 12 weekly sessions Patients introduced by therapist to the first steps of Alcoholics Anonymous and encouraged to attend meetings Acceptance of the disease of alcoholism and loss of control over drinking TSF (Twelve Step Facilitation) 12 weekly sessions Coping and drink-refusal skills taught by therapist to handle states and situations known to precipitate relapse Learn skills to achieve and maintain sobriety CBT (Cognitive Behavioral Therapy) FrequencyDescription Goal of Treatment Type of Treatment Project MATCH Treatment Conditions

Project MATCH Results: N = 1,726 outpatients (n=952) and aftercare (n=774) at 5 sites (one of largest clinical trials ever) 25% were women; 15% were minority group members 10 client characteristics studied: severity etoh, sociopathy, cognitive impairment, gender, meaning seeking, motivation, psych severity, etc. 90% of the participants were assessed at 1-year follow-up pre-post differences in drinking days per month (25  6) and drinks per “drinking” day (15  3) each of the 3 treatments worked about equally well in reducing drinking

TSF outpatients more likely to remain sober (24%) at 1 yr. than outpatients in CBT or MET (about 15%) only 1 “matching” prediction supported: outpatients with few or no psychiatric problems had more abstinent days in TSF tx than in CBT At 3-yr. follow-up: 36% of TSF clients abstinent vs. 27% MET and 24% CBT clients *** strong correlation between abstinence rates and compliance with aftercare (“recovery” is a PROCESS).

Principles of Effective Treatment No single treatment is appropriate for all individuals. Treatment needs to be readily available. Effective treatment attends to multiple needs of the individual, not just his or her drug use. Clients with coexisting mental disorders should have both disorders treated in an integrated way. In order to meet the changing needs of the client, the treatment plan must be continually assessed and modified.

Remaining in treatment for an adequate period of time is critical for treatment effectiveness. Counseling (individual, couple, and/or group) and other behavioral therapies are critical components of effective treatment for addiction... Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.

Treatment does not need to be voluntary to be effective Possible drug use during treatment must be monitored continuously. Treatment programs should provide assessment and counseling for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases to help patients modify or change behaviors that place themselves or others at risk of infection. Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment.