Treatment Ch18
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Transcript of Treatment Ch18
© 2009 McGraw-Hill Higher Education. All rights reserved.
Chapter 18
Treating Substance Abuse and Dependence
© 2009 McGraw-Hill Higher Education. All rights reserved.
Treatment
§ Hundreds of thousands of Americans undergo treatment for substance abuse and dependence each year
§ A variety of treatment approaches are used, often in combination § Behavioral/psychosocial treatments § Pharmacotherapies
§ Different approaches reflect § Different substance abuse problems § Different theories about substance abuse
© 2009 McGraw-Hill Higher Education. All rights reserved.
Defining Treatment Goals
§ Treatment goals are influenced by the underlying theoretical view of substance abuse
§ Alcohol § View that alcohol dependence is a biological
disease that someone either has or does not have § Only acceptable treatment goal is complete
abstinence § View that alcohol dependence represents one end
of a continuum of drinking § A possible treatment goal is controlled social
drinking
© 2009 McGraw-Hill Higher Education. All rights reserved.
Defining Treatment Goals
§ Opioids § View that opioid dependence undermines the physical
and mental health of its victims § Only acceptable treatment goal is abstinence (traditional
view) § View that dependence on legal methadone is
preferable to dependence on illegal heroin § Goal of treatment has changed from eliminating opioid use to
eliminating heroin use
§ Tobacco § Complete abstinence (most common goal) vs. cutting
down on smoking or switching to cigarettes lower in tar and nicotine
© 2009 McGraw-Hill Higher Education. All rights reserved.
Defining Treatment Goals
§ How to evaluate treatment outcomes of reduced use as opposed to abstinence?
§ Researchers are beginning to develop cost/benefit analyses § Cost of treatment
vs.
§ Cost savings from increased employment and decreased crime after treatment
© 2009 McGraw-Hill Higher Education. All rights reserved.
Alcoholics Anonymous
§ Founded in 1935: A loose affiliation of local groups that adhere to common methods
§ Based on the disease model of dependence § An alcoholic is biologically different from others, so
abstinence is the only appropriate goal § The disease takes away a person’s control over his
or her own drinking behavior § It removes the blame for the problem from the alcoholic
but not the responsibility for dealing with it
§ Major approaches are group support and a buddy system
© 2009 McGraw-Hill Higher Education. All rights reserved.
Alcoholics Anonymous
§ Formal evaluations of AA have not been very positive § However, studying people who have court-ordered
referrals to AA might not be an appropriate evaluation method
§ A more appropriate evaluation might be to determine which types of drinkers are most likely to benefit from AA’s programs
§ Evaluation is important because many treatment programs follow the 12-step model of AA § Betty Ford Center, Hazelden, Phoenix House
© 2009 McGraw-Hill Higher Education. All rights reserved.
Motivational Enhancement Therapy
§ Conventional wisdom about people with substance abuse problems: § Most substance abusers use the
defense mechanism of denial and are unwilling to admit they have a problem
§ Only when a user suffers serious consequences (“hits bottom”) will he or she be ready to seek help
§ Problem with this perspective is that very serious consequences may occur before the abuser is ready for treatment
© 2009 McGraw-Hill Higher Education. All rights reserved.
Motivational Enhancement Therapy
§ Motivational enhancement therapy attempts to shift the focus away from denial and toward motivation to change
§ Motivational interviewing § Used to boost the motivation to change of an
ambivalent or less ready substance abuser § A nonconfrontational process of determining
the abuser’s current stage of change and then helping the individual move forward
© 2009 McGraw-Hill Higher Education. All rights reserved.
Motivational Enhancement Therapy
§ Stages of change § Precontemplation: Individual doesn’t recognize
that a problem exists § Contemplation: Individual recognizes there is a
problem and begins to consider the possibility of changing her or his behavior
§ Preparation: Individual decides to change and makes plans to change
§ Action: Individual takes active steps toward change § Maintenance: Individual engages in activities
intended to maintain the change
© 2009 McGraw-Hill Higher Education. All rights reserved.
Motivational Enhancement Therapy
§ Goals of motivational interviews § Help the client focus on
problem behaviors § Help the client move forward
to the next stage of change
§ Motivational enhancement therapy is probably best conceptualized as preparation for other therapies rather than as a stand-alone treatment
© 2009 McGraw-Hill Higher Education. All rights reserved.
Contingency Management
§ An approach in which individuals receive immediate rewards for providing drug-free urine samples § Value of the rewards increases with consecutive
drug-free samples § Clients also participate in weekly skill-building
counseling sessions § Has produced consistent reduction in use § Downside of approach is the cost of rewards
© 2009 McGraw-Hill Higher Education. All rights reserved.
Relapse Prevention
§ An approach that combines cognitive therapy techniques with behavioral skills training
§ Individuals learn to identify and change behaviors that could lead to relapse, such as associating with drug users
§ Evaluation § Shown to be more effective than most therapies § Considered challenging because it places significant
demands on patients
© 2009 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies
§ Study of dependence as a brain disease has focused research efforts on developing medications for treatment
§ Many experts believe that pharmacotherapies alone will not cure a chronic, relapsing, behavioral disorder like substance abuse
§ Pharmacotherapies can provide a window of opportunity for behavioral/psychosocial treatments by relieving withdrawal symptoms
© 2009 McGraw-Hill Higher Education. All rights reserved.
Detoxification
§ Detoxification is an initial and immediate phase of treatment
§ Medications are administered to alleviate unpleasant and/or dangerous withdrawal symptoms that may appear following abrupt cessation of drug use
§ Some of these medications may also be used during maintenance stage
© 2009 McGraw-Hill Higher Education. All rights reserved.
Maintenance
§ Maintenance is a longer-term strategy used to help a dependent individual avoid relapse
§ Three general categories of pharmacotherapy for maintenance § Agonist or substitution therapy § Antagonist therapy § Punishment therapy
© 2009 McGraw-Hill Higher Education. All rights reserved.
Maintenance
§ Agonist or substitution therapy is used to induce cross-tolerance to the abused drug § Examples: methadone for heroin dependence,
buprenorphine (subutex) for opioid dependence, nicotine replacement for tobacco dependence
§ Agonists typically have safer routes of administration and/or diminished psychoactive effects compared to the original drug
§ Substituting a longer-acting, pharmacologically equivalent drug allows the user to be stabilized on the agonist and then slowly tapered off it, avoiding withdrawal symptoms
© 2009 McGraw-Hill Higher Education. All rights reserved.
Maintenance
§ Antagonist therapy is used to prevent the user from experiencing the reinforcing effects of the abused drug § Example: naltrexone, which blocks opioid effects
§ Punishment therapy is used to produce an aversive reaction following ingestion of the abused drug § Example: disulfiram for alcohol dependence
© 2009 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for Alcohol
§ Detoxification phase § Pharmacological therapies are important
because acute alcohol withdrawal syndrome has serious effects
§ Medical risks often require an inpatient medical setting for alcohol detoxification
§ Benzodiazepines are typically used § Reduce autonomic hyperactivity and
prevent seizures § Best choices are those with a slow onset
of action
© 2009 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for Alcohol
§ Maintenance therapy § Usually given for weeks or months rather
than indefinitely § Three approved medications
§ Disulfiram (Antabuse) § Naltrexone § Acamprosate
© 2009 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for Alcohol
§ Disulfiram (Antabuse) causes unpleasant symptoms (headache, vomiting, and breathing difficulties) if alcohol is consumed § Inhibits aldehyde dehydrogenase, thereby increasing acetaldehyde § Not very effective because most people don’t take the medication
§ Naltrexone § Reduces alcohol craving, days per week of drinking, and rate of
relapse—but hasn’t had a large impact on overall treatment success § Unclear how it works; it may block opioid receptors and the reinforcing
effects of alcohol § Acamprosate, a compound structurally similar to GABA
§ Normalizes basal GABA concentrations § Blocks the glutamate increases observed during alcohol withdrawal § Recently approved, so effectiveness hasn’t been determined
© 2009 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for Nicotine
§ Nicotine withdrawal symptoms (anxiety, depression, insomnia, cigarette cravings) occur in most smokers who stop smoking
§ Five nicotine replacement products are approved by the FDA § Transdermal nicotine patch § Nicotine gum § Nicotine nasal spray § Nicotine vapor inhaler § Nicotine lozenge
§ Smokers should stop smoking before using any of them to avoid nicotine toxicity
§ Use of nicotine replacement products has been shown to increase quit rates in controlled clinical studies § Success rates are probably lower in a real world setting
© 2009 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for Nicotine
§ Bupropion (Zyban), a non-nicotine pharmacotherapy for smoking cessation § Approved by the FDA in 1997 § Also used in the treatment of depression § Mechanisms of action haven’t been definitively
determined § May inhibit reuptake of dopamine and norepinephrine and,
to a lesser extent, block acetylcholine receptors
§ Has been shown to gradually decrease cigarette craving and use
© 2009 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for Opioids
§ Traditionally, anticholinergic drugs like belladonna were used to treat opioid dependence § Goal: To produce a state of delirium for several days so that
the dependent person would avoid experiencing withdrawal
§ More recent version is “rapid opioid detoxification,” in which a dependent person is anesthetized and given an opioid antagonist that causes immediate withdrawal § Person is released after 24 hours and enters a period of
counseling while continuing to take an opioid antagonist § Criticisms of approach
§ Medical risks of rapid withdrawal process § Behavioral/psychosocial aftercare is often deemphasized § Long term outcome studies suggest that relapse is likely
© 2009 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for Opioids
§ Detoxification § Medications given to reduce withdrawal symptoms
(nausea, vomiting, diarrhea, aches, pain) § Methadone, a long-acting opioid § Buprenorphine, a partial opioid agonist with a long duration
of action
§ Maintenance § Methadone maintenance is the most common form
of treatment for opioid dependence § May continue for months or years
§ Less data available on more recently approved buprenorphine maintenance
© 2009 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for Opioids
§ Naloxone, a short-acting opioid antagonist, is used to treat opioid overdose
§ Naltrexone, a long-acting opioid antagonist, is approved for treating opioid dependence § Has been shown to be effective, but it is appropriate
only for highly motivated individuals § A once-per-month form is being studied; initial
findings are promising
© 2009 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for Cocaine
§ Withdrawal symptoms § Can include depression, nervousness, anhedonia (lack of
emotional response), fatigue, irritability, sleep and activity disturbances, craving for cocaine
§ Risk of relapse may be greatest during withdrawal period § Reduced monoamine neurotransmitter activity may
underlie withdrawal symptoms § Medications that increase monoamine neurotransmitter
activity have been tested but have not been found useful in treating withdrawal symptoms or dependence
§ Currently no approved pharmacotherapy for cocaine dependence
© 2009 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for Cannabis
§ Withdrawal from cannabis § People seeking treatment for cannabis dependence
often report withdrawal symptoms that make it more difficult to maintain abstinence
§ Symptoms may include irritability, anxiety, sleep disruption, aches
§ Many medications have been tested for relief of cannabis withdrawal symptoms § One drug has been found effective: oral ∆9-THC
§ Currently no approved pharmacotherapy for cannabis dependence
© 2009 McGraw-Hill Higher Education. All rights reserved.
Treatment: The Big Picture in the United States
§ Most frequently reported drugs for substance abuse treatment admissions § Alcohol (40 percent) § Opioids (18 percent) § Marijuana (16 percent) § Cocaine (14 percent)
§ Abusers admitted for treatment § Average age of those admitted with marijuana as the primary
drug of abuse is 24 § Sites of treatment
§ 50 percent treated as outpatients § 13 percent treated as hospital inpatients (detoxification) § 17 percent treated in a residential setting
© 2009 McGraw-Hill Higher Education. All rights reserved.
Treatment: The Big Picture in the United States
§ Substance abuse treatment development should focus on § More effective interventions for commonly abused
drugs § Alcohol § Opioids § Marijuana § Cocaine
§ Treatment delivery on an outpatient basis § Effective outpatient behavioral/psychosocial
interventions are needed to improve the overall success of treatment
© 2009 McGraw-Hill Higher Education. All rights reserved.
Is Treatment Effective?
§ Substance dependence is a chronic illness § Treatment doesn’t work for every
individual every time § Condition may require continuing
care throughout life § Studies show that treatment is
cost-effective by reducing crime and increasing employment
§ Treatment also saves lives in the long term