Principles of Effective Treatment

1. Addiction is a complex but treatable disease that affects brain function and behavior. Drugs of abuse alter the brain’s structure and function, resulting in changes that persist long after drug use has ceased. This may explain why drug abusers are at risk for relapse even after long periods of abstinence and despite the potentially devastating consequences.
2. No single treatment is appropriate for everyone. Matching treatment settings, interventions, and services to an individual’s particular problems and needs is critical to his or her ultimate success in returning to productive functioning in the family, workplace, and society.
3. Treatment needs to be readily available. Because drug-addicted individuals may be uncertain about entering treatment, taking advantage of available services the moment people are ready for treatment is critical. Potential patients can be lost if treatment is not immediately available or readily accessible. As with other chronic diseases, the earlier treatment is offered in the disease process, the greater the likelihood of positive outcomes.
4. Effective treatment attends to multiple needs of the individual, not just his or her drug abuse. To be effective, treatment must address the individual’s drug abuse and any associated medical, psychological, social, vocational, and legal problems. It is also important that treatment be appropriate to the individual’s age, gender, ethnicity, and culture.
5. Remaining in treatment for an adequate period of time is critical. The appropriate duration for an individual depends on the type and degree of his or her problems and needs. Research indicates that most addicted individuals need at least 3 months in treatment to significantly reduce or stop their drug use and that the best outcomes occur with longer durations of treatment. Recovery from drug addiction is a long-term process and frequently requires multiple episodes of treatment. As with other chronic illnesses, relapses to drug abuse can occur and should signal a need for treatment to be reinstated or adjusted. Because individuals often leave treatment prematurely, programs should include strategies to engage and keep patients in treatment.
6. Counseling—individual and/or group—and other behavioral therapies are the most commonly used forms of drug abuse treatment. Behavioral therapies vary in their focus and may involve addressing a patient’s motivation to change, providing incentives for abstinence, building skills to resist drug use, replacing drug-using activities with constructive and rewarding activities, improving problem solving skills, and facilitating better interpersonal relationships.
7. Self-help encouragement and availability. Participation in group peer support programs during and following treatment can help maintain abstinence.
8. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies. For example, methadone and buprenorphine are effective in helping individuals addicted to heroin or other opioids stabilize their lives and reduce their illicit drug use. Naltrexone is also an effective medication for some opioid-addicted individuals and some patients with alcohol dependence. Other medications for alcohol dependence include acamprosate, disulfiram, and topiramate. For persons addicted to nicotine, a nicotine replacement product (such as patches, gum, or lozenges) or an oral medication (such as bupropion or varenicline) can be an effective component of treatment when part of a comprehensive behavioral treatment program.
9. An individual’s treatment and services plan must be assessed continually and modified as necessary to ensure that it meets his or her changing needs. A patient may require varying combinations of services and treatment components during the course of treatment and recovery. In addition to counseling or psychotherapy, a patient may require medication, medical services, family therapy, parenting instruction, vocational rehabilitation, and/or social and legal services. For many patients, a continuing care approach provides the best results, with the treatment intensity varying according to a person’s changing needs.
10. Many drug-addicted individuals also have other mental disorders. Because drug abuse and addiction—both of which are mental disorders—often co-occur with other mental illnesses, patients presenting with one condition should be assessed for the other(s). And when these problems co-occur, treatment should address both (or all), including the use of medications as appropriate.
11. Medically assisted detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug abuse. Although medically assisted detoxification can safely manage the acute physical symptoms of withdrawal and, for some, can pave the way for effective long-term addiction treatment, detoxification alone is rarely sufficient to help addicted individuals achieve long-term abstinence. Thus, patients should be encouraged to continue drug treatment following detoxification. Motivational enhancement and incentive strategies, begun at initial patient intake, can improve treatment engagement.
12. Treatment does not need to be voluntary to be effective. Sanctions or enticements from family, employment settings, and/or the criminal justice system can significantly increase treatment entry, retention rates, and the ultimate success of drug treatment interventions.
13. Drug use during treatment must be monitored continuously, as lapses during treatment do occur. Knowing their drug use is being monitored can be a powerful incentive for patients and can help them withstand urges to use drugs. Monitoring also provides an early indication of a return to drug use, signaling a possible need to adjust an individual’s treatment plan to better meet his or her needs.
14. Treatment programs should assess patients for the presence of HIV/ AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well as provide targeted risk-reduction counseling to help patients modify or change behaviors that place them at risk of contracting or spreading infectious diseases. Typically, drug abuse treatment addresses some of the drug-related behaviors that put people at risk of infectious diseases. Targeted counseling specifically focused on reducing infectious disease risk can help patients further reduce or avoid substance-related and other high-risk behaviors. Counseling can also help those who are already infected to manage their illness. Moreover, engaging in substance abuse treatment can facilitate adherence to other medical treatments. Patients may be reluctant to accept screening for HIV (and other infectious diseases); therefore, it is incumbent upon treatment providers to encourage and support HIV screening and inform patients that highly active antiretroviral therapy (HAART) has proven effective in combating HIV, including among drug abusing populations.

See also

• 5 Alcoholism Myths
• 5 Alcoholism Subtypes
• Brief-TSF can assist patients cease alcohol consumption.
• Improving Treatment Compliance

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Alcohol Screening and Brief Intervention in Primary Care Settings

Michael F. Fleming, M.D., M.P.H.

Primary care practitioners are in a unique position to identify patients with potential alcohol problems and intervene when appropriate. Screening, the process by which practitioners can identify at-risk drinkers, can be followed by one-time or repeated short counseling sessions, known as brief interventions, which are designed to help the patient reduce drinking and minimize related problems. Varied levels of screening and brief intervention can be implemented in the primary care setting, depending on patient and physician factors. Although screening and brief intervention are valuable tools, they are underutilized in primary care practices. Strategies that may help increase physicians’ use of these techniques in the primary care setting include skills-based role-playing, performance feedback, clinical protocols, clinic-based education, and training by credible experts.

Full text available at; http://pubs.niaaa.nih.gov/publications/arh28-2/57-62.htm

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Those under age 25 are particularly vulnerable to dual abuse.

Men and women with alcohol use disorders (AUD’s) are 18 times more likely to report nonmedical use of prescription drugs than people who don’t drink at all, according to researchers at the University of Michigan. Dr. Sean Esteban McCabe and colleagues documented this link in two NIDA-funded studies; they also discovered that young adults were most at risk for concurrent or simultaneous abuse of both alcohol and prescription drugs.

“The message of these studies is that clinicians should conduct thorough drug use histories, particularly when working with young adults,” says Dr. McCabe. “Clinicians should ask patients with alcohol use disorders about nonmedical use of prescription drugs [NMUPD] and in turn ask nonmedical users of prescription medications about their drinking behaviors.” The authors also recommend that college staff educate students about the adverse health outcomes associated with using alcohol and prescription medications at the same time.

TWO STUDIES

The authors’ first study looked at the prevalence of AUD’s and NMUPD in 43,093 individuals 18 and older who participated in the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC) between 2001 and 2005. Participants lived across the United States in a broad spectrum of household arrangements and represented White, African-American, Asian, Hispanic, and Native American populations. Although people with AUD’s constituted only 9 percent of NESARC’s total sample, they accounted for more than a third of those who reported NMUPD.

Since the largest group of alcohol/prescription drug abusers were between the ages of 18 and 24, the team’s second study focused entirely on this population and involved 4,580 young adults at a large, public, Midwestern university. The participants completed a self-administered Web survey, which revealed that 12 percent of them had used both alcohol and prescription drugs nonmedically within the last year but at different times (concurrent use), and 7 percent had taken them at the same time (simultaneous use).

When alcohol and prescription drugs are used simultaneously, severe medical problems can result, including alcohol poisoning, unconsciousness, respiratory depression, and sometimes death. In addition, college students who drank and took prescription drugs simultaneously were more likely than those who did not to blackout, vomit, and engage in other risky behaviors such as drunk driving and unplanned sex.

Prescription drug misuse rises with drinking severity. Increases are most pronounced in adults aged 18-24.

WHO, WHAT, AND WHEN

The prescription drugs that were combined with alcohol in order of prevalence included prescription opiates (e.g., Vicodin, OxyContin, Tylenol 3 with codeine, Percocet), stimulant medication (e.g., Ritalin, Adderall, Concerta), sedative/anxiety medication (e.g., Ativan, Xanax, Valium), and sleeping medication (e.g., Ambien, Halcion, Restoril). The college study asked about the respondent’s use of medications prescribed for other people while the NESARC explored both use of someone else’s prescription medications as well as the use of one’s own prescription medications in a manner not intended by the prescribing clinician (e.g., to get high).

The researchers found that the more alcohol a person drank and the younger he or she started drinking, the more likely he or she was to report NMUPD. Compared with people who did not drink at all, drinkers who did not binge were almost twice as likely to engage in NMUPD; binge drinkers with no AUD’s were three times as likely; people who abused alcohol but were not dependent on alcohol were nearly seven times as likely; and people who were dependent on alcohol were 18 times as likely to report NMUPD (see figure, page 8).

While the majority of the respondents in both studies were White (71 percent in NESARC and 65 percent in the college group), an even higher percentage of the simultaneous polydrug users in the college study were White males who had started drinking in their early teens. The NESARC study also found that Whites in general were two to five times more likely than African-Americans to report NMUPD during the past year. Native Americans were at increased risk for NMUPD, and the authors indicated that this subpopulation should receive greater research attention in the future.

Dr. McCabe emphasizes that many people who simultaneously drink alcohol and use prescription medications have no idea how dangerous the interactions between these substances can be. “Passing out is a protective mechanism that stops people from drinking when they are approaching potentially dangerous blood alcohol concentrations,” he explains. “But if you take stimulants when you drink, you can potentially override this mechanism and this could lead to life-threatening consequences.”

Dr. James Colliver, formerly of NIDA’s Division of Epidemiology, Services and Prevention Research, offers perspective on these studies. “Prescription sedatives, tranquilizers, painkillers, and stimulants are generally safe and effective medications for patients who take them as prescribed by a clinician,” Dr. Colliver states. “They are used to treat acute and chronic pain, attention deficit hyperactivity disorder, anxiety disorders, and sleep disorders.

“The problem is that many people think that, because prescription drugs have been tested and approved by the Food and Drug Administration, they are always safe to use; but they are safe only when used under the direction of a physician for the purpose for which they are prescribed.”

Nonmedical Use of Prescription Drugs

The National Epidemiologic Survey on Alcohol and Related Conditions (NESARC), sponsored by the National Institutes of Health, defines nonmedical use as follows:

Using drugs that were not prescribed to you by a doctor, or using drugs in a manner not intended by the prescribing clinician (e.g., to get high). Nonmedical use does not include taking prescription medications as directed by a health practitioner or the use of over the- counter medications.

NIDA Research Findings; Vol. 21, No. 5 (March 2008)

See also;

• Brief-TSF can assist patients cease alcohol consumption.
• Alcohol & Medication Interactions

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Six-month changes in spirituality, religiousness, and heavy drinking in a treatment-seeking sample.

OBJECTIVE: This descriptive and exploratory study investigated change in alcoholics’ spirituality and/or religiousness (S/R) from treatment entry to 6 months later and whether those changes were associated with drinking outcomes.

METHOD: Longitudinal survey data were collected from 123 outpatients with alcohol use disorders (66% male; mean age = 39; 83% white) on 10 measures of S/R, covering behaviors, beliefs, and experiences, including the Daily Spiritual Experiences and Purpose in Life scales. Drinking behaviors were assessed with the Timeline Followback interview. Alcoholics Anonymous (AA) participation and attendance were also measured.

RESULTS: Over 6 months, there were statistically significant increases in half of the S/R measures, specifically the Daily Spiritual Experiences scale, the Purpose in Life scale, S/R practices scale, Forgiveness scale, and the Positive Religious Coping scale.

There were also clinically and statistically significant decreases in alcohol use.

• Multiple logistic regression analyses showed that increases in Daily Spiritual Experiences and in Purpose in Life scores were associated with increased odds of no heavy drinking at 6 months, even after controlling for AA involvement and gender.

CONCLUSIONS: In the first 6 months of recovery, many dimensions of S/R increased, particularly those associated with behaviors and experiences. Values, beliefs, self-assessed religiousness, perceptions of a Higher Power, and the use of negative religious coping did not change.

Increases in day-to-day experiences of spirituality and sense of purpose/meaning in life were associated with absence of heavy drinking at 6 months, regardless of gender and AA involvement.

The results of this descriptive study support the perspective of many clinicians and recovering individuals that changes in alcoholics’ S/R occur in recovery and that such changes are important to sobriety.

Robinson EA, Cranford JA, Webb JR, Brower KJ. Six month changes in spirituality religiousness and heavy drinking in a treatment-seeking sample. J Stud Alcohol Drugs. 2007 Mar;68(2):282-90.

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Brief-TSF Treatment Setting

Brief-TSF can be used with both individuals who have never sought treatment and those who had previous treatment and aftercare clients. The model is flexible enough to accommodate all of these client groups.

However, since Brief-TSF relies heavily on client involvement in community-based 12 step fellowship and meetings, it would be less ideally implemented in a long-term inpatient setting.

Many Twelve Step Fellowship members are willing to visit ‘Newcomers’ in hospital. Brief-TSF can easily be integrated into a general mental health outpatient clinic setting.

BriefTSF is designed to be used in the context of short-term individual adjunct therapy by general healthcare and other helping profession workers. BriefTSF is specifically intended to be implemented by nurses, doctors, psychologists, social workers, counselors etc while addressing other current issues (ie, medical treatment, relationship counselling, legal issues).

Brief-TSF is not time limited. After assessment support can last as long as the healthcare worker is seeing the client. It is intended to be implemented within a scheduled session often with another focus. The initial assessment session can last up to one hour, and regular support can be incorporated into other sessions.

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12-Step Involvement Increases Sobriety and Reduces Costs

BACKGROUND: Accumulating evidence indicates that addiction and psychiatric treatment programs that actively promote self-help group involvement can reduce their patients’ health care costs in the first year after treatment, but such initially impressive effects may wane over time. This paper examines whether the positive clinical outcomes and reduced health care costs evident 1 year after treatment among substance-dependent patients who were strongly encouraged to attend 12-step self-help groups were sustained at 2-year follow-up.

METHODS: A 2-year quasi-experimental analysis of matched samples of male substance-dependent patients who were treated in either 12-step-based (n=887 patients) or cognitive-behavioral (CB, n=887 patients) treatment programs. The 12-step-based programs placed substantially more emphasis on 12-step concepts, had more staff members "in recovery," had a more spiritually oriented treatment environment, and promoted self-help group involvement much more extensively than did the CB programs. The 2-year follow-up assessed patients’ substance use, psychiatric functioning, self-help group affiliation, and mental health care utilization and costs.

RESULTS: As had been the case in the 1-year follow-up of this sample, the only difference in clinical outcomes was a substantially higher abstinence rate among patients treated in 12-step (49.5%) versus CB (37.0%) programs. Twelve-step treatment patients had 50 to 100% higher scores on indices of 12-step self-help group involvement than did patients from CB programs. In contrast, patients from CB programs relied significantly more on outpatient and inpatient mental health services, leading to 30% lower costs in the 12-step treatment programs. This was smaller than the difference in cost identified at 1 year, but still significant ($2,440 per patient, p=0.01).

CONCLUSIONS: Promoting self-help group involvement appears to improve posttreatment outcomes while reducing the costs of continuing care. Even cost offsets that somewhat diminish over the long term can yield substantial savings. Actively promoting self-help group involvement may therefore be a useful clinical practice for helping addicted patients recover in a time of constrained fiscal resources.

Humphreys K, Moos RH. Alcohol Clin Exp Res. 2007 Jan;31(1):64-8. Encouraging posttreatment self-help group involvement to reduce demand for continuing care services: two-year clinical and utilization outcomes.

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The present study aimed to determine whether alcoholics who attend self-help groups experience fewer deaths than those who do not.

Subjects were patients from the Alcoholism Treatment Program (ATP) of Matsuzawa hospital.

A cohort of alcoholic patients recruited into a prospective study was followed from April 1994 to March 1999. A total of 469 alcoholic patients met the International Classification of Diseases (10th edition) criteria for alcohol dependency. Of these, 94 patients refused to participate in the study, leaving a total of 375 participants.

After discharge from the ATP and a complete explanation of the present study, subjects decided whether to attend a self-help group (SHG) or not.

The SHG comprised 208 subjects, and the non-self-help group (NSHG) comprised 167 subjects. Outcomes were evaluated with regard to death during follow-up for a mean of 2.4 years. Death was ascertained through the records of the Setagaya Department of Health and Welfare center, Matsuzawa hospital and other hospitals, and through personal contact with informants, relatives, and significant others of subjects.

Deaths were confirmed for 47 NSHG subjects and only five SHG subjects. NSHG displayed a significantly decreased cumulative survival compared with SHG (P < 0.0001). Cox proportion hazard analysis was used to examine variables that may help to predict mortality among alcoholics.

Alcoholics who attended self-help groups differed from those who did not, with regard to mortality experience.

Attending a self-help group represented the most important predictor of prognosis for alcoholics.

Self-help groups reduce mortality risk: A 5-year follow-up study of alcoholics in the Tokyo metropolitan area; Ichiro Masudomi, Kunihiro Isse, Makoto Uchiyama, And Hirohumi Watanabe, Psychiatry and Clinical Neurosciences (2004), 58, 551–557

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Alcohol abuse and dependence, referred to as alcohol-use disorders (AUDs), affect 76.3 million people worldwide and account for 1.8 million deaths per year. AUDs affect 18.3 million Americans (7.3% of the population), and up to 40% of hospitalized patients have AUDs.

This review discusses the development and progression of critical illness in patients with AUDs.

In contrast to acute intoxication, AUDs have been linked to increased severity of illness in a number of studies.

In particular, surgical patients with AUDs experience higher rates of

• postoperative hemorrhage,
• cardiac complications,
• sepsis, and
• need for repeat surgery.

Outcomes from trauma are worse for patients with chronic alcohol abuse, whereas burn patients who are acutely intoxicated may not have worse outcomes.

AUDs are linked to not only a higher likelihood of community-acquired pneumonia and sepsis but also a higher severity of illness and higher rates of nosocomial pneumonia and sepsis.

The management of sedation in patients with AUDs may be particularly challenging because of the increased need for sedatives and opioids and the difficulty in diagnosing withdrawal syndrome.

The health-care provider also must be watchful for the development of dangerous agitation and violence, as these problems are not uncommonly seen in hospital ICUs.

Despite studies showing that up to 40% of hospitalized patients have AUDs, relatively few guidelines exist on the specific management of the critically ill patient with AUDs.

AUDs are underdiagnosed, and a first step to improving patient outcomes may lie in systematically and accurately identifying AUDs.

Alcohol-Use Disorders in the Critically Ill Patient. CHEST October 2010 vol. 138 no. 4 994-1003 Marjolein de Wit, MD, Drew G. Jones, MD, Curtis N. Sessler, MD, FCCP, Marya D. Zilberberg, MD, FCCP and Michael F. Weaver, MD

Alcohol Use Disorders (Advances in Psychotherapy; Evidence-Based Practice) by Stephen A. Maisto

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Safe Treatment of Pain in the Patient With a Substance Use Disorder

Conditions associated with severe pain can and do develop in persons who have active addiction or who are in remission from an addictive disease, and these patients may require treatment for pain relief. This presents a challenge to clinicians: How can pain be relieved in these patients without exacerbating or reactivating the addictive disorder?

There is little research data on this topic; however, experiential and anecdotal reports collected over the past 3 decades indicate that there are safe and effective approaches to pain management in these patients. In general, the pain treatment regimen for a person recovering from an addiction involves the use of long-acting opioids, such as sustained-release oxycodone, methadone, or buprenorphine, administered on a fixed dosage schedule, with another person holding the medication. Specific dosing recommendations are provided.

By: Penelope P. Ziegler, MD; Psychiatric Times (CMP Medica), 24(1), 2007.

HTML available online at: http://www.psychiatrictimes.com/showArticle.jhtml?articleID=196902132 (Free registration may be required.)

Brief-TSF professional training is complimentary to pain treatment.

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Painkiller abuse continues to grow; new treatments offer hope

Increasingly, drug abusers are getting their next fix from their medicine cabinets, instead of from drug dealers.

More than 6 million Americans abuse prescription drugs, according to the U.S. Drug Enforcement Administration. One in 10 teenagers admits to abusing painkillers, such as Vicodin and Oxycontin. Painkillers cause more overdoses than cocaine and heroin combined.

“Access to prescription painkillers has never been easier,” says addictions psychiatrist Donna Yi, MD, associate chief of staff and clinical director for The Menninger Clinic and assistant professor in the Menninger Department of Psychiatry & Behavioral Sciences at Baylor College of Medicine. “Many people start taking prescription painkillers for a legitimate reason, for pain after surgery or childbirth, or to deal with chronic pain. As the sense of euphoria and relaxation provided by the drugs gets reinforced, they become increasingly reliant on the drugs even when they no longer need them for pain.”

Once hooked, patients may doctor shop to get multiple prescriptions to painkillers, forge prescriptions, order painkillers from web sites that don’t require prescriptions or take a road trip to Mexico to supply their habits. Teenagers can get prescription painkillers from their parents’ medicine cabinets and their friends-even dealers. Because prescription painkillers are so readily available, they don’t have the stigma of illegal drugs, like heroin.

Yi adds that it may seem much easier and acceptable to swallow a pill than to find a vein, inject yourself with a drug and risk getting AIDS or overdosing. The word “heroin” instantly evokes a negative image-usually that of someone homeless and on the street.

However, like heroin, prescription painkillers such as Oxycontin and Vicodin stimulate opiate receptors in the brain, relieving pain and providing a sense of euphoria, and are highly addictive and difficult to quit without medical intervention.

Because opiates are so rewarding and reinforcing, once a person stops using them, the body goes into shock and withdrawal. Symptoms of withdrawal are similar to a severe case of the flu and may include fever, vomiting, diarrhea, muscle and bone pain, insomnia, cold flashes with goose bumps and involuntary leg movements. To avoid pain, many people abusing painkillers keep using.

New medications help painkiller abusers avoid the painful symptoms of withdrawal and cut the time of withdrawal. The drug buprenorphine was approved by the FDA in 2002 to help ease the symptoms of detoxification and radically decreases the time of detox from an average of two weeks to one or two days. Buprenorphine is a safer alternative to methadone and is available in a convenient pill form. The medication speeds a patient’s entry into treatment, cutting down the time he or she is in bed and feeling uncomfortable withdrawal symptoms and drug cravings.

Patients may have accompanying mental illness and issues driving their addiction, such as anxiety, depression, life stresses, relationship problems, personality disorders or poor coping skills. A successful treatment program for addiction includes a thorough patient assessment and offers group and individual therapy, psychoeducation and access to self-help groups. Patients’ families are also involved in the treatment process.

Relapse rates for patients who abuse painkillers are high, so creating a relapse prevention plan is crucial. Patients at Menninger leave with a wellness plan that might include appointments with therapists, support group meetings and exercise to improve their mood and health. Patients also learn the signs and symptoms that constitute a lapse, so they can stop a full-blown relapse.

Some patients may also need medications on a continual basis, such as prenorphine or naltrexone, to help them avoid relapse. Both buprenorphine and naltrexone block the effects of opiates on the body. Patients who take buprenorphine, however, will feel mild withdrawal symptoms if they stop taking the drug-reminding them to consistently take their medicine. Doctors often prescribe a version of buprenorphine, combined with another opiate-blocker, naloxone, to guard against the intravenous use of buprenorphine. If the drug combination is injected, the naloxone can cause that person to quickly go into withdrawal.

“As the supply and variety of painkillers increase, more people will try them for non-medical reasons, and some will become addicted,” Yi says. “Increased awareness, new medications used to treat painkiller abuse and novel therapies offer hope for people struggling with painkiller abuse.”

From a press release of the Menninger Clinic

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