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
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
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
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 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 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
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
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
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.
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
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