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  • Image source: Royalty-Free/Corbis (Ch18_04DepressedDrinker) Image source: Stockbyte/PictureQuest (Image Ch18_11NicotinePatch) Image source: National Institute on Drug Abuse (Ch18_02GroupTherapy)
  • Image source: Nancy R. Cohen/Getty Images (Image Ch18_01PillsSpellHelp) Image source: National Institute on Drug Abuse (Ch18_02GroupTherapy)
  • Image source: Dynamic Graphics / JupiterImages (Image Chapter 18_03ManwithDrink)
  • Image source: Royalty-Free/Corbis (Image Ch18_05CostBenefit)
  • The complete text of the 12 steps of AA and the 12 traditions of AA are available at the AA website (http://www.alcoholics-anonymous.org/en_pdfs/p-42_abriefguidetoaa.pdf)
  • Image source: McGraw-Hill Companies, Inc./Gary He, photographer (Image Ch18_06HitBottom)
  • Image source: Geoff Manasse/Getty Images (Image Ch18_07TherapySession)
  • Image source: Digital Vision/PunchStock (Image Ch18_08AddictCollage)
  • Image source: Brand X Pictures/PunchStock (Ch18_09OverdoseCollage)
  • Image source: Jack Star/PhotoLink/Getty Images (Ch18_10Liquor)
  • Image source: Stockbyte/PictureQuest (Image Ch18_11NicotinePatch)
  • Image source: US Drug Enforcement Administration (see Chapter 13; Image Ch13_01OpiumPoppy)
  • Image source: Brand X Pictures/PunchStock (see Chapter 15; Image Ch15_02CannabisLeaf1)
  • Image source: BananaStock/PunchStock (Image Ch18_12DrugCrime) Image source: Royalty-Free/Corbis (Image Ch18_13Employment)
  • Image source: Royalty-Free/Corbis (Ch18_04DepressedDrinker) Image source: Stockbyte/PictureQuest (Image Ch18_11NicotinePatch) Image source: National Institute on Drug Abuse (Ch18_02GroupTherapy)

Hart13 ppt ch18 Hart13 ppt ch18 Presentation Transcript

  • Chapter 18 Treating Substance Abuse and Dependence© 2011 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© 2011 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 substance dependence is a biological disease that someone either has or does not have  Only acceptable treatment goal is complete abstinence  View that substance dependence represents one end of a continuum of drinking  A possible treatment goal is controlled social use© 2011 McGraw-Hill Higher Education. All rights reserved.
  • Defining Treatment Goals  Opioids  View that substance 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© 2011 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© 2011 McGraw-Hill Higher Education. All rights reserved.
  • Alcoholics Anonymous and Others  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© 2011 McGraw-Hill Higher Education. All rights reserved.
  • Alcoholics Anonymous and Others  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© 2011 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© 2011 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© 2011 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© 2011 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© 2011 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© 2011 McGraw-Hill Higher Education. All rights reserved.
  • Cognitive Behavioral Therapy (CBT)  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  Despite this, it remains one of the most widely used substance abuse treatment strategy© 2011 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© 2011 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© 2011 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© 2011 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, 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© 2011 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© 2011 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© 2011 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© 2011 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© 2011 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© 2011 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© 2011 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© 2011 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© 2011 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© 2011 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© 2011 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© 2011 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 (19 percent)  Marijuana/hashish (16 percent)  Cocaine (13 percent)  Stimulants (8 percent, primarily methamphetamine)  Abusers admitted for treatment  Average age of those admitted with marijuana as the primary drug of abuse is 24  Sites of treatment  47 percent treated as outpatients  13 percent treated as hospital inpatients (detoxification)  18 percent treated in a residential setting© 2011 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© 2011 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© 2011 McGraw-Hill Higher Education. All rights reserved.
  • Chapter 18 Treating Substance Abuse and Dependence© 2011 McGraw-Hill Higher Education. All rights reserved.