SOC 204 Goldberg Ch 15 Treatment
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The document discusses substance abuse treatment and its effectiveness. It covers various treatment programs and approaches, including inpatient/outpatient treatment, counseling, pharmacotherapies, 12-step models, cognitive behavioral therapy, and motivational enhancement. It also addresses factors that can contribute to relapse, such as negative emotional states and interpersonal conflicts. Overall, studies have found that treatment can significantly reduce drug use and criminal behavior while increasing employment and stability. However, barriers like client and community resistance, continuing drug use, and personnel issues can challenge treatment effectiveness.
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SOC 204 Goldberg Ch 15 Treatment
- 1. SOC 204 Drugs & Society Chapter 15 Substance Abuse Treatment Goldberg
- 2. Attendance: How are you doing? A. Doing GREAT! B. Okay C. Feeling stressed 0% 0% 0% Doing GREAT! Okay Feeling stressed Response
- 4. Treatment & Recovery • Defining treatment goals • Programs: • Inpatient • Outpatient • Counseling • Individual • Group • Family • Pharmacotherapies • AA and other 12-step models
- 5. Before we can evaluate the success of a drug treatment program, we have to understand the program’s A. Administrative structure. B. Training requirements. C. Goals. D. Theoretical approach. 0% 0% 0% 0% Training requirements. Administrative structure. Goals. Theoretical approach. Response
- 6. Opinion: What do you think the goal of treatment should be? A. Complete abstinence B. Controlled substance use C. Helping the user make better decisions D. Other 0% 0% 0% 0% Complete abstinence Controlled substance use Helping the user make be... Other Response
- 7. Stages of Change • Motivational Enhancement Interview • Resistance • Client • Community
- 9. The goal of motivational enhancement is 1. To confront the user with his/her negative behavior 2. Find alternatives to substance use 3. Encourage the user to move to another stage of change To confront the user with... 0% 0% 0% Find alternatives to subs... Encourage the user to m... Response
- 10. How was your Thanksgiving? A. Awesome! B. Too short. C. Okay. D. Don’t ask. 25% 25% 25% 25% Awesome! Too short. Okay. Don’t ask. Response
- 11. Drug Courts • Drug treatment courts combine the power of the justice system with effective treatment services • First drug court was established in 1989 for nonviolent drug offenders whose underlying problem is substance use • Offenders who complete substance abuse programs may have their sentences dismissed or reduced
- 12. Treatment • Contingency Management • Cognitive Behavioral Therapy (CBT) • Pharmacotherapies • Detoxification • Maintenance
- 13. The most widely used treatment for substance abuse is: A. Motivational enhancement B. Pharmacotherapy C. Cognitive-behavioral therapy D. Detoxification 0% 0% 0% 0% Pharmacotherapy Cognitive-behavioral the... Motivational enhancement Detoxification Response
- 14. The goal of the maintenance phase of treatment is A. Preventing seizures B. Preventing cross tolerance C. Preventing relapse 0% 0% 0% Preventing seizures Preventing cross tolerance Preventing relapse Response
- 16. The Big Picture
- 17. Is Treatment Effective? • Relapse • Factors: • Negative emotional states • Interpersonal conflicts • Social pressure
- 18. Benefits of Treatment • Less expensive than incarceration • Reduced use of illicit drugs • Decline in criminal activity • More stable employment • Reduced transmission of AIDS • Reported benefits: • Drug use declined from 73% before treatment to 38% one year after treatment • Increase in employment from 51% to 60% • Decline in clients receiving welfare from 40% to 35% • Drop in homelessness from 19% to 11% • 53% decline in substance-related medical visits • 56% reduction in people exchanging sex for drugs • 51% drop in people having sex with an IV drug user
- 19. Treatment Issues • Four pertinent issues in treating drug abuse: 1. Voluntary or compulsory treatment 2. Matching patients to the best treatment 3. Effectiveness of treatment programs designed for adults for adolescent substance abusers 4. Programs to address female addicts
- 20. Reasons Women Avoid Treatment
- 21. Barriers • Client Resistance to Treatment: • Many treatment facilities are not readily available or accessible • A large percentage of clients lack insurance and cannot afford the cost of treatment • Policies and philosophies of some facilities deter drug abusers from pursuing help • Benefits of using drugs outweigh the disadvantages • Clients think that legal authorities will be made aware of their drug-taking behavior if they enter treatment
- 22. Barriers • Community Resistance: • People do not want drug treatment centers in their neighborhoods • Concerned about more crime, more traffic, exposure of children to bad influences, and lower property values • NIMBY (not in my backyard) syndrome
- 23. Barriers • Continuing Drug Use: • The goal of abstinence is often not realized • Treatment of at least six months seems to be necessary to reduce drug use significantly • One study of adolescents in treatment reported that drug usage declined somewhat, but remained high
- 24. Barriers • Factors that contribute to relapse among alcoholics: 1. Negative emotional states such as frustration, anxiety, depression, anger, or boredom 2. Interpersonal conflicts with a spouse, family member, friend, or employer 3. Social pressure from a person or group of people
- 25. Barriers • Factors in Personnel Recruitment and Retention: • Reluctance to work with drug abusers • Undesirable locations of facilities • Inadequate supply of applicants with professional experiences and qualifications • Fear of contracting AIDS
Editor's Notes
- 23.5 million persons aged 12 and older need treatment for either an illicit drug or alcohol Only 11.2% of those individuals receive treatment from a specialized facility The federal government allocates more than two-thirds of its drug-control budget to law enforcement and interdiction efforts, rather than treatment People in treatment for substance abuse: Disadvantaged in education and employment More likely to be male, Caucasian, aged 25 to 45 Increasing trend toward veterans and the elderly Most people in drug treatment : Caucasian males Average age at admission is 34 Less than one-fourth are employed One third completed high school or a GED Many have mental health problems 30-40% of homeless population are drug abusers Most use more than one drug The goals of a treatment program differ, depending on whether drug abuse is seen as a medical problem, as a breakdown in society, or as a personality weakness 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 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 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 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 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 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
- 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 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 Motivational enhancement therapy attempts to shift the focus away from denial and toward motivation to change Client Resistance to Treatment: Many treatment facilities are not readily available or accessible A large percentage of clients lack insurance and cannot afford the cost of treatment Policies and philosophies of some facilities deter drug abusers from pursuing help Benefits of using drugs outweigh the disadvantages Clients think that legal authorities will be made aware of their drug-taking behavior if they enter treatment Community Resistance: People do not want drug treatment centers in their neighborhoods Concerned about more crime, more traffic, exposure of children to bad influences, and lower property values NIMBY (not in my backyard) syndrome VOLUNTARY or INVOLUNTARY Some studies show that volunteers fare better than those required to be in treatment Other studies show that those required to receive treatment make as much progress, as those who enter voluntarily The key issue could be how long the person stays in treatment 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 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
- Using drugs to treat drug abuse was common in early treatment programs US Public Health Service established two hospitals to serve the growing number of addicts in federal prisons The relapse rate of people released in the 1940s through early 1960s ranged between 87% and 96% Therapeutic community – a residential facility staffed by former drug addicts Methadone maintenance programs – outpatient programs in which opiate addicts receive methadone daily Methadone Maintenance Treatment that involves the dispensing of methadone for opiate addiction for more than 30 days Eliminates withdrawal symptoms and prevents euphoria Given orally, every 24 hours Effective only for heroin addiction Psychotherapy in conjunction with methadone yields the best results Crime reduction and relapse rates improve with duration of treatment Alternatives to Methadone: Extended-release form of naltrexone allows patients to be treated on a monthly rather daily basis Levo-alpha-acetylmethadol (LAAM) works for three days, but has side effects Other drugs that block the effects of opiates are naltrexone, naloxone, clonidine, and buprenorphine Some narcotic addicts say that methadone withdrawal is worse than going cold turkey Therapeutic communities (TCs) Drug-free residential settings where abusers reside for one or two years Philosophy is that drug abuse is incurable, but can benefit from behavioral intervention Stress group intervention techniques, especially encounter groups Provide vocational and educational assistance and improve the self-esteem of residents Outpatient Treatment: Most common form of drug abuse treatment Less disruptive and stigmatizing than inpatient treatment Ranges from counseling centers to halfway houses to community centers Frequently is used after a client leaves methadone maintenance Clients often go back to the environments that contributed to their drug abuse initially Inpatient Treatment: Typically hospital based Expensive No more effective than intensive outpatient treatment Tend to be highly structured Group therapy and drug education are stressed Self-Help Groups: Members are bound by a common denominator such as alcohol, gambling, food, shopping, or sex Largest self-help group is Alcoholics Anonymous (AA), based on a 12-step model Offer fellowship and support Used in lieu of traditional therapies or after a person stops other therapies Cost-effective for maintaining changes and preventing relapse Narcotics Anonymous (NA) Emanated from Alcoholics Anonymous Open to all drug addicts Principles of the NA recovery program: Admitting there is a problem Seeking help Engaging in a thorough self-examination; Confidential self-disclosure; Making amends for harm done Helping other drug addicts who want to recover AA advocates total abstinence, a view that is not universally accepted Some treatments advocate a controlled drinking approach in which the patient learns to drink in a nonabusive manner Drug therapy in the form of Antabuse (disulfiram) has been used as well Alcoholics Anonymous Started in 1935 by an alcoholic surgeon (Dr. Bob) and an alcoholic stockbroker (Bill W.) Goals are sobriety and spiritual renewal Based on the premise that alcoholism is a disease over which the person has no control Based on a 12-step plan 1. We admitted we were powerless over alcohol—that our lives had become unmanageable 2. Came to believe that a Power greater than ourselves could restore us to sanity 3. Made a decision to turn our will and our lives over to the care of God as we understood Him 4. Made a searching and fearless moral inventory of ourselves 5. Admitted to God, to ourselves, and to another human being the exact nature of our wrongs 6. Were entirely ready to have God remove all these defects of character. 7. Humbly asked Him to remove our shortcomings 8. Made a list of all persons we had harmed, and became willing to make amends to them all 9. Made direct amends to such people wherever possible, except when to do so would injure them or others 10. Continued to take personal inventory and when we were wrong promptly admitted it 11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him 12. We tried to carry this message to alcoholics and to practice these principles in all our affairs Moderation Management (MM) is a controlled drinking model of behavioral self-management Drinkers are taught to cope with peer pressure and situations that tempt them to drink excessively The longer a person has been an alcoholic, the less likely it is that he or she can return to social drinking The controlled drinking model is contrary to the disease model Disulfiram (Antabuse) Acts as an aversive agent by interacting with alcohol in such a way that the drinker becomes violently ill Naltrexone Reduces alcohol craving among heavy drinkers, but has not been shown to result in abstinence Acamprosate Inhibits the craving for alcohol and food Detoxification – a medically supervised program to withdraw from drugs on which they are physically dependent Three immediate goals of detoxification: To provide safe withdrawal from drugs To provide withdrawal that is humane and protects the person’s dignity To prepare the person for ongoing treatment Self-help programs based on the principles of Alcoholics Anonymous are growing in popularity 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 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 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 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 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 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 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 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 Chlordiazepoxide (Librium) or diazepam (Valium) Maintenance therapy Usually given for weeks or months rather than indefinitely Three approved medications Disulfiram (Antabuse) Naltrexone (Revia) Acamprosate (Campral) 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 (Revia) 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 (Campral) 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 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 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 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 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 (Subutex) maintenance Buprenorphine + naloxone (Suboxone) Naloxone (Narcan), a short-acting opioid antagonist, is used to treat opioid overdose Naltrexone (Revia), 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 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 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 (Marinol) Currently no approved pharmacotherapy for cannabis dependence
- 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 23.5 million persons aged 12 and older need treatment for either an illicit drug or alcohol Only 11.2% of those individuals receive treatment from a specialized facility The federal government allocates more than two-thirds of its drug-control budget to law enforcement and interdiction efforts, rather than treatment People in treatment for substance abuse: Disadvantaged in education and employment More likely to be male, Caucasian, aged 25 to 45 Increasing trend toward veterans and the elderly Most people in drug treatment : Caucasian males Average age at admission is 34 Less than one-fourth are employed One third completed high school or a GED Many have mental health problems 30-40% of homeless population are drug abusers Most use more than one drug 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 Outpatient Treatment: Most common form of drug abuse treatment Less disruptive and stigmatizing than inpatient treatment Ranges from counseling centers to halfway houses to community centers Frequently is used after a client leaves methadone maintenance Clients often go back to the environments that contributed to their drug abuse initially Inpatient Treatment: Typically hospital based Expensive No more effective than intensive outpatient treatment Tend to be highly structured Group therapy and drug education are stressed Self-Help Groups: Members are bound by a common denominator such as alcohol, gambling, food, shopping, or sex Largest self-help group is Alcoholics Anonymous (AA), based on a 12-step model Offer fellowship and support Used in lieu of traditional therapies or after a person stops other therapies Cost-effective for maintaining changes and preventing relapse
- Benefits of drug treatment: Less expensive than incarceration Reduced use of illicit drugs Decline in criminal activity More stable employment Reduced transmission of AIDS Reported benefits: Drug use declined from 73% before treatment to 38% one year after treatment Increase in employment from 51% to 60% Decline in clients receiving welfare from 40% to 35% Drop in homelessness from 19% to 11% 53% decline in substance-related medical visits 56% reduction in people exchanging sex for drugs 51% drop in people having sex with an IV drug user Continuing Drug Use: The goal of abstinence is often not realized Treatment of at least six months seems to be necessary to reduce drug use significantly One study of adolescents in treatment reported that drug usage declined somewhat ,but remained high Substance dependence is a chronic illness Treatment doesn’t work for every individual every time Condition may require continuing care throughout life Factors that contribute to relapse among alcoholics: Negative emotional states such as frustration, anxiety, depression, anger, or boredom Interpersonal conflicts with a spouse, family member, friend, or employer Social pressure from a person or group of people Studies show that treatment is cost-effective by reducing crime and increasing employment Treatment also saves lives in the long term Benefits of drug treatment: Less expensive than incarceration Reduced use of illicit drugs Decline in criminal activity More stable employment Reduced transmission of AIDS Reported benefits: Drug use declined from 73% before treatment to 38% one year after treatment Increase in employment from 51% to 60% Decline in clients receiving welfare from 40% to 35% Drop in homelessness from 19% to 11% 53% decline in substance-related medical visits 56% reduction in people exchanging sex for drugs 51% drop in people having sex with an IV drug user Questions to be addressed: Which treatment produces the best outcomes for a specific group or person? Do members of certain ethnic or socioeconomic groups respond similarly to certain types of treatment? Is the effectiveness of a specific program linked to age of participants? Do females and males differ in their responses to treatment? ADOLESCENTS In 2009, in the US, 149,277 individuals aged 12 to 17 were admitted to a drug treatment facility The primary drug of abuse was marijuana More intensive, longer programs (three months) are more effective than short (two session) programs Teens who enter treatment do better academically than teens who do not receive treatment WOMEN Treatment programs for women are scarce Women substance abusers are more likely to have poor family relationships and psychological health than men Even when treatment is available, many women are reluctant to enter a program Women in female-only drug abuse treatment centers are more likely to benefit from treatment
- Some studies show that volunteers fare better than those required to be in treatment Other studies show that those required to receive treatment make as much progress, as those who enter voluntarily The key issue could be how long the person stays in treatment Questions to be addressed: Which treatment produces the best outcomes for a specific group or person? Do members of certain ethnic or socioeconomic groups respond similarly to certain types of treatment? Is the effectiveness of a specific program linked to age of participants? Do females and males differ in their responses to treatment? In 2009, in the US, 149,277 individuals aged 12 to 17 were admitted to a drug treatment facility The primary drug of abuse was marijuana More intensive, longer programs (three months) are more effective than short (two session) programs Teens who enter treatment do better academically than teens who do not receive treatment Treatment programs for women are scarce Women substance abusers are more likely to have poor family relationships and psychological health than men Even when treatment is available, many women are reluctant to enter a program Women in female-only drug abuse treatment centers are more likely to benefit from treatment
- Figure 15.1 Percentages of Reasons* for Not Receiving Substance Use Treatment in the Past Year among Women Aged 18 to 49 Who Needed Treatment and Who Perceived a Need for It: 2004–2006