Psychology 317 Chapter 15

1. Psychology 317 Chapter 15 Treatment of Substance Use Disorders

2. Treatment of Substance Use Disorders • Drug abuse is an expensive personal, social and economic problem. • In spite of demands by politicians and the public to incarcerate drug abusers, drug abuse prevention is much less expensive in terms of; cost to individuals, families and society. • Health costs in 1988 due to alcohol abuse only, from lost employment and lost productivity, was $150 billion.

3. Treatment of Substance Use Disorders continued • Treatment costs less than incarceration because • Treatment reduces illicit drug use and expenditure • Treatment reduces criminal activity • Treatment reduces escalation of AIDS. Lifetime care for AIDS patient $75,000 approx. • Majority of those in treatment are: young, male, socially disadvantaged, distrust authority, have mental problems, engaged in criminal activity. • In 1960s treatment was sought for heroin use, today for multiple drug use. • In 1930 US Public Service established two drug treatment hospitals, Lexington, KY and Fort Worth, TX

4. Treatment of Substance Use Disorders continued • Individuals sentenced to the hospitals by courts. There was 90% relapse before program completion. • By 1960 treatment programs were individualized with emphasis on cost effectiveness. • Voluntary treatment found more effective than compulsory, regardless of treatment form. • Individuals from supportive social and economic backgrounds benefitted most from treatment.

5. Motivation to Change • Motivation to change is essential for behavioral or psychological treatment to be effective. • For treatment to happen individual must admit there is a problem. • After problem admission individual may decide to change or not change behavior. • Change may be spontaneous (spontaneous remission), self-help group (AA), professional treatment, combination of self-help and professional treatment. • One model of determining readiness is the stages of change model.

6. Motivation to Change continued • The model has 5 stages; • Precomtemplation- Unaware of problem, have no interest in change (denial). • Contemplation- Vacillation between pros and cons of problem behavior and pros & cons of making behavior change. • Preparation- On edge of taking action to change, may have tried in recent past. • Action- Engaged in explicit activities to change. • Maintenance- continued use of behavior-change activities may last as long as 3 yrs. after beginning of action.

7. Change Without Formal Treatment • More individuals resolve addiction problems on their own than with self-help groups or professional treatment. • 57% said change came from weighing benefits/ costs of continuing behaviors. • Change occurred when costs outweighed benefits. • 29% said change was immediate but could not recall what triggered change, or said major serious event triggered change.

8. Self-Help Groups • Self-help groups play major role in treatment abuse disorders. • Members perform therapeutic functions without professional training. • Members have identified problem that is the focus of group’s therapeutic activity. • Members give and receive help with problems. • AA, prototype of self-help groups, was established in 1935. • Alcoholic surgeon, (Dr. Bob) & stockbroker (Bill w.) helped each other maintain sobriety.

9. Self-Help Groups continued • Bob & Bill established first AA group in Ohio, today AA is international. • AA model of recovery is stated in 12 steps with frequent reference to God. (Table 15.1) • AA is criticized for emphasis on God • Critics claim emphasis on God by AA turns off nonreligious individuals. • AA says emphasis on God refers to supreme being and not just Christian God.

10. Self-Help Groups continued • Other self-help groups were formed as alternatives to AA but many adopted a philosophy/ format similar to AA’s • Other self-help groups that became popular are: • Narcotics Anonymous (NA), formed to help heroin addicts but now welcomes anyone with addiction to drugs. • Women for Sobriety (WFS), formed for alcoholic women and is now international, has 13 statements re spiritual and emotional change and growth.

11. Self-Help Groups continued • Self –Management Recovery Training (SMART), designed to make people aware of • Motives for using and ceasing use of alcohol and drugs. • Beliefs that can help or hinder alcohol use. • Emotions • Behavior • Addiction Voice Recognition Treatment (AVRT), Goal to get addicts to stop and take control of inner voice saying drink. • Secular Organization for Sobriety (SOS, Save Our Selves), Began in 1986 as alternative to AA and SMART; no emphasis on spirituality.

12. Models of Substance-Use Disorder • The treatment design of alcohol drug abuse programs is based on the model and origin of alcohol drug use disorder subscribed to by the program designer. • The models are biological, psychological, and social/environmental. • The models and theories are organized into 5 categories: moral model, American disease model, biological model, social learning model, sociocultural model (See Table 15.2).

13. Biopsychosocial Model • Because of belief that single-factor models explaining the etiology of drug use or abuse are inadequate, the biopsychosocial model was developed. • The biopsychosocial model combines the major types of factors that seem to influence development of alcohol and drug use disorders.

14. Professional Treatment: Assessment and Goals • Treatments have goals. • Alcohol and drug treatment usually begins with a thorough assessment. • Assessment may involve formal and or informal procedures to determine individuals’ functioning and effects of drugs on other parts of their lives. • The goal of most treatment programs for alcohol problems is alcohol abstinence.

15. Professional Treatment: Assessment and Goals continued • Self-help programs are adamant that abstinence is essential for long-term improvement in functioning. • For some, fear of complete abstinence inhibits seeking treatment or stopping alcohol use. • For those individuals a moderate or controlled drinking treatment model is seen as a reasonable outcome goal.

16. Alcohol Treatment Settings and Services • Alcohol treatment settings can be classified into three categories: hospital, intermediate and outpatient. • Hospital setting; Inpatient in hospital setting for specified treatment services- medical model is used although rehabilitation treatment consist primarily of psychological programs, detoxification mainly. • Intermediate setting: Halfway-house services/ milieutreatment setting; patients are residents during program; other treatments include counseling, psychotherapy and self-help groups.

17. Alcohol Treatment Settings and Services continued • Outpatient setting, most idiosyncratic. • Can be one on one, individual couples, or family, with professionals, but with greatly reduced therapist contact.

18. Pharmacology Treatment • Alcohol pharmacology treatment includes medication to manage withdrawal, using alcohol-sensitizing, drugs that alter reinforcement from alcohol use, drugs to manage alcohol craving. • Withdrawal Management; Little controversy about use of drugs to manage acute withdrawal, but disagreement in drug use to treat post-detoxification activities. • Sensitizing drugs; Drugs that control metabolism of alcohol if consumed. • With 2 drinks disulfiram or Carbimide increase blood acetaldehyde, tachycardia, tachypnea (rapid respiration), warm body sensation, shortness of breath. • Larger quantities produce increase in above symptoms, coma and death.

19. Pharmacology Treatment continued • Other drugs that affect brain activity (reinforcement properties of alcohol) eg. opiate antagonists, anti-anxiety and GABA receptors drugs, have also been used. See Table (15.3).

20. Effectiveness of Alcohol Treatment • No one treatment for alcohol problems seems to be superior to others. • Length of stay in treatment is associated with better outcomes. • One-on-one treatment more is effective if matched to patients’ characteristics. • Controlled research on self-help groups is difficult- However, research suggests AA helps some but not others. • Pharmacotherapies are recent developments thus little data on them. Three agents currently approved by FDA, are disulfiram, maltrexone and acamprosite.

21. Drug Treatment Setting and Services • Traditionally drug treatment settings have been defined by heroin abuse treatment. • Abusers of other drugs now appear in most of these settings. • Drug treatment settings traditionally include: detoxification, methadone maintenance, residential and out-patient treatments. • Pharmacological treatment of Heroin addiction include • Methadone & levo-alpha-acetylmethadol (LAAM) • LAAM is longer acting but both are addicting, Naltrexone and Nolaxone are other opioid treatment drugs.

22. Drug Treatment Setting and Services continued • Cocaine addiction treatment include desipramine, amantadine and fluoxetine. • Length of stay in residential or nonmethadone outpatient treatment is associated with reduced substance use and more socially productive lifestyle. • Pharmacotherapies for opioid dependence have had some success but cocaine dependence less successful.

23. Drug Treatment Setting and Services continued • Nonpharmacological treatments of illicit drug use include: structured contingency reinforcement programs. • Combined pharmacological and psychosocial therapies • Program reinforces desired behaviors to maintain sobriety- (no use of punishment). • Community reinforcement approach: involving the community in the reinforcement contingency is effective in treating cocaine dependency.

24. Drug Treatment Setting and Services continued • Conjoint therapies; Community Reinforcement approach that includes family/couples (cojoint) component, based on social learning principles. • Treatment providers for drug and alcohol users have found that a large percentage of patients are multiple drug users. • This has resulted in recognition of settings for treatment of multiple drug users, not drug or alcohol treatment alone. • There has also been recognition that many who show up for alcohol and drug treatment have major psychiatric disorders • Psychotropic medication is one approach to treating these individuals.

25. Relapse • Relapse is reappearance of problem(s) after period of remission. • Relapse rate is high and related to environmental factors. • Research in relapse challenges over last 25 years have resulted in treatment applications called relapse prevention. • Relapse prevention focuses on • Assessment of high risk situations • (eg. negative/positive moods, presence of people, temptations) • Looks at ways of coping with situation without using drugs and self-efficacy to do so.

26. Economic Factors in Alcohol and Drug Treatment • Cost of health insurance and other factors have greatly influenced treatment. • Financial factors (personal income, insurance coverage) influence accessibility to treatment type and length.

27. The Stepped Care Approach • Stepped care is an approach to professional treatment selection that integrates current knowledge about alcohol and drug treatment effectiveness and conditions under which it is delivered. • Stepped Care approach is guided by 3 principles • Individualized treatment to the person’s needs and problems. • Consistency of selected treatment with knowledge of effectiveness. • Treatment selected should be least restrictive.