SUBSTANCE ABUSE AND TREATMENT: PUBLIC HEALTH, GENETICS, AND

REHABILITATION

by

Emily Russell

B.S. Psychology, University of Pittsburgh, 2007

Submitted to the Graduate Faculty of

the Department of Human Genetics

Graduate School of Public Health in partial fulfillment

of the requirements for the degree of

Master of Public Health

University of Pittsburgh

2016

UNIVERSITY OF PITTSBURGH

GRADUATE SCHOOL OF PUBLIC HEALTH

This essay is submitted

by

Emily Russell

on

April 27, 2016

and approved by

Essay Advisor:Candace Kammerer, B.S., Ph.D. ____________________________________Associate Professor Department of Human GeneticsGraduate School of Public HealthUniversity of Pittsburgh

Essay Reader:Martha Ann Terry, B.A., M.A., Ph.D. ____________________________________Assistant ProfessorDepartment of Behavioral and Community Health SciencesGraduate School of Public HealthUniversity of Pittsburgh

Copyright © by Emily Russell

2016

ABSTRACT

Substance abuse is a complex health problem with global public health significance. It is thought

to be a result of a combination of factors, including genetics, the environment, and exposure to

substances. It has a significant public health impact on mortality and health. Deaths from

overdoses, certain cancers, and accidents are linked to substance abuse. Drug and alcohol abuse

does not only affect the addict. Family members, friends, and community members are also

impacted by the addict’s behavior. Substance abuse also contributes to other societal costs such

as lost wages, healthcare expenses, and criminal justice costs. Treatment for substance abuse is

difficult and complex. One of the main goals of treatment is to prevent relapse. This is

particularly challenging in the outpatient treatment setting where clients are exposed to the

stressors of everyday life while in treatment. At a local intensive outpatient therapy program,

treatment professionals identified some challenges that they encounter while providing

treatment. A public health intervention could be implemented to mitigate some of these

challenges and improve rehabilitation service delivery.

Candace Kammerer, B.S., Ph.D.

SUBSTANCE ABUSE AND TREATMENT: PUBLIC HEALTH, GENETICS,

AND REHABILITATION

Emily Russell, MPH

University of Pittsburgh, 2016

TABLE OF CONTENTS

1.0 INTRODUCTION AND EPIDEMIOLOGY............................................................................1

1.1 GLOBAL HEALTH PROBLEM...........................................................................................................1

1.2 ECONOMIC IMPACT............................................................................................................................ 3

1.3 IMPACT ON FAMILY AND SOCIETY.............................................................................................4

2.0 GENETICS OF SUBSTANCE ABUSE AND TREATMENT..........................................5

2.1 GENETICS OF SUSCEPTIBILITY FOR SUBSTANCE ABUSE................................................5

2.2 PHARMACOGENOMICS OF ALCOHOL ABUSE........................................................................7

3.0 OVERVIEW OF PRACTICUM AT AN INTENSIVE OUTPATIENT

REHABILITATION PROVIDER.................................................................................................... 9

3.1 EFFECTIVE TREATMENT STRATEGIES...................................................................................10

3.2 CHALLENGES TO EFFECTIVE TREATMENT.........................................................................10

4.0 DEVELOPMENT OF A PROPOSED INTERVENTION..................................................12

4.1 HEALTH PROBLEM IDENTIFICATION......................................................................................12

4.2 IDENTIFYING CAUSAL FACTORS...............................................................................................13

4.3 IDENTIFYING AN INTERVENTION..............................................................................................17

4.4 EVALUATE THE INTERVENTION................................................................................................22

5.0 CONCLUSION............................................................................................................................ 23

BIBLIOGRAPHY.............................................................................................................................. 25

LIST OF FIGURES

Figure 1: Health problem analysis of causal factors for drug and alcohol relapse following

completion of a rehabilitation program .................................................................................15

Figure 2: Health problem analysis of direct and indirect consequences of drug and alcohol

relapse following completion of a rehabilitation program.....................................................16

Figure 3: Logic model....................................................................................................................21

1.0 INTRODUCTION AND EPIDEMIOLOGY

Substance abuse is a widespread problem that affects individuals of all ethnicities and

socioeconomic statuses both in the United States and globally. Substance abuse is a maladaptive

pattern of alcohol or drug use that is evidenced by one or more of the following: failure to fulfill

major obligations at work, school, or home because of the use of drugs or alcohol, repeatedly

using substances when it is dangerous to do so (for instance, driving under the influence),

repeated legal problems as a result of using drugs or alcohol, and continuing to use substances

despite problems with family members or friends that are caused by the use of drugs or alcohol

(American Psychiatric Association, 2000).

Substance dependence is a more serious pattern of substance use manifested by three or more of

the following: alcohol or drugs taken in larger quantities or over a longer period of time than

planned, having a desire to stop using the substance or to use less of it, spending a great deal of

time using drugs or alcohol, using drugs or alcohol instead of engaging in important social,

occupational or recreational activities, continuing to use the substance even after developing

physical or psychological problems as a result of using, tolerance to the substance, and

withdrawal symptoms (American Psychiatric Association, 2000).

1.1 GLOBAL HEALTH PROBLEM

According to data from the World Health Organization (WHO), alcohol has been linked to 3.8%

of all deaths globally as a result of certain cancers, cardiovascular disease, accidents, overdoses,

and other injury deaths (Rehm et al., 2009). Alcohol consumption and mortality are higher in

European countries, the western Pacific region and the Americas when compared to consumption

and mortality in Africa, the southeast Asia region, and the eastern Mediterranean region (Rehm

et al., 2009). Worldwide, more alcohol is consumed by men than women and there are also

higher rates of mortality due to alcohol consumption for men (Rehm et al., 2009).

Limited data are available on the global prevalence of substance dependence due to different

survey methods and the lack of information on substance use and abuse in every country

(Degenhardt & Hall, 2012). A WHO survey in 27 countries in five WHO regions found that

high-income countries typically had higher rates of drug dependence (Degenhardt & Hall, 2012).

In the United States, it was estimated that 21.5 million people have a substance use problem such

as substance abuse or dependence in 2014 (Center for Behavioral Health Statistics and Quality,

2015). Excessive alcohol consumption, which is defined as binge drinking (a woman consuming

four or more drinks or a man consuming five or more drinks in a two hour period), heavy

drinking (consuming more than one drink per day for a woman or more than two drinks per day

for a man), underage drinking (any alcohol consumption before age 21), or drinking during

pregnancy (drinking any amount during pregnancy), is responsible for an average of 79,000

deaths per year in the United States (Bouchery, Harwood, Sacks, Simon, & Brewer, 2011).

Alcohol related deaths are attributed to a variety of reasons including cirrhosis of the liver,

alcohol poisoning, and alcohol related accidents, including motor vehicle crashes (Bouchery et

al., 2011).

According to mortality data from the Centers for Disease Control and Prevention (CDC) using

the Tenth Revision of the International Classification of Disease (ICD-10), drug overdoses for all

licit and illicit drugs were responsible for over 47,000 deaths in the United States in 2014

(Rossen LM, 2016). Mortality due to drug overdoses was most common for males and

individuals between the ages of 25 and 54 (Rossen LM, 2016). According to data coded by the

National Center for Health Statistics (NCHS) using the ICD-10 classification, fatal overdoses of

opioid analgesics such as oxycodone have increased by 91.2% in the United States between 1999

and 2002, making opioid analgesic overdoses more common in 2002 than fatal heroin or cocaine

overdoses (Paulozzi, Budnitz, & Xi, 2006). Due to changes in regulations for prescribing pain

medication, the number of prescriptions for opioid analgesics increased in the early 1990’s; some

researchers suggest that this contributed to the rise in opioid use and mortality (Manchikanti et

al., 2012; Paulozzi et al., 2006).

1.2 ECONOMIC IMPACT

Substance abuse has an economic impact as well. It can lead to lost wages, higher healthcare

costs, criminal justice costs and the costs of motor vehicle accidents. For the United States

economy in 2007, the monetary impact of drug abuse was estimated to be a loss of $193 billion

in lost productivity, healthcare, and criminal justice costs (National Drug Intelligence Center,

2011). It is estimated that excessive alcohol consumption, such as binge drinking, heavy

drinking, underage drinking, or drinking during pregnancy costs the United States economy

$223.5 billion in lost productivity, healthcare, and criminal justice costs (Bouchery et al., 2011).

Addiction treatments can help to reduce these societal costs. It is estimated that for every dollar

that is put into treatment programs, there is a $7,000 economic savings (Department of Drug and

Alcohol Programs, 2015).

According to the 2010 National Survey on Drug Use and Health, (NSDUH) drug overdose

deaths increased for more than two decades in Pennsylvania (Substance Abuse and Mental

Health Services Administration, 2011). The age-adjusted mortality rate for drug poisoning deaths

in Pennsylvania was 21.9/100,000 and in Allegheny County it was also more than 20/100,000

(Rossen LM, 2016). Based on the 2010 NSDUH survey, the prevalence of drug and alcohol

substance use disorders in Pennsylvania is estimated to be 900,000 or nearly 7% of the

population (Substance Abuse and Mental Health Services Administration, 2011). This is a

significant number of people who could benefit from effective treatment options.

1.3 IMPACT ON FAMILY AND SOCIETY

Alcohol and drug abuse and dependence are major public health issues that not only impact an

individual struggling with addiction, but also family members and other individuals in the

community (Lander, Howsare, & Byrne, 2013; Li, Brady, & Chen, 2013). Children of substance

abusers are more likely to experience conflict at home and emotional or physical violence

(Johnson & Leff, 1999). Driving while under the influence of alcohol or drugs is associated with

an increased risk of being involved in an accident that is fatal for either the driver or others (Li et

al., 2013).

2.0 GENETICS OF SUBSTANCE ABUSE AND TREATMENT

The genetics of alcohol and drug use problems are not fully understood, but it is thought that

genes and environmental factors interact to cause them. Learning about this interaction could be

informative for designing an effective treatment program for drug and alcohol abuse.

Substance use and abuse involve a three-stage cycle that begins with cravings (preoccupation-

anticipation), then use of the substance (binge-intoxication) and finally the aftermath

(withdrawal-negative affect) (Wong, Mill, & Fernandes, 2011). Genetic factors and the

environment can have an influence on each of these stages. Cravings are unlikely to occur

without the environmental exposure to the substance, but genetic factors can modulate how

intense the cravings are. Genes that influence the metabolism of drugs and alcohol play a role in

both the binge-intoxication phase and the withdrawal-negative affect phase (Gelernter &

Kranzler, 2009).

2.1 GENETICS OF SUSCEPTIBILITY FOR SUBSTANCE ABUSE

For alcohol abuse, heritability (the proportion of the total variation in a trait between individuals

that is due to genetic variation) is estimated to be between 50-65% based on two large (sample

sizes of 9,000 and 6,000) twin studies of males and females of European ancestry (Heath et al.,

1997; Kendler, Prescott, Neale, & Pedersen, 1997). The remainder of the risk for alcohol abuse is

thought to be environmental in nature, caused by shared family factors or unshared

environmental factors (Gelernter & Kranzler, 2009). Family factors include the positive or

negative attitudes of family members towards drinking as well as responsible or reckless

drinking behaviors that may be witnessed during childhood.

Heritability estimates for non-alcohol drug abuse vary based on the class of drug. Based on large

(more than 2,200 pairs) twin studies of men and women of European ancestry, heritability is

estimated to range from 39% for hallucinogens to 72% for cocaine (Goldman, Oroszi, & Ducci,

2005). The biological pathways for the individual drugs may also vary, but the underlying

genetic variations in genes that influence risk taking and the reward centers in the brain are likely

to be similar in both alcohol and non-alcohol drug abuse (Volkow & Baler, 2014).

Given that alcohol abuse is heritable, investigators have tried to identify specific genetic variants

that may influence susceptibility to alcohol abuse. The alcohol dehydrogenases, coded by the

ADH gene cluster, are thought to be of interest for alcohol abuse because they are responsible for

metabolizing alcohol into acetaldehyde, a toxic intermediary in the conversion of alcohol to

acetic acid (Gelernter & Kranzler, 2009). Acetaldehyde is responsible for the flushing cheeks

that some people experience after drinking alcohol (Gelernter & Kranzler, 2009). Acetaldehyde

is further metabolized to a non-toxic acetic acid by acetaldehyde dehydrogenases (ALDH), one

of which is encoded by ALDH2 (Gelernter & Kranzler, 2009). A genetic variant that reduces

ALDH function may be protective against alcohol abuse and dependence because the resulting

buildup of acetaldehyde results in uncomfortable symptoms such as flushed skin and nausea. A

meta-analysis of 15 studies with a combined sample size of 4,458 conducted in an Asian

population indicated that individuals who have one copy of the non-functional ALDH2 allele,

ALDH2*2, which encodes a non-functional protein subunit of the ALDH2 enzyme, have less

than half of the risk for alcohol dependence when compared to individuals who have two

functional copies of the ALDH2 allele (Luczak, Glatt, & Wall, 2006).

Another biological pathway that may affect susceptibility to alcohol abuse is the pathway

involving gamma-aminobutyric acid (GABA), the main inhibitory neurotransmitter (Gelernter &

Kranzler, 2009). Alcohol can bind directly to the GABA receptors in the brain. A linkage

disequilibrium analysis of families with multiple alcoholics found an association between

alcohol dependence and thirty-one SNPs in the GABRA2 gene, which codes for part of the

GABA receptor (Edenberg et al., 2004).

2.2 PHARMACOGENOMICS OF ALCOHOL ABUSE

In addition to identifying individuals at higher risk for alcohol abuse, identifying appropriate

treatment for specific individuals based on their genotype is the overarching goal of

pharmacogenomics. Specific genetic variants are known to affect drug metabolism, and

therefore, the effectiveness of the drug; this can result in the drug either not working as well as

expected or causing toxic effects even at standard doses (Kitzmiller, Groen, Phelps, & Sadee,

2011). For example, the Food and Drug Administration (FDA) recommends genotype testing

prior to prescribing clopidogrel (also known as Plavix), an antiplatelet drug that is prescribed to

prevent blood clots in individuals with certain cardiovascular diseases (Kitzmiller et al., 2011).

Clopidogrel is transformed into the active metabolite that prevents platelet clotting by the

CYP2C19 enzyme; however, individuals with one of the CYP2C19 loss-of-function alleles are

unable to metabolize clopidogrel as efficiently, resulting in reduced drug efficacy (Kitzmiller et

al., 2011).

Naltrexone is an opioid agonist that can be prescribed as part of treatment for alcohol abuse and

dependence because it has been shown to reduce cravings for alcohol (Anton et al., 2008). A mu-

opioid receptor gene (OPRM1) has been associated with responses to naltrexone (Anton et al.,

2008). The Asp40 missense allele is the minor allele of a polymorphism in OPRM1 that alters

beta-endorphin binding to the mu-opioid receptor (Anton et al., 2008). Studies with fewer than

1,000 men and women of European, African American, and Hispanic ancestry have shown that

individuals with one or two copies of the Asp40 allele have fewer alcohol cravings and a greater

reduction in alcohol cravings when taking naltrexone versus a placebo than individuals with the

more common Asn40 allele (Anton et al., 2008; Gelernter & Kranzler, 2009). Larger

pharmacogenomics studies are needed to further explore the effect of the Asp40 allele on

naltrexone treatment response.

3.0 OVERVIEW OF PRACTICUM AT AN INTENSIVE OUTPATIENT

REHABILITATION PROVIDER

For alcohol or drug related offenses, outpatient rehabilitation services are often suggested or

mandated following (or in lieu of) inpatient rehabilitation or incarceration. In contrast to

inpatient services, outpatient services work with individuals while they are dealing with the

temptations and stressors of living in their usual environment while trying to change their pattern

of substance use. Although maintaining sobriety during the less structured outpatient treatment is

more challenging for the individuals, one of the goals of the intervention is to help individuals

learn and apply coping skills in the real world.

Relapse prevention is a major goal of rehabilitation services. Relapse can happen for a variety of

reasons, such as stress or pressure from family members or friends who are still using drugs or

alcohol. Individuals may be at a higher risk for relapse based on a combination of genetic and

environmental factors. Learning different ways to deal with stress and temptation are important

skills for preventing relapse.

As part of the intensive outpatient therapy at a service provider in Allegheny County, individuals

attend group therapy three times per week and meet with their individual therapist weekly or

every other week. Treatment in the group or in one-on-one counseling sessions could last for as

long as twelve weeks or as few as eight weeks, depending on how the therapists feel that the

clients are progressing through treatment. The agency provides treatment for many different

substance use issues, including alcohol and opioid abuse.

3.1 EFFECTIVE TREATMENT STRATEGIES

The program is structured so that individuals enter and graduate from group sessions at different

times. The intent of this structure is to benefit newer clients, as clients who are further along in

treatment are able to contribute additional advice and support to the group. Each group session is

designed to begin with a check-in, so every member of the group is given an opportunity to

discuss topics that are on their mind or events that have occurred since the last group session.

This often leads to discussions of how to deal with relapse triggers or how to cope with a relapse.

Pairing one-on-one therapy sessions with the group therapy gives clients a chance to discuss

issues that they may not feel comfortable bringing up in the group session. The individual

meetings also allow therapists to engage in case management to help their clients work through

other stressors in their lives, such as housing, employment, and relationship issues.

3.2 CHALLENGES TO EFFECTIVE TREATMENT

In contrast to the effective procedures described above, there are also several challenges to

providing effective treatment that were identified by the therapists. These challenges can be

categorized as resource or behavioral challenges.

Resource Challenges: One challenge that was reported by the therapists at this particular service

provider is a slow and unwieldy computer system for keeping track of clients and their progress

in treatment. Not all of the therapists have been trained to use the system in a consistent manner.

This system is designed to track the topics during group and individual therapy, but entry of

these data is a manual process performed after therapy. Since all information is entered as text

and is not further categorized or organized by the system itself, retrieval of the topics covered

during therapy is done by manual human inspection, unassisted by the program.

A second resource challenge is an absence of curriculum modules for the intensive outpatient

group therapy. Because of new issues and crises that need to be addressed during group, it is not

possible to stick to a rigid curriculum schedule for each class. However, the lack of a flexible

curriculum for treatment, at best, results in therapists scrambling to produce topics that would be

engaging and informative for group three nights a week. At worst, it results in uneventful therapy

sessions with little to no group discussion.

A third resource challenge is the lack of easily tracked guidelines or measurable outcomes to

indicate when clients are considered to have successfully completed treatment. The decision is

discussed as a group with all of the counseling staff, but it is largely up to the judgment of the

individual therapist, and there is variability among therapists regarding requirements for

graduation from the program.

Behavioral challenges: A number of individuals attending group therapy are court mandated to

attend the intensive outpatient program. This results in a significant population that is reluctant to

participate in treatment, and thus it is often difficult for the therapists to engage everyone in the

group discussion. A particularly resistant client can often derail the group discussions.

4.0 DEVELOPMENT OF A PROPOSED INTERVENTION

An intervention could be designed to mitigate some of the resource challenges that were

identified by the therapists at the intensive outpatient therapy program. If successful, this

intervention could quantify reasons for graduating from the treatment program and track the

effectiveness of the curriculum topics that are covered during the group therapy sessions.

4.1 HEALTH PROBLEM IDENTIFICATION

The problem is drug and alcohol relapse among individuals who have completed an intensive

outpatient rehabilitation treatment. Stakeholders, which are defined as the people and

organizations who have a direct interest in resolving the problem and in an intervention (Brugha

& Varvasovszky, 2000), include the clients who are going through the intensive outpatient

therapy treatment, friends and family members of the clients, the therapists for the intensive

outpatient program, individuals in the community and law enforcement.

Clients are the most directly affected stakeholders because they could face legal consequences if

they relapse following treatment. They could also overdose or harm their health in other ways

because of their use of drugs and alcohol. Having a friend or family member with an addiction

can be emotionally draining and stressful. Friends and family members of the clients may be

impacted by relapse if they are relying on them for financial stability or if they are providing

them with financial assistance while they are in recovery. The therapists may be emotionally

invested in whether or not their clients successfully complete treatment. The reputation of the

program also depends on being able to provide effective treatment. Individuals in the community

may be impacted financially by the added burden on the healthcare and legal system. They also

may become victims of a crime if an individual uses theft or other criminal activities to support

their addiction or drives under the influence of drugs or alcohol. Law enforcement may be

needed to investigate and enforce laws pertaining to probation violations, drug sales, drunk

driving, or theft. Parole officers often mandate successful completion of a treatment program for

their parolees so they are invested in having them attend an effective treatment center.

4.2 IDENTIFING CAUSAL FACTORS

The social ecological model can be used to design an intervention that could be implemented in

the intensive outpatient therapy setting. This model examines factors that influence a problem at

five different levels: intrapersonal or individual factors, interpersonal or familial factors,

community factors, institutional factors, and public policy (McLeroy, Bibeau, Steckler, & Glanz,

1988). A multilevel intervention can be designed to address targets at multiple factors (Burke,

Joseph, Pasick, & Barker, 2009).

The individual level identifies the personal factors that influence a person’s abuse of drugs and

alcohol (McLeroy et al., 1988). Factors that may affect relapse include an individual’s response

to stress, genes, and attitudes towards drug and alcohol use.

The interpersonal level identifies the relationships that impact sobriety such as support from

family and friends to stay sober and perceived judgments from family and friends about being in

recovery (McLeroy et al., 1988). The community level identifies settings in which social

relationships occur that impact sobriety such as support groups like Alcoholics Anonymous and

Narcotics Anonymous and community treatment centers (McLeroy et al., 1988). The institutional

level identifies organizational factors that impact sobriety, such as the availability of insurance

coverage for rehabilitation services and support for drug and alcohol treatment from legal

services (McLeroy et al., 1988). The policy level includes the broader societal factors that have

an impact on the use of drugs and alcohol (McLeroy et al., 1988). The availability of medical

coverage, government budgets for rehabilitation services and law enforcement regulations

concerning drug and alcohol treatment are all examples of factors at the policy level.

The health problem analysis model is used to identify points in the causal chain where an

intervention can be introduced (Turnock, 2011). Direct and indirect contributing factors and risk

factors as well as direct and indirect consequences are linked to the health problem with arrows

to indicate the relationship (Turnock, 2011). The health problems analysis model helps to

visualize the upstream and downstream causal factors involved in drug and alcohol relapse and

to identify potential areas for intervention (Turnock, 2011).

Figure 1: Health problem analysis of causal factors for drug and alcohol relapse following completion of a rehabilitation program

Figure 2: Health problem analysis of direct and indirect consequences of drug and alcohol relapse following completion of a rehabilitation program

4.3 IDENTIFYING AN INTERVENTION

Based on feedback from the therapists at the service provider, the proposed intervention intends

to change how the therapists keep track of their clients who are in the intensive outpatient

therapy and how they gather information to make the decision to have them graduate from the

program. One goal of the intervention is to identify measurable outcomes and use this

information to develop a flexible curriculum. Computer-automated methods will track the parts

of the curriculum that were attended by each individual in order to evaluate which parts of the

curriculum are most useful in treatment.

Another target of the intervention is improving access to mental health treatment. Psychiatric

disorders and addiction disorders commonly co-occur. Participants in the intensive outpatient

program frequently complained about the lack of access that they had to the psychiatrist on staff

and their inability to find inexpensive care elsewhere in the community. The shortage in

psychiatric services led to long waiting lists for care which could result in an individual not

receiving psychiatric services until the end of his time in the intensive outpatient program.

A goal of the intervention should be to move the clients through the stages of change and to use

these stages as a measurement tool to determine the effectiveness of the intervention. The stages

of change can also be used to decide when clients are ready to be released from treatment.

Prochaska and DiClemente describe the stages of change as part of the transtheoretical model of

intentional behavior change (DiClemente, Schlundt, & Gemmell, 2004; Prochaska, Diclemente,

& Norcross, 1992). To change a pattern of behavior, individuals travel through five stages:

precontemplation, contemplation, preparation, action, and maintenance (DiClemente et al.,

2004).

During the pre-contemplation stage, the client is not currently thinking about stopping his use of

drugs and/or alcohol (DiClemente et al., 2004). The counselors could encourage him to move to

the next stage by increasing the client’s knowledge of drug and alcohol abuse. The counselors

could also have him describe the events that brought them to treatment and what the impact of

that has been on his life.

When he reaches the contemplation stage, the client is thinking about stopping his use of drugs

and/or alcohol (DiClemente et al., 2004). The counselors could encourage him to move to the

next stage by asking him to think about how his use of drugs and/or alcohol has affected himself

and others.

As part of the preparation phase, the client is prepared to take action to stop using drugs and/or

alcohol, or the client has stopped using drugs or alcohol for less than 30 days (DiClemente et al.,

2004). The counselors should help him to weigh the pros and cons of abstaining from drugs

and/or alcohol and help him to develop confidence in his course of action.

During the action phase, the client has stopped using drugs and/or alcohol for more than 30 days

and less than 180 days (DiClemente et al., 2004). The counselors should help him to control

triggers to use and help him come up with ways to substitute healthy behaviors for risky

behaviors.

As part of the maintenance phase, the client has had a sustained (longer than 180 days)

abstinence from using drugs and/or alcohol (DiClemente et al., 2004). The counselors should

invite the client to share his journey with the other individuals in the treatment group and talk

about what worked and what did not work for him.

Relapse can occur at any point in the stages of change. The counselors should work with the

client based on his current stage after the relapse has occurred. For instance, if he relapsed from

maintenance to contemplation, the counselors should encourage him to think about the affect

drugs and/or alcohol have had on his life and about the benefits of sobriety.

As part of the budget for the intervention, a software or database programmer would be needed

to improve the tracking system and to generate reports on which parts of the curriculum the

clients had completed. Coming up with a curriculum will also require extra time for the

counselors in short term, but it will save time on curriculum development long term.

The counselors should work to develop a twelve-week curriculum that covers informative topics

for the group therapy sessions. Since clients enter the group therapy at different times, the

curriculum should not be sequential so that it could be prioritized depending on the group’s

needs. Also, since an entire group is sometimes devoted to helping a client who is going through

a particular crisis, the curriculum should not be mandatory for each therapy session.

Following the curriculum development, the computer system should be designed to include a

way to track which curriculum sessions were presented to each client. This will prevent an

individual from being presented with the same information more than once. Reports can be

generated with the curriculum sessions that were attended by each client and questions about the

individual sessions can be included in the feedback on treatment satisfaction that the client gives

in their exit interview. A questionnaire given to clients after each meeting can help determine

how informative they found each of the sessions that they attended. They should also be given a

questionnaire in their exit interview that asks them to recall information that was covered during

the therapy sessions. The computer system should also include a way to track which level in the

stages of change an individual is in. The counselors should be trained in how to use the computer

system for tracking and generating reports.

The computer system should also track when clients request psychiatric services and when they

actually receive them. This information could be used to evaluate whether more personal is

needed to provide psychiatric support for the individuals in the intensive outpatient therapy

program.

A logic model is a tool that is used for program or intervention planning. It describes the linkages

between the inputs that are needed for the program, the outputs and the desired short term,

intermediate term, and long term outcomes (McLaughlin & Jordan, 1999). The logic model

below outlines the goals of the intervention and how it will work (McLaughlin & Jordan, 1999).

Figure 3: Logic model

4.4 EVALUATE THE INTERVENTION

The logic model can also be used to guide the evaluation of the intervention (McLaughlin &

Jordan, 1999). The program inputs should be examined to determine whether other materials are

needed for the intervention and whether the intervention is costing more than expected.

Some ways that the outputs of this intervention can be evaluated include monitoring whether or

not the curriculum is being followed and used by the therapists and whether they are tracking the

use of the curriculum. Also, it should be determined whether the therapists are tracking the

stages of change for each client and using this to inform their treatment. Additionally, feedback

should be solicited from the therapists about how the curriculum is working and the ease of using

the tracking system.

The outcomes of the intervention should be evaluated by getting feedback from the clients about

their ability to recall information that was presented during the curriculum. Additionally, the

relapse rate for the treatment center should be measured by using existing data on the current

relapse rate and comparing it to the relapse rate for individuals who complete the revised

program. Another way to evaluate the outcome is to contact clients who completed the program

before and after the revised curriculum was implemented six months after they have completed

treatment to ask them about relapse.

5.0 CONCLUSION

Drug and alcohol abuse is a serious problem nationally and locally. It has a significant negative

impact on communities and family members of drug abusers. There are many factors involved in

drug and alcohol abuse and dependence, including genetics and the environment.

One important method of treatment is intensive outpatient therapy, which allows individuals in

the program to remain in their homes while receiving treatment for addiction. A rehabilitation

program in Allegheny County provides an intensive outpatient program for the local community.

As is true for most community services, there are many ways that they positively impact the

local community, but there are also ways that they could improve the services that they offer to

more effectively reduce the relapse rates among their clients.

The intervention described above is designed to make preparing for the group therapy sessions

easier and less stressful for the therapists and to make the sessions themselves more informative

and useful for the clients in treatment. Since the group meets three times per week it can be

difficult to keep the group interested and engaged, especially if there is not a defined idea for the

group topics for the day. Having a curriculum with a set list of topic ideas and materials for

group should improve the group experience for both the therapists and individuals in treatment.

Another benefit of having a curriculum with ideas for group therapy is the ability to quantify the

effectiveness of a particular topic or lesson. With the new tracking system, reports could be

generated to identify topics that have been covered with individuals who have moved through the

stages of change quickly to see if there are topics that are particularly effective. If so, these

lessons could be recommended for each client that enters the intensive outpatient therapy.

The feedback from clients on how interesting and informative each group session was can be

used to improve and revise the curriculum. While the curriculum is being evaluated, clients can

be surveyed both after each group therapy session and when they have graduated from the

program. During their exit interviews, the therapist can administer questionnaires to determine

how much the clients recall from each of the curriculum modules that were attended. Another

more general follow-up could occur via phone six months after they have graduated from the

program to check on whether or not they have relapsed.

This intervention is designed to decrease relapse rates among graduates of the intensive

outpatient program by making the group therapy program run more smoothly. It also allows for

more evaluation of the effectiveness of the group therapy, which may lead to additional

improvements to the program.

Improving the outpatient rehabilitation program and reducing relapse rates should have a

significant positive impact on individuals who attend the intervention program. Additionally,

improving rehabilitation services should benefit family and community members by improving

personal relations and reducing health care costs. Implementation of this intervention is a

reasonable step that can be taken to ensure that this program provides a higher quality of service,

which should result in a smaller probability of relapse, cumulative increase of quality of life, and

decrease of healthcare costs incurred by drug and alcohol addiction.

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