Research Based Principles

of Drug Addiction Treatment

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Preface

Drugaddictionisacomplexillness.

Itischaracterizedbyintenseand,attimes,uncontrollabledrugcraving,along

withcompulsivedrugseekingandusethatpersisteveninthefaceof

devastatingconsequences.ThisupdateoftheNationalInstituteonDrug

Abuse’sPrinciplesofDrugAddictionTreatmentisintendedtoaddressaddiction

toawidevarietyofdrugs,includingnicotine,alcohol,andillicitandprescription

drugs.Itisdesignedtoserveasaresourceforhealthcareproviders,family

members,andotherstakeholderstryingtoaddressthemyriadproblemsfaced

bypatientsinneedoftreatmentfordrugabuseoraddiction.

Addictionaffectsmultiplebraincircuits,includingthoseinvolvedinrewardand

motivation,learningandmemory,andinhibitorycontroloverbehavior.Thatis

whyaddictionisabraindisease.Someindividualsaremorevulnerablethan

otherstobecomingaddicted,dependingontheinterplaybetweengenetic

makeup,ageofexposuretodrugs,andotherenvironmentalinfluences.Whilea

personinitiallychoosestotakedrugs,overtimetheeffectsofprolonged

exposureonbrainfunctioningcompromisethatabilitytochoose,andseeking

andconsumingthedrugbecomecompulsive,ofteneludingaperson’sself-

controlorwillpower.

Butaddictionismorethanjustcompulsivedrugtaking—itcanalsoproducefar-

reachinghealthandsocialconsequences.Forexample,drugabuseand

addictionincreaseaperson’sriskforavarietyofothermentalandphysical

illnessesrelatedtoadrug-abusinglifestyleorthetoxiceffectsofthedrugs

themselves.Additionally,thedysfunctionalbehaviorsthatresultfromdrug

abusecaninterferewithaperson’snormalfunctioninginthefamily,the

workplace,andthebroadercommunity.

Becausedrugabuseandaddictionhavesomanydimensionsanddisruptso

manyaspectsofanindividual’slife,treatmentisnotsimple.Effectivetreatment

programstypicallyincorporatemanycomponents,eachdirectedtoaparticular

aspectoftheillnessanditsconsequences.Addictiontreatmentmusthelpthe

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individualstopusingdrugs,maintainadrug-freelifestyle,andachieve

productivefunctioninginthefamily,atwork,andinsociety.Becauseaddiction

isadisease,mostpeoplecannotsimplystopusingdrugsforafewdaysandbe

cured.Patientstypicallyrequirelong-termorrepeatedepisodesofcareto

achievetheultimategoalofsustainedabstinenceandrecoveryoftheirlives.

Indeed,scientificresearchandclinicalpracticedemonstratethevalueof

continuingcareintreatingaddiction,withavarietyofapproacheshavingbeen

testedandintegratedinresidentialandcommunitysettings.

Aswelooktowardthefuture,wewillharnessnewresearchresultsonthe

influenceofgeneticsandenvironmentongenefunctionandexpression(i.e.,

epigenetics),whichareheraldingthedevelopmentofpersonalizedtreatment

interventions.Thesefindingswillbeintegratedwithcurrentevidencesupporting

themosteffectivedrugabuseandaddictiontreatmentsandtheir

implementation,whicharereflectedinthisguide.

NoraD.Volkow,M.D.

Director

NationalInstituteonDrugAbuse

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PrinciplesofEffectiveTreatment

1. Addictionisacomplexbuttreatablediseasethataffectsbrainfunction

andbehavior.Drugsofabusealterthebrain’sstructureandfunction,

resultinginchangesthatpersistlongafterdrugusehasceased.Thismay

explainwhydrugabusersareatriskforrelapseevenafterlongperiodsof

abstinenceanddespitethepotentiallydevastatingconsequences.

2. Nosingletreatmentisappropriateforeveryone.Treatmentvaries

dependingonthetypeofdrugandthecharacteristicsofthepatients.

Matchingtreatmentsettings,interventions,andservicestoanindividual’s

particularproblemsandneedsiscriticaltohisorherultimatesuccessin

returningtoproductivefunctioninginthefamily,workplace,andsociety.

3. Treatmentneedstobereadilyavailable.Becausedrug-addicted

individualsmaybeuncertainaboutenteringtreatment,takingadvantageof

availableservicesthemomentpeoplearereadyfortreatmentiscritical.

Potentialpatientscanbelostiftreatmentisnotimmediatelyavailableor

readilyaccessible.Aswithotherchronicdiseases,theearliertreatmentis

offeredinthediseaseprocess,thegreaterthelikelihoodofpositive

outcomes.

4. Effectivetreatmentattendstomultipleneedsoftheindividual,notjust

hisorherdrugabuse.Tobeeffective,treatmentmustaddressthe

individual’sdrugabuseandanyassociatedmedical,psychological,social,

vocational,andlegalproblems.Itisalsoimportantthattreatmentbe

appropriatetotheindividual’sage,gender,ethnicity,andculture.

5. Remainingintreatmentforanadequateperiodoftimeiscritical.The

appropriatedurationforanindividualdependsonthetypeanddegreeof

thepatient’sproblemsandneeds.Researchindicatesthatmostaddicted

individualsneedatleast3monthsintreatmenttosignificantlyreduceor

stoptheirdruguseandthatthebestoutcomesoccurwithlongerdurations

oftreatment.Recoveryfromdrugaddictionisalong-termprocessand

frequentlyrequiresmultipleepisodesoftreatment.Aswithotherchronic

illnesses,relapsestodrugabusecanoccurandshouldsignalaneedfor

treatmenttobereinstatedoradjusted.Becauseindividualsoftenleave

treatmentprematurely,programsshouldincludestrategiestoengageand

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keeppatientsintreatment.

6. Behavioraltherapies—includingindividual,family,orgroupcounseling—

arethemostcommonlyusedformsofdrugabusetreatment.

Behavioraltherapiesvaryintheirfocusandmayinvolveaddressinga

patient’smotivationtochange,providingincentivesforabstinence,building

skillstoresistdruguse,replacingdrug-usingactivitieswithconstructiveand

rewardingactivities,improvingproblem-solvingskills,andfacilitatingbetter

interpersonalrelationships.Also,participationingrouptherapyandother

peersupportprogramsduringandfollowingtreatmentcanhelpmaintain

abstinence.

7. Medicationsareanimportantelementoftreatmentformanypatients,

especiallywhencombinedwithcounselingandotherbehavioral

therapies.Forexample,methadone,buprenorphine,andnaltrexone

(includinganewlong-actingformulation)areeffectiveinhelpingindividuals

addictedtoheroinorotheropioidsstabilizetheirlivesandreducetheirillicit

druguse.Acamprosate,disulfiram,andnaltrexonearemedications

approvedfortreatingalcoholdependence.Forpersonsaddictedtonicotine,

anicotinereplacementproduct(availableaspatches,gum,lozenges,or

nasalspray)oranoralmedication(suchasbupropionorvarenicline)can

beaneffectivecomponentoftreatmentwhenpartofacomprehensive

behavioraltreatmentprogram.

8. Anindividual'streatmentandservicesplanmustbeassessed

continuallyandmodifiedasnecessarytoensurethatitmeetshisorher

changingneeds.Apatientmayrequirevaryingcombinationsofservices

andtreatmentcomponentsduringthecourseoftreatmentandrecovery.In

additiontocounselingorpsychotherapy,apatientmayrequiremedication,

medicalservices,familytherapy,parentinginstruction,vocational

rehabilitation,and/orsocialandlegalservices.Formanypatients,a

continuingcareapproachprovidesthebestresults,withthetreatment

intensityvaryingaccordingtoaperson’schangingneeds.

9. Manydrug-addictedindividualsalsohaveothermentaldisorders.

Becausedrugabuseandaddiction—bothofwhicharementaldisorders—

oftenco-occurwithothermentalillnesses,patientspresentingwithone

conditionshouldbeassessedfortheother(s).Andwhentheseproblemsco-

occur,treatmentshouldaddressboth(orall),includingtheuseof

medicationsasappropriate.

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10. Medicallyassisteddetoxificationisonlythefirststageofaddiction

treatmentandbyitselfdoeslittletochangelong-termdrugabuse.

Althoughmedicallyassisteddetoxificationcansafelymanagetheacute

physicalsymptomsofwithdrawalandcan,forsome,pavethewayfor

effectivelong-termaddictiontreatment,detoxificationaloneisrarely

sufficienttohelpaddictedindividualsachievelong-termabstinence.Thus,

patientsshouldbeencouragedtocontinuedrugtreatmentfollowing

detoxification.Motivationalenhancementandincentivestrategies,begunat

initialpatientintake,canimprovetreatmentengagement.

11. Treatmentdoesnotneedtobevoluntarytobeeffective.Sanctionsor

enticementsfromfamily,employmentsettings,and/orthecriminaljustice

systemcansignificantlyincreasetreatmententry,retentionrates,andthe

ultimatesuccessofdrugtreatmentinterventions.

12. Druguseduringtreatmentmustbemonitoredcontinuously,aslapses

duringtreatmentdooccur.Knowingtheirdruguseisbeingmonitoredcan

beapowerfulincentiveforpatientsandcanhelpthemwithstandurgesto

usedrugs.Monitoringalsoprovidesanearlyindicationofareturntodrug

use,signalingapossibleneedtoadjustanindividual’streatmentplanto

bettermeethisorherneeds.

13. TreatmentprogramsshouldtestpatientsforthepresenceofHIV/AIDS,

hepatitisBandC,tuberculosis,andotherinfectiousdiseasesaswellas

providetargetedrisk-reductioncounseling,linkingpatientstotreatment

ifnecessary.Typically,drugabusetreatmentaddressessomeofthedrug-

relatedbehaviorsthatputpeopleatriskofinfectiousdiseases.Targeted

counselingfocusedonreducinginfectiousdiseaseriskcanhelppatients

furtherreduceoravoidsubstance-relatedandotherhigh-riskbehaviors.

Counselingcanalsohelpthosewhoarealreadyinfectedtomanagetheir

illness.Moreover,engaginginsubstanceabusetreatmentcanfacilitate

adherencetoothermedicaltreatments.Substanceabusetreatmentfacilities

shouldprovideonsite,rapidHIVtestingratherthanreferralstooffsitetesting

—researchshowsthatdoingsoincreasesthelikelihoodthatpatientswillbe

testedandreceivetheirtestresults.Treatmentprovidersshouldalsoinform

patientsthathighlyactiveantiretroviraltherapy(HAART)hasproven

effectiveincombatingHIV,includingamongdrug-abusingpopulations,and

helplinkthemtoHIVtreatmentiftheytestpositive.

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FrequentlyAskedQuestions

Treatmentvariesdependingonthetypeofdrugandthecharacteristicsof

thepatient.Thebestprogramsprovideacombinationoftherapiesand

otherservices.

Whydodrug-addictedpersonskeep

usingdrugs?

Nearlyalladdictedindividualsbelieveattheoutsetthattheycanstopusing

drugsontheirown,andmosttrytostopwithouttreatment.Althoughsome

peoplearesuccessful,manyattemptsresultinfailuretoachievelong-term

abstinence.Researchhasshownthatlong-termdrugabuseresultsinchanges

inthebrainthatpersistlongafterapersonstopsusingdrugs.Thesedrug-

inducedchangesinbrainfunctioncanhavemanybehavioralconsequences,

includinganinabilitytoexertcontrolovertheimpulsetousedrugsdespite

adverseconsequences—thedefiningcharacteristicofaddiction.

Long-termdruguseresultsinsignificantchangesinbrainfunctionthatcan

persistlongaftertheindividualstopsusingdrugs.

Understandingthataddictionhassuchafundamentalbiologicalcomponent

mayhelpexplainthedifficultyofachievingandmaintainingabstinencewithout

treatment.Psychologicalstressfromwork,familyproblems,psychiatricillness,

painassociatedwithmedicalproblems,socialcues(suchasmeeting

individualsfromone’sdrug-usingpast),orenvironmentalcues(suchas

encounteringstreets,objects,orevensmellsassociatedwithdrugabuse)can

triggerintensecravingswithouttheindividualevenbeingconsciouslyawareof

thetriggeringevent.Anyoneofthesefactorscanhinderattainmentofsustained

abstinenceandmakerelapsemorelikely.Nevertheless,researchindicatesthat

activeparticipationintreatmentisanessentialcomponentforgoodoutcomes

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andcanbenefiteventhemostseverelyaddictedindividuals.

Whatisdrugaddictiontreatment?

Drugtreatmentisintendedtohelpaddictedindividualsstopcompulsivedrug

seekinganduse.Treatmentcanoccurinavarietyofsettings,takemany

differentforms,andlastfordifferentlengthsoftime.Becausedrugaddictionis

typicallyachronicdisordercharacterizedbyoccasionalrelapses,ashort-term,

one-timetreatmentisusuallynotsufficient.Formany,treatmentisalong-term

processthatinvolvesmultipleinterventionsandregularmonitoring.

Thereareavarietyofevidence-basedapproachestotreatingaddiction.Drug

treatmentcanincludebehavioraltherapy(suchascognitive-behavioraltherapy

orcontingencymanagement),medications,ortheircombination.Thespecific

typeoftreatmentorcombinationoftreatmentswillvarydependingonthe

patient’sindividualneedsand,often,onthetypesofdrugstheyuse.

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Drugaddictiontreatmentcanincludemedications,behavioraltherapies,or

theircombination.

Treatmentmedications,suchasmethadone,buprenorphine,andnaltrexone

(includinganewlong-actingformulation),areavailableforindividualsaddicted

toopioids,whilenicotinepreparations(patches,gum,lozenges,andnasal

spray)andthemedicationsvareniclineandbupropionareavailablefor

individualsaddictedtotobacco.Disulfiram,acamprosate,andnaltrexone

aremedicationsavailablefortreatingalcoholdependence, whichcommonly

co-occurswithotherdrugaddictions,includingaddictiontoprescription

medications.

Treatmentsforprescriptiondrugabusetendtobesimilartothoseforillicitdrugs

thataffectthesamebrainsystems.Forexample,buprenorphine,usedtotreat

heroinaddiction,canalsobeusedtotreataddictiontoopioidpainmedications.

Addictiontoprescriptionstimulants,whichaffectthesamebrainsystemsas

illicitstimulantslikecocaine,canbetreatedwithbehavioraltherapies,asthere

arenotyetmedicationsfortreatingaddictiontothesetypesofdrugs.

Behavioraltherapiescanhelpmotivatepeopletoparticipateindrugtreatment,

offerstrategiesforcopingwithdrugcravings,teachwaystoavoiddrugsand

preventrelapse,andhelpindividualsdealwithrelapseifitoccurs.Behavioral

therapiescanalsohelppeopleimprovecommunication,relationship,and

parentingskills,aswellasfamilydynamics.

Manytreatmentprogramsemploybothindividualandgrouptherapies.Group

therapycanprovidesocialreinforcementandhelpenforcebehavioral

contingenciesthatpromoteabstinenceandanon-drug-usinglifestyle.Someof

themoreestablishedbehavioraltreatments,suchascontingencymanagement

andcognitive-behavioraltherapy,arealsobeingadaptedforgroupsettingsto

improveefficiencyandcost-effectiveness.However,particularlyinadolescents,

therecanalsobeadangerofunintendedharmful(oriatrogenic)effectsof

grouptreatment—sometimesgroupmembers(especiallygroupsofhighly

delinquentyouth)canreinforcedruguseandtherebyderailthepurposeofthe

therapy.Thus,trainedcounselorsshouldbeawareofandmonitorforsuch

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effects.

Becausetheyworkondifferentaspectsofaddiction,combinationsofbehavioral

therapiesandmedications(whenavailable)generallyappeartobemore

effectivethaneitherapproachusedalone.

Finally,peoplewhoareaddictedtodrugsoftensufferfromotherhealth(e.g.,

depression,HIV),occupational,legal,familial,andsocialproblemsthatshould

beaddressedconcurrently.Thebestprogramsprovideacombinationof

therapiesandotherservicestomeetanindividualpatient’sneeds.

Psychoactivemedications,suchasantidepressants,anti-anxietyagents,mood

stabilizers,andantipsychoticmedications,maybecriticalfortreatmentsuccess

whenpatientshaveco-occurringmentaldisorderssuchasdepression,anxiety

disorders(includingpost-traumaticstressdisorder),bipolardisorder,or

schizophrenia.Inaddition,mostpeoplewithsevereaddictionabusemultiple

drugsandrequiretreatmentforallsubstancesabused.

Treatmentfordrugabuseandaddictionisdeliveredinmanydifferent

settingsusingavarietyofbehavioralandpharmacologicalapproaches.

Anotherdrug,topiramate,hasalsoshownpromiseinstudiesandissometimes

prescribed(off-label)forthispurposealthoughithasnotreceivedFDAapproval

asatreatmentforalcoholdependence.

Howeffectiveisdrugaddiction

treatment?

Inadditiontostoppingdrugabuse,thegoaloftreatmentistoreturnpeopleto

productivefunctioninginthefamily,workplace,andcommunity.Accordingto

researchthattracksindividualsintreatmentoverextendedperiods,most

peoplewhogetintoandremainintreatmentstopusingdrugs,decreasetheir

criminalactivity,andimprovetheiroccupational,social,andpsychological

functioning.Forexample,methadonetreatmenthasbeenshowntoincrease

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participationinbehavioraltherapyanddecreasebothdruguseandcriminal

behavior.However,individualtreatmentoutcomesdependontheextentand

natureofthepatient’sproblems,theappropriatenessoftreatmentandrelated

servicesusedtoaddressthoseproblems,andthequalityofinteractionbetween

thepatientandhisorhertreatmentproviders.

Relapseratesforaddictionresemblethoseofotherchronicdiseasessuch

asdiabetes,hypertension,andasthma.

Likeotherchronicdiseases,addictioncanbemanagedsuccessfully.Treatment

enablespeopletocounteractaddiction’spowerfuldisruptiveeffectsonthebrain

andbehaviorandtoregaincontroloftheirlives.Thechronicnatureofthe

diseasemeansthatrelapsingtodrugabuseisnotonlypossiblebutalsolikely,

withsymptomrecurrenceratessimilartothoseforotherwell-characterized

chronicmedicalillnesses—suchasdiabetes,hypertension,andasthma(see

figure,"ComparisonofRelapseRatesBetweenDrugAddictionandOther

ChronicIllnesses”)—thatalsohavebothphysiologicalandbehavioral

components.

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Unfortunately,whenrelapseoccursmanydeemtreatmentafailure.Thisisnot

thecase:Successfultreatmentforaddictiontypicallyrequirescontinual

evaluationandmodificationasappropriate,similartotheapproachtakenfor

otherchronicdiseases.Forexample,whenapatientisreceivingactive

treatmentforhypertensionandsymptomsdecrease,treatmentisdeemed

successful,eventhoughsymptomsmayrecurwhentreatmentisdiscontinued.

Fortheaddictedindividual,lapsestodrugabusedonotindicatefailure—rather,

theysignifythattreatmentneedstobereinstatedoradjusted,orthatalternate

treatmentisneeded(seefigure,"WhyisAddictionTreatmentEvaluated

Differently?").

Isdrugaddictiontreatmentworthits

cost?

SubstanceabusecostsourNationover$600billionannuallyandtreatmentcan

helpreducethesecosts.Drugaddictiontreatmenthasbeenshowntoreduce

associatedhealthandsocialcostsbyfarmorethanthecostofthetreatment

itself.Treatmentisalsomuchlessexpensivethanitsalternatives,suchas

incarceratingaddictedpersons.Forexample,theaveragecostfor1fullyearof

methadonemaintenancetreatmentisapproximately$4,700perpatient,

whereas1fullyearofimprisonmentcostsapproximately$24,000perperson.

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Drugaddictiontreatmentreducesdruguseanditsassociatedhealthand

socialcosts.

Accordingtoseveralconservativeestimates,everydollarinvestedinaddiction

treatmentprogramsyieldsareturnofbetween$4and$7inreduceddrug-

relatedcrime,criminaljusticecosts,andtheft.Whensavingsrelatedto

healthcareareincluded,totalsavingscanexceedcostsbyaratioof12to1.

Majorsavingstotheindividualandtosocietyalsostemfromfewer

interpersonalconflicts;greaterworkplaceproductivity;andfewerdrug-related

accidents,includingoverdosesanddeaths.

Howlongdoesdrugaddictiontreatment

usuallylast?

Individualsprogressthroughdrugaddictiontreatmentatvariousrates,sothere

isnopredeterminedlengthoftreatment.However,researchhasshown

unequivocallythatgoodoutcomesarecontingentonadequatetreatment

length.Generally,forresidentialoroutpatienttreatment,participationforless

than90daysisoflimitedeffectiveness,andtreatmentlastingsignificantly

longerisrecommendedformaintainingpositiveoutcomes.Formethadone

maintenance,12monthsisconsideredtheminimum,andsomeopioid-addicted

individualscontinuetobenefitfrommethadonemaintenanceformanyyears.

Goodoutcomesarecontingentonadequatetreatmentlength.

Treatmentdropoutisoneofthemajorproblemsencounteredbytreatment

programs;therefore,motivationaltechniquesthatcankeeppatientsengaged

willalsoimproveoutcomes.Byviewingaddictionasachronicdiseaseand

offeringcontinuingcareandmonitoring,programscansucceed,butthiswill

oftenrequiremultipleepisodesoftreatmentandreadilyreadmittingpatientsthat

haverelapsed.

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Whathelpspeoplestayintreatment?

Becausesuccessfuloutcomesoftendependonaperson’sstayingintreatment

longenoughtoreapitsfullbenefits,strategiesforkeepingpeopleintreatment

arecritical.Whetherapatientstaysintreatmentdependsonfactorsassociated

withboththeindividualandtheprogram.Individualfactorsrelatedto

engagementandretentiontypicallyincludemotivationtochangedrug-using

behavior;degreeofsupportfromfamilyandfriends;and,frequently,pressure

fromthecriminaljusticesystem,childprotectionservices,employers,orfamily.

Withinatreatmentprogram,successfulclinicianscanestablishapositive,

therapeuticrelationshipwiththeirpatients.Theclinicianshouldensurethata

treatmentplanisdevelopedcooperativelywiththepersonseekingtreatment,

thattheplanisfollowed,andthattreatmentexpectationsareclearlyunderstood.

Medical,psychiatric,andsocialservicesshouldalsobeavailable.

Whetherapatientstaysintreatmentdependsonfactorsassociatedwith

boththeindividualandtheprogram.

Becausesomeproblems(suchasseriousmedicalormentalillnessorcriminal

involvement)increasethelikelihoodofpatientsdroppingoutoftreatment,

intensiveinterventionsmayberequiredtoretainthem.Afteracourseof

intensivetreatment,theprovidershouldensureatransitiontolessintensive

continuingcaretosupportandmonitorindividualsintheirongoingrecovery.

Howdowegetmoresubstance-abusing

peopleintotreatment?

Ithasbeenknownformanyyearsthatthe"treatmentgap”ismassive—thatis,

amongthosewhoneedtreatmentforasubstanceusedisorder,fewreceiveit.In

2011,21.6millionpersonsaged12orolderneededtreatmentforanillicitdrug

oralcoholuseproblem,butonly2.3millionreceivedtreatmentataspecialty

substanceabusefacility.

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Reducingthisgaprequiresamultiprongedapproach.Strategiesinclude

increasingaccesstoeffectivetreatment,achievinginsuranceparity(nowinits

earliestphaseofimplementation),reducingstigma,andraisingawareness

amongbothpatientsandhealthcareprofessionalsofthevalueofaddiction

treatment.Toassistphysiciansinidentifyingtreatmentneedintheirpatients

andmakingappropriatereferrals,NIDAisencouragingwidespreaduseof

screening,briefintervention,andreferraltotreatment(SBIRT)toolsforusein

primarycaresettingsthroughitsNIDAMEDinitiative.SBIRT,whichevidence

showstobeeffectiveagainsttobaccoandalcoholuse—and,increasingly,

againstabuseofillicitandprescriptiondrugs—hasthepotentialnotonlyto

catchpeoplebeforeseriousdrugproblemsdevelop,butalsotoidentifypeople

inneedoftreatmentandconnectthemwithappropriatetreatmentproviders.

Howcanfamilyandfriendsmakea

differenceinthelifeofsomeoneneeding

treatment?

Familyandfriendscanplaycriticalrolesinmotivatingindividualswithdrug

problemstoenterandstayintreatment.Familytherapycanalsobeimportant,

especiallyforadolescents.Involvementofafamilymemberorsignificantother

inanindividual'streatmentprogramcanstrengthenandextendtreatment

benefits.

Wherecanfamilymembersgofor

informationontreatmentoptions?

Tryingtolocateappropriatetreatmentforalovedone,especiallyfindinga

programtailoredtoanindividual'sparticularneeds,canbeadifficultprocess.

However,therearesomeresourcestohelpwiththisprocess.Forexample,

NIDA’shandbookSeekingDrugAbuseTreatment:KnowWhattoAskoffers

guidanceinfindingtherighttreatmentprogram.Numerousonlineresources

canhelplocatealocalprogramorprovideotherinformation,including:

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TheSubstanceAbuseandMentalHealthServicesAdministration

(SAMHSA)maintainsaWebsite(www.findtreatment.samhsa.gov)that

showsthelocationofresidential,outpatient,andhospitalinpatienttreatment

programsfordrugaddictionandalcoholismthroughoutthecountry.This

informationisalsoaccessiblebycalling1-800-662-HELP.

TheNationalSuicidePreventionLifeline(1-800-273-TALK)offersmorethan

justsuicideprevention—itcanalsohelpwithahostofissues,includingdrug

andalcoholabuse,andcanconnectindividualswithanearbyprofessional.

TheNationalAllianceonMentalIllness(www.nami.org)andMentalHealth

America(www.mentalhealthamerica.net)arealliancesofnonprofit,self-help

supportorganizationsforpatientsandfamiliesdealingwithavarietyof

mentaldisorders.BothhaveStateandlocalaffiliatesthroughoutthecountry

andmaybeespeciallyhelpfulforpatientswithcomorbidconditions.

TheAmericanAcademyofAddictionPsychiatryandtheAmericanAcademy

ofChildandAdolescentPsychiatryeachhavephysicianlocatortools

postedontheirWebsitesataaap.organdaacap.org,respectively.

Faces&VoicesofRecovery(facesandvoicesofrecovery.org),foundedin

2001,isanadvocacyorganizationforindividualsinlong-termrecoverythat

strategizesonwaystoreachouttothemedical,publichealth,criminal

justice,andothercommunitiestopromoteandcelebraterecoveryfrom

addictiontoalcoholandotherdrugs.

ThePartnershipatDrugfree.org(drugfree.org)isanorganizationthat

providesinformationandresourcesonteendruguseandaddictionfor

parents,tohelpthempreventandinterveneintheirchildren’sdruguseor

findtreatmentforachildwhoneedsit.Theyofferatoll-freehelplinefor

parents(1-855-378-4373).

TheAmericanSocietyofAddictionMedicine(asam.org)isasocietyof

physiciansaimedatincreasingaccesstoaddictiontreatment.TheirWeb

sitehasanationwidedirectoryofaddictionmedicineprofessionals.

NIDA’sNationalDrugAbuseTreatmentClinicalTrialsNetwork

(drugabuse.gov/about-nida/organization/cctn/ctn)providesinformationfor

thoseinterestedinparticipatinginaclinicaltrialtestinga

promisingsubstanceabuseintervention;orvisitclinicaltrials.gov.

NIDA’sDrugPubsResearchDisseminationCenter

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(drugpubs.drugabuse.gov)providesbooklets,pamphlets,factsheets,and

otherinformationalresourcesondrugs,drugabuse,andtreatment.

TheNationalInstituteonAlcoholAbuseandAlcoholism(niaaa.nih.gov)

providesinformationonalcohol,alcoholuse,andtreatmentofalcohol-

relatedproblems(niaaa.nih.gov/search/node/treatment).

Howcantheworkplaceplayarolein

substanceabusetreatment?

ManyworkplacessponsorEmployeeAssistancePrograms(EAPs)thatoffer

short-termcounselingand/orassistanceinlinkingemployeeswithdrugor

alcoholproblemstolocaltreatmentresources,includingpeersupport/recovery

groups.Inaddition,therapeuticworkenvironmentsthatprovideemploymentfor

drug-abusingindividualswhocandemonstrateabstinencehavebeenshown

notonlytopromoteacontinueddrug-freelifestylebutalsotoimprovejobskills,

punctuality,andotherbehaviorsnecessaryforactiveemploymentthroughout

life.Urinetestingfacilities,trainedpersonnel,andworkplacemonitorsare

neededtoimplementthistypeoftreatment.

Whatrolecanthecriminaljusticesystem

playinaddressingdrugaddiction?

Itisestimatedthataboutone-halfofStateandFederalprisonersabuseorare

addictedtodrugs,butrelativelyfewreceivetreatmentwhileincarcerated.

Initiatingdrugabusetreatmentinprisonandcontinuingituponreleaseisvital

tobothindividualrecoveryandtopublichealthandsafety.Variousstudieshave

shownthatcombiningprison-andcommunity-basedtreatmentforaddicted

offendersreducestheriskofbothrecidivismtodrug-relatedcriminalbehavior

andrelapsetodruguse—which,inturn,netshugesavingsinsocietalcosts.A

2009studyinBaltimore,Maryland,forexample,foundthatopioid-addicted

prisonerswhostartedmethadonetreatment(alongwithcounseling)inprison

andthencontinueditafterreleasehadbetteroutcomes(reduceddruguseand

criminalactivity)thanthosewhoonlyreceivedcounselingwhileinprisonor

thosewhoonlystartedmethadonetreatmentaftertheirrelease.

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Individualswhoentertreatmentunderlegalpressurehaveoutcomesas

favorableasthosewhoentertreatmentvoluntarily.

Themajorityofoffendersinvolvedwiththecriminaljusticesystemarenotin

prisonbutareundercommunitysupervision.Forthosewithknowndrug

problems,drugaddictiontreatmentmayberecommendedormandatedasa

conditionofprobation.Researchhasdemonstratedthatindividualswhoenter

treatmentunderlegalpressurehaveoutcomesasfavorableasthosewhoenter

treatmentvoluntarily.

Thecriminaljusticesystemrefersdrugoffendersintotreatmentthrougha

varietyofmechanisms,suchasdivertingnonviolentoffenderstotreatment;

stipulatingtreatmentasaconditionofincarceration,probation,orpretrial

release;andconveningspecializedcourts,ordrugcourts,thathandledrug

offensecases.Thesecourtsmandateandarrangefortreatmentasan

alternativetoincarceration,activelymonitorprogressintreatment,andarrange

forotherservicesfordrug-involvedoffenders.

Themosteffectivemodelsintegratecriminaljusticeanddrugtreatmentsystems

andservices.Treatmentandcriminaljusticepersonnelworktogetheron

treatmentplanning—includingimplementationofscreening,placement,testing,

monitoring,andsupervision—aswellasonthesystematicuseofsanctionsand

rewards.Treatmentforincarcerateddrugabusersshouldincludecontinuing

care,monitoring,andsupervisionafterincarcerationandduringparole.

Methodstoachievebettercoordinationbetweenparole/probationofficersand

healthprovidersarebeingstudiedtoimproveoffenderoutcomes.(Formore

information,pleaseseeNIDA’sPrinciplesofDrugAbuseTreatmentforCriminal

JusticePopulations:AResearch-BasedGuide[revised2012].)

Whataretheuniqueneedsofwomenwith

substanceusedisorders?

Gender-relateddrugabusetreatmentshouldattendnotonlytobiological

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differencesbutalsotosocialandenvironmentalfactors,allofwhichcan

influencethemotivationsfordruguse,thereasonsforseekingtreatment,the

typesofenvironmentswheretreatmentisobtained,thetreatmentsthataremost

effective,andtheconsequencesofnotreceivingtreatment.Manylife

circumstancespredominateinwomenasagroup,whichmayrequirea

specializedtreatmentapproach.Forexample,researchhasshownthatphysical

andsexualtraumafollowedbypost-traumaticstressdisorder(PTSD)ismore

commonindrug-abusingwomenthaninmenseekingtreatment.Otherfactors

uniquetowomenthatcaninfluencethetreatmentprocessincludeissues

aroundhowtheycomeintotreatment(aswomenaremorelikelythanmento

seektheassistanceofageneralormentalhealthpractitioner),financial

independence,andpregnancyandchildcare.

Whataretheuniqueneedsofpregnant

womenwithsubstanceusedisorders?

Usingdrugs,alcohol,ortobaccoduringpregnancyexposesnotjustthewoman

butalsoherdevelopingfetustothesubstanceandcanhavepotentially

deleteriousandevenlong-termeffectsonexposedchildren.Smokingduring

pregnancycanincreaseriskofstillbirth,infantmortality,suddeninfantdeath

syndrome,pretermbirth,respiratoryproblems,slowedfetalgrowth,andlow

birthweight.Drinkingduringpregnancycanleadtothechilddevelopingfetal

alcoholspectrumdisorders,characterizedbylowbirthweightandenduring

cognitiveandbehavioralproblems.

Prenataluseofsomedrugs,includingopioids,maycauseawithdrawal

syndromeinnewbornscalledneonatalabstinencesyndrome(NAS).Babies

withNASareatgreaterriskofseizures,respiratoryproblems,feeding

difficulties,lowbirthweight,andevendeath.

Researchhasestablishedthevalueofevidence-basedtreatmentsforpregnant

women(andtheirbabies),includingmedications.Forexample,althoughno

medicationshavebeenFDA-approvedtotreatopioiddependenceinpregnant

women,methadonemaintenancecombinedwithprenatalcareanda

comprehensivedrugtreatmentprogramcanimprovemanyofthedetrimental

21

outcomesassociatedwithuntreatedheroinabuse.However,newborns

exposedtomethadoneduringpregnancystillrequiretreatmentforwithdrawal

symptoms.Recently,anothermedicationoptionforopioiddependence,

buprenorphine,hasbeenshowntoproducefewerNASsymptomsinbabies

thanmethadone,resultinginshorterinfanthospitalstays.Ingeneral,itis

importanttocloselymonitorwomenwhoaretryingtoquitdruguseduring

pregnancyandtoprovidetreatmentasneeded.

Whataretheuniqueneedsofadolescents

withsubstanceusedisorders?

Adolescentdrugabusershaveuniqueneedsstemmingfromtheirimmature

neurocognitiveandpsychosocialstageofdevelopment.Researchhas

demonstratedthatthebrainundergoesaprolongedprocessofdevelopment

andrefinementfrombirththroughearlyadulthood.Overthecourseofthis

developmentalperiod,ayoungperson’sactionsgofrombeingmoreimpulsive

tobeingmorereasonedandreflective.Infact,thebrainareasmostclosely

associatedwithaspectsofbehaviorsuchasdecision-making,judgment,

planning,andself-controlundergoaperiodofrapiddevelopmentduring

adolescenceandyoungadulthood.

Adolescentdrugabuseisalsooftenassociatedwithotherco-occurringmental

healthproblems.Theseincludeattention-deficithyperactivitydisorder(ADHD),

oppositionaldefiantdisorder,andconductproblems,aswellasdepressiveand

anxietydisorders.

Adolescentsarealsoespeciallysensitivetosocialcues,withpeergroupsand

familiesbeinghighlyinfluentialduringthistime.Therefore,treatmentsthat

facilitatepositiveparentalinvolvement,integrateothersystemsinwhichthe

adolescentparticipates(suchasschoolandathletics),andrecognizethe

importanceofprosocialpeerrelationshipsareamongthemosteffective.Access

tocomprehensiveassessment,treatment,casemanagement,andfamily-

supportservicesthataredevelopmentally,culturally,andgender-appropriateis

alsointegralwhenaddressingadolescentaddiction.

22

Medicationsforsubstanceabuseamongadolescentsmayincertaincasesbe

helpful.Currently,theonlyaddictionmedicationsapprovedbyFDAforpeople

under18areover-the-countertransdermalnicotineskinpatches,chewinggum,

andlozenges(physicianadviceshouldbesoughtfirst).Buprenorphine,a

medicationfortreatingopioidaddictionthatmustbeprescribedbyspecially

trainedphysicians,hasnotbeenapprovedforadolescents,butrecentresearch

suggestsitcouldbeeffectiveforthoseasyoungas16.Studiesareunderway

todeterminethesafetyandefficacyofthisandothermedicationsforopioid-,

nicotine-,andalcohol-dependentadolescentsandforadolescentswithco-

occurringdisorders.

Aretherespecificdrugaddiction

treatmentsforolderadults?

Withtheagingofthebabyboomergeneration,thecompositionofthegeneral

populationischangingdramaticallywithrespecttothenumberofolderadults.

Suchachange,coupledwithagreaterhistoryoflifetimedruguse(than

previousoldergenerations),differentculturalnormsandgeneralattitudesabout

druguse,andincreasesintheavailabilityofpsychotherapeuticmedications,is

alreadyleadingtogreaterdrugusebyolderadultsandmayincrease

substanceuseproblemsinthispopulation.Whilesubstanceabuseinolder

adultsoftengoesunrecognizedandthereforeuntreated,researchindicatesthat

currentlyavailableaddictiontreatmentprogramscanbeaseffectiveforthemas

foryoungeradults.

Canapersonbecomeaddictedto

medicationsprescribedbyadoctor?

Yes.Peoplewhoabuseprescriptiondrugs—thatis,takingtheminamanneror

adoseotherthanprescribed,ortakingmedicationsprescribedforanother

person—riskaddictionandotherserioushealthconsequences.Suchdrugs

includeopioidpainrelievers,stimulantsusedtotreatADHD,and

benzodiazepinestotreatanxietyorsleepdisorders.Indeed,in2010,an

estimated2.4millionpeople12oroldermetcriteriaforabuseofordependence

23

onprescriptiondrugs,thesecondmostcommonillicitdruguseaftermarijuana.

Tominimizetheserisks,aphysician(orotherprescribinghealthprovider)

shouldscreenpatientsforpriororcurrentsubstanceabuseproblemsand

assesstheirfamilyhistoryofsubstanceabuseoraddictionbeforeprescribinga

psychoactivemedicationandmonitorpatientswhoareprescribedsuchdrugs.

Physiciansalsoneedtoeducatepatientsaboutthepotentialriskssothatthey

willfollowtheirphysician’sinstructionsfaithfully,safeguardtheirmedications,

anddisposeofthemappropriately.

Isthereadifferencebetweenphysical

dependenceandaddiction?

Yes.Addiction—orcompulsivedrugusedespiteharmfulconsequences—is

characterizedbyaninabilitytostopusingadrug;failuretomeetwork,social,or

familyobligations;and,sometimes(dependingonthedrug),toleranceand

withdrawal.Thelatterreflectphysicaldependenceinwhichthebodyadaptsto

thedrug,requiringmoreofittoachieveacertaineffect(tolerance)andeliciting

drug-specificphysicalormentalsymptomsifdruguseisabruptlyceased

(withdrawal).Physicaldependencecanhappenwiththechronicuseofmany

drugs—includingmanyprescriptiondrugs,eveniftakenasinstructed.Thus,

physicaldependenceinandofitselfdoesnotconstituteaddiction,butitoften

accompaniesaddiction.Thisdistinctioncanbedifficulttodiscern,particularly

withprescribedpainmedications,forwhichtheneedforincreasingdosages

canrepresenttoleranceoraworseningunderlyingproblem,asopposedtothe

beginningofabuseoraddiction.

Howdoothermentaldisorderscoexisting

withdrugaddictionaffectdrugaddiction

treatment?

Drugaddictionisadiseaseofthebrainthatfrequentlyoccurswithothermental

disorders.Infact,asmanyas6in10peoplewithanillicitsubstanceuse

disorderalsosufferfromanothermentalillness;andratesaresimilarforusers

oflicitdrugs—i.e.,tobaccoandalcohol.Fortheseindividuals,onecondition

24

becomesmoredifficulttotreatsuccessfullyasanadditionalconditionis

intertwined.Thus,peopleenteringtreatmenteitherforasubstanceusedisorder

orforanothermentaldisordershouldbeassessedfortheco-occurrenceofthe

othercondition.Researchindicatesthattreatingboth(ormultiple)illnesses

simultaneouslyinanintegratedfashionisgenerallythebesttreatment

approachforthesepatients.

Istheuseofmedicationslikemethadone

andbuprenorphinesimplyreplacingone

addictionwithanother?

No.Buprenorphineandmethadoneareprescribedoradministeredunder

monitored,controlledconditionsandaresafeandeffectivefortreatingopioid

addictionwhenusedasdirected.Theyareadministeredorallyorsublingually

(i.e.,underthetongue)inspecifieddoses,andtheireffectsdifferfromthoseof

heroinandotherabusedopioids.

Heroin,forexample,isofteninjected,snorted,orsmoked,causinganalmost

immediate"rush,"orbriefperiodofintenseeuphoria,thatwearsoffquicklyand

endsina"crash."Theindividualthenexperiencesanintensecravingtousethe

drugagaintostopthecrashandreinstatetheeuphoria.

Thecycleofeuphoria,crash,andcraving—sometimesrepeatedseveraltimesa

day—isahallmarkofaddictionandresultsinseverebehavioraldisruption.

Thesecharacteristicsresultfromheroin’srapidonsetandshortdurationof

actioninthebrain.

Asusedinmaintenancetreatment,methadoneandbuprenorphinearenot

heroin/opioidsubstitutes.

Incontrast,methadoneandbuprenorphinehavegradualonsetsofactionand

producestablelevelsofthedruginthebrain.Asaresult,patientsmaintained

25

onthesemedicationsdonotexperiencearush,whiletheyalsomarkedly

reducetheirdesiretouseopioids.

Ifanindividualtreatedwiththesemedicationstriestotakeanopioidsuchas

heroin,theeuphoriceffectsareusuallydampenedorsuppressed.Patients

undergoingmaintenancetreatmentdonotexperiencethephysiologicalor

behavioralabnormalitiesfromrapidfluctuationsindruglevelsassociatedwith

heroinuse.Maintenancetreatmentssavelives—theyhelptostabilize

individuals,allowingtreatmentoftheirmedical,psychological,andother

problemssotheycancontributeeffectivelyasmembersoffamiliesandof

society.

Wheredo12-steporself-helpprograms

fitintodrugaddictiontreatment?

Self-helpgroupscancomplementandextendtheeffectsofprofessional

treatment.Themostprominentself-helpgroupsarethoseaffiliatedwith

AlcoholicsAnonymous(AA),NarcoticsAnonymous(NA),andCocaine

Anonymous(CA),allofwhicharebasedonthe12-stepmodel.Mostdrug

addictiontreatmentprogramsencouragepatientstoparticipateinself-help

grouptherapyduringandafterformaltreatment.Thesegroupscanbe

particularlyhelpfulduringrecovery,offeringanaddedlayerofcommunity-level

socialsupporttohelppeopleachieveandmaintainabstinenceandother

healthylifestylebehaviorsoverthecourseofalifetime.

Canexerciseplayaroleinthetreatment

process?

Yes.Exerciseisincreasinglybecomingacomponentofmanytreatment

programsandhasproveneffective,whencombinedwithcognitive-behavioral

therapy,athelpingpeoplequitsmoking.Exercisemayexertbeneficialeffects

byaddressingpsychosocialandphysiologicalneedsthatnicotinereplacement

alonedoesnot,byreducingnegativefeelingsandstress,andbyhelping

preventweightgainfollowingcessation.Researchtodetermineifandhow

26

exerciseprogramscanplayasimilarroleinthetreatmentofotherformsofdrug

abuseisunderway.

Howdoesdrugaddictiontreatmenthelp

reducethespreadofHIV/AIDS,Hepatitis

C(HCV),andotherinfectiousdiseases?

Drug-abusingindividuals,includinginjectingandnon-injectingdrugusers,are

atincreasedriskofhumanimmunodeficiencyvirus(HIV),hepatitisCvirus

(HCV),andotherinfectiousdiseases.Thesediseasesaretransmittedby

sharingcontaminateddruginjectionequipmentandbyengaginginriskysexual

behaviorsometimesassociatedwithdruguse.Effectivedrugabusetreatmentis

HIV/HCVpreventionbecauseitreducesactivitiesthatcanspreaddisease,such

assharinginjectionequipmentandengaginginunprotectedsexualactivity.

CounselingthattargetsarangeofHIV/HCVriskbehaviorsprovidesanadded

levelofdiseaseprevention.

DrugabusetreatmentisHIVandHCVprevention.

Injectiondruguserswhodonotentertreatmentareuptosixtimesmorelikelyto

becomeinfectedwithHIVthanthosewhoenterandremainintreatment.

ParticipationintreatmentalsopresentsopportunitiesforHIVscreeningand

referraltoearlyHIVtreatment.Infact,recentresearchfromNIDA’sNational

DrugAbuseTreatmentClinicalTrialsNetworkshowedthatprovidingrapid

onsiteHIVtestinginsubstanceabusetreatmentfacilitiesincreasedpatients’

likelihoodofbeingtestedandofreceivingtheirtestresults.HIVcounselingand

testingarekeyaspectsofsuperiordrugabusetreatmentprogramsandshould

beofferedtoallindividualsenteringtreatment.Greateravailabilityof

inexpensiveandunobtrusiverapidHIVtestsshouldincreaseaccesstothese

importantaspectsofHIVpreventionandtreatment.

27

DrugAddictionTreatmentinthe

UnitedStates

Treatmentfordrugabuseandaddictionisdeliveredinmanydifferent

settings,usingavarietyofbehavioralandpharmacologicalapproaches.

Drugaddictionisacomplexdisorderthatcaninvolvevirtuallyeveryaspectof

anindividual'sfunctioning—inthefamily,atworkandschool,andinthe

community.

Becauseofaddiction'scomplexityandpervasiveconsequences,drugaddiction

treatmenttypicallymustinvolvemanycomponents.Someofthosecomponents

focusdirectlyontheindividual'sdruguse;others,likeemploymenttraining,

focusonrestoringtheaddictedindividualtoproductivemembershipinthe

familyandsociety(Seediagram"ComponentsofComprehensiveDrugAbuse

Treatment"),enablinghimorhertoexperiencetherewardsassociatedwith

abstinence.

Treatmentfordrugabuseandaddictionisdeliveredinmanydifferentsettings

usingavarietyofbehavioralandpharmacologicalapproaches.IntheUnited

States,morethan14,500specializeddrugtreatmentfacilitiesprovide

counseling,behavioraltherapy,medication,casemanagement,andothertypes

ofservicestopersonswithsubstanceusedisorders.

Alongwithspecializeddrugtreatmentfacilities,drugabuseandaddictionare

treatedinphysicians'officesandmentalhealthclinicsbyavarietyofproviders,

includingcounselors,physicians,psychiatrists,psychologists,nurses,and

socialworkers.Treatmentisdeliveredinoutpatient,inpatient,andresidential

settings.Althoughspecifictreatmentapproachesoftenareassociatedwith

particulartreatmentsettings,avarietyoftherapeuticinterventionsorservices

canbeincludedinanygivensetting.

28

Becausedrugabuseandaddictionaremajorpublichealthproblems,alarge

portionofdrugtreatmentisfundedbylocal,State,andFederalgovernments.

Privateandemployer-subsidizedhealthplansalsomayprovidecoveragefor

treatmentofaddictionanditsmedicalconsequences.Unfortunately,managed

carehasresultedinshorteraveragestays,whileahistoricallackofor

insufficientcoverageforsubstanceabusetreatmenthascurtailedthenumberof

operationalprograms.Therecentpassageofparityforinsurancecoverageof

mentalhealthandsubstanceabuseproblemswillhopefullyimprovethisstate

ofaffairs.HealthCareReform(i.e.,thePatientProtectionandAffordableCare

Actof2010,"ACA")alsostandstoincreasethedemandfordrugabuse

treatmentservicesandpresentsanopportunitytostudyhowinnovationsin

servicedelivery,organization,andfinancingcanimproveaccesstoanduseof

them.

TypesofTreatmentPrograms

Researchstudiesonaddictiontreatmenttypicallyhaveclassifiedprogramsinto

severalgeneraltypesormodalities.Treatmentapproachesandindividual

programscontinuetoevolveanddiversify,andmanyprogramstodaydonotfit

neatlyintotraditionaldrugadictiontreatmentclassifications.

Most,however,startwithdetoxificationandmedicallymanagedwithdrawal,

oftenconsideredthefirststageoftreatment.Detoxification,theprocessby

whichthebodyclearsitselfofdrugs,isdesignedtomanagetheacuteand

potentiallydangerousphysiologicaleffectsofstoppingdruguse.Asstated

previously,detoxificationalonedoesnotaddressthepsychological,social,and

behavioralproblemsassociatedwithaddictionandthereforedoesnottypically

producelastingbehavioralchangesnecessaryforrecovery.Detoxification

shouldthusbefollowedbyaformalassessmentandreferraltodrugaddiction

treatment.

Becauseitisoftenaccompaniedbyunpleasantandpotentiallyfatalsideeffects

stemmingfromwithdrawal,detoxificationisoftenmanagedwithmedications

administeredbyaphysicianinaninpatientoroutpatientsetting;therefore,itis

referredtoas"medicallymanagedwithdrawal.”Medicationsareavailableto

assistinthewithdrawalfromopioids,benzodiazepines,alcohol,nicotine,

29

barbiturates,andothersedatives.

FurtherReading:

Kleber,H.D.Outpatientdetoxificationfromopiates.PrimaryPsychiatry1:42-52,

1996.

Long-TermResidentialTreatment

Long-termresidentialtreatmentprovidescare24hoursaday,generallyinnon-

hospitalsettings.Thebest-knownresidentialtreatmentmodelisthetherapeutic

community(TC),withplannedlengthsofstayofbetween6and12months.TCs

focusonthe"resocialization"oftheindividualandusetheprogram’sentire

community—includingotherresidents,staff,andthesocialcontext—asactive

componentsoftreatment.Addictionisviewedinthecontextofanindividual’s

socialandpsychologicaldeficits,andtreatmentfocusesondeveloping

personalaccountabilityandresponsibilityaswellassociallyproductivelives.

Treatmentishighlystructuredandcanbeconfrontationalattimes,withactivities

designedtohelpresidentsexaminedamagingbeliefs,self-concepts,and

destructivepatternsofbehaviorandadoptnew,moreharmoniousand

constructivewaystointeractwithothers.ManyTCsoffercomprehensive

services,whichcanincludeemploymenttrainingandothersupportservices,

onsite.ResearchshowsthatTCscanbemodifiedtotreatindividualswith

specialneeds,includingadolescents,women,homelessindividuals,people

withseverementaldisorders,andindividualsinthecriminaljusticesystem(see

"TreatingCriminalJustice-InvolvedDrugAbusersandAddictedIndividuals").

FurtherReading:

Lewis,B.F.;McCusker,J.;Hindin,R.;Frost,R.;andGarfield,F.Fourresidential

drugtreatmentprograms:ProjectIMPACT.In:J.A.Inciardi,F.M.Tims,andB.W.

Fletcher(eds.),InnovativeApproachesintheTreatmentofDrugAbuse,

Westport,CT:GreenwoodPress,pp.45-60,1993.

Sacks,S.;Banks,S.;McKendrick,K.;andSacks,J.Y.Modifiedtherapeutic

communityforco-occurringdisorders:Asummaryoffourstudies.Journalof

30

SubstanceAbuseTreatment34(1):112-122,2008.

Sacks,S.;Sacks,J.;DeLeon,G.;Bernhardt,A.;andStaines,G.Modified

therapeuticcommunityformentallyillchemical"abusers":Background;

influences;programdescription;preliminaryfindings.SubstanceUseand

Misuse32(9):1217-1259,1997.

Stevens,S.J.,andGlider,P.J.Therapeuticcommunities:Substanceabuse

treatmentforwomen.In:F.M.Tims,G.DeLeon,andN.Jainchill(eds.),

TherapeuticCommunity:AdvancesinResearchandApplication,National

InstituteonDrugAbuseResearchMonograph144,NIHPub.No.94-3633,U.S.

GovernmentPrintingOffice,pp.162-180,1994.

Sullivan,C.J.;McKendrick,K.;Sacks,S.;andBanks,S.M.Modifiedtherapeutic

communityforoffenderswithMICAdisorders:Substanceuseoutcomes.

AmericanJournalofDrugandAlcoholAbuse33(6):823-832,2007.

Short-TermResidentialTreatment

Short-termresidentialprogramsprovideintensivebutrelativelybrieftreatment

basedonamodified12-stepapproach.Theseprogramswereoriginally

designedtotreatalcoholproblems,butduringthecocaineepidemicofthemid-

1980s,manybegantotreatothertypesofsubstanceusedisorders.Theoriginal

residentialtreatmentmodelconsistedofa3-to6-weekhospital-basedinpatient

treatmentphasefollowedbyextendedoutpatienttherapyandparticipationina

self-helpgroup,suchasAA.Followingstaysinresidentialtreatmentprograms,

itisimportantforindividualstoremainengagedinoutpatienttreatment

programsand/oraftercareprograms.Theseprogramshelptoreducetheriskof

relapseonceapatientleavestheresidentialsetting.

FurtherReading:

Hubbard,R.L.;Craddock,S.G.;Flynn,P.M.;Anderson,J.;andEtheridge,R.M.

Overviewof1-yearfollow-upoutcomesintheDrugAbuseTreatmentOutcome

Study(DATOS).PsychologyofAddictiveBehaviors11(4):291-298,1998.

31

Miller,M.M.Traditionalapproachestothetreatmentofaddiction.In:A.W.

GrahamandT.K.Schultz(eds.),PrinciplesofAddictionMedicine(2nded.).

Washington,D.C.:AmericanSocietyofAddictionMedicine,1998.

OutpatientTreatmentPrograms

Outpatienttreatmentvariesinthetypesandintensityofservicesoffered.Such

treatmentcostslessthanresidentialorinpatienttreatmentandoftenismore

suitableforpeoplewithjobsorextensivesocialsupports.Itshouldbenoted,

however,thatlow-intensityprogramsmayofferlittlemorethandrugeducation.

Otheroutpatientmodels,suchasintensivedaytreatment,canbecomparableto

residentialprogramsinservicesandeffectiveness,dependingontheindividual

patient’scharacteristicsandneeds.Inmanyoutpatientprograms,group

counselingcanbeamajorcomponent.Someoutpatientprogramsarealso

designedtotreatpatientswithmedicalorothermentalhealthproblemsin

additiontotheirdrugdisorders.

FurtherReading:

Hubbard,R.L.;Craddock,S.G.;Flynn,P.M.;Anderson,J.;andEtheridge,R.M.

Overviewof1-yearfollow-upoutcomesintheDrugAbuseTreatmentOutcome

Study(DATOS).PsychologyofAddictiveBehaviors11(4):291-298,1998.

InstituteofMedicine.TreatingDrugProblems.Washington,D.C.:National

AcademyPress,1990.

McLellan,A.T.;Grisson,G.;Durell,J.;Alterman,A.I.;Brill,P.;andO'Brien,C.P.

Substanceabusetreatmentintheprivatesetting:Aresomeprogramsmore

effectivethanothers?JournalofSubstanceAbuseTreatment10:243-254,

1993.

Simpson,D.D.,andBrown,B.S.Treatmentretentionandfollow-upoutcomesin

theDrugAbuseTreatmentOutcomeStudy(DATOS).PsychologyofAddictive

Behaviors11(4):294-307,1998.

32

IndividualizedDrugCounseling

Individualizeddrugcounselingnotonlyfocusesonreducingorstoppingillicit

drugoralcoholuse;italsoaddressesrelatedareasofimpairedfunctioning—

suchasemploymentstatus,illegalactivity,andfamily/socialrelations—aswell

asthecontentandstructureofthepatient’srecoveryprogram.Throughits

emphasisonshort-termbehavioralgoals,individualizedcounselinghelpsthe

patientdevelopcopingstrategiesandtoolstoabstainfromdruguseand

maintainabstinence.Theaddictioncounselorencourages12-stepparticipation

(atleastoneortwotimesperweek)andmakesreferralsforneeded

supplementalmedical,psychiatric,employment,andotherservices.

GroupCounseling

Manytherapeuticsettingsusegrouptherapytocapitalizeonthesocial

reinforcementofferedbypeerdiscussionandtohelppromotedrug-free

lifestyles.Researchhasshownthatwhengrouptherapyeitherisofferedin

conjunctionwithindividualizeddrugcounselingorisformattedtoreflectthe

principlesofcognitive-behavioraltherapyorcontingencymanagement,positive

outcomesareachieved.Currently,researchersaretestingconditionsinwhich

grouptherapycanbestandardizedandmademorecommunity-friendly.

TreatingCriminalJustice-InvolvedDrugAbusersand

AddictedIndividuals

Often,drugabuserscomeintocontactwiththecriminaljusticesystemearlier

thanotherhealthorsocialsystems,presentingopportunitiesforintervention

andtreatmentpriorto,during,after,orinlieuofincarceration.Researchhas

shownthatcombiningcriminaljusticesanctionswithdrugtreatmentcanbe

effectiveindecreasingdrugabuseandrelatedcrime.Individualsunderlegal

coerciontendtostayintreatmentlongeranddoaswellasorbetterthanthose

notunderlegalpressure.Studiesshowthatforincarceratedindividualswith

drugproblems,startingdrugabusetreatmentinprisonandcontinuingthesame

treatmentuponrelease—inotherwords,aseamlesscontinuumofservices—

resultsinbetteroutcomes:lessdruguseandlesscriminalbehavior.More

informationonhowthecriminaljusticesystemcanaddresstheproblemofdrug

33

addictioncanbefoundinPrinciplesofDrugAbuseTreatmentforCriminal

JusticePopulations:AResearch-BasedGuide(NationalInstituteonDrug

Abuse,revised2012).

TreatingCriminalJustice-InvolvedDrug

AbusersandAddictedIndividuals

Often,drugabuserscomeintocontactwiththecriminaljusticesystemearlier

thanotherhealthorsocialsystems,presentingopportunitiesforintervention

andtreatmentpriorto,during,after,orinlieuofincarceration.Researchhas

shownthatcombiningcriminaljusticesanctionswithdrugtreatmentcanbe

effectiveindecreasingdrugabuseandrelatedcrime.Individualsunderlegal

coerciontendtostayintreatmentlongeranddoaswellasorbetterthanthose

notunderlegalpressure.Studiesshowthatforincarceratedindividualswith

drugproblems,startingdrugabusetreatmentinprisonandcontinuingthesame

treatmentuponrelease—inotherwords,aseamlesscontinuumofservices—

resultsinbetteroutcomes:lessdruguseandlesscriminalbehavior.More

informationonhowthecriminaljusticesystemcanaddresstheproblemofdrug

addictioncanbefoundinPrinciplesofDrugAbuseTreatmentforCriminal

JusticePopulations:AResearch-BasedGuide(NationalInstituteonDrug

Abuse,revised2012).

34

Evidence-BasedApproachestoDrug

AddictionTreatment

Eachapproachtodrugtreatmentisdesignedtoaddresscertainaspectsof

drugaddictionanditsconsequencesfortheindividual,family,andsociety.

Thissectionpresentsexamplesoftreatmentapproachesandcomponentsthat

haveanevidencebasesupportingtheiruse.Eachapproachisdesignedto

addresscertainaspectsofdrugaddictionanditsconsequencesforthe

individual,family,andsociety.Someoftheapproachesareintendedto

supplementorenhanceexistingtreatmentprograms,andothersarefairly

comprehensiveinandofthemselves.

ThefollowingsectionisbrokendownintoPharmacotherapies,Behavioral

Therapies,andBehavioralTherapiesPrimarilyforAdolescents.Theyarefurther

subdividedaccordingtoparticularsubstanceusedisorders.Thislistisnot

exhaustive,andnewtreatmentsarecontinuallyunderdevelopment.

Pharmacotherapies

OpioidAddiction

Methadone

Methadoneisalong-actingsyntheticopioidagonistmedicationthatcanprevent

withdrawalsymptomsandreducecravinginopioid-addictedindividuals.Itcan

alsoblocktheeffectsofillicitopioids.Ithasalonghistoryofuseintreatmentof

opioiddependenceinadultsandistakenorally.Methadonemaintenance

treatmentisavailableinallbutthreeStatesthroughspeciallylicensedopioid

treatmentprogramsormethadonemaintenanceprograms.

35

Combinedwithbehavioraltreatment:Researchhasshownthatmethadone

maintenanceismoreeffectivewhenitincludesindividualand/orgroup

counseling,withevenbetteroutcomeswhenpatientsareprovidedwith,or

referredto,otherneededmedical/psychiatric,psychological,andsocial

services(e.g.,employmentorfamilyservices).

FurtherReading:

Dole,V.P.;Nyswander,M.;andKreek,M.J.Narcoticblockade.Archivesof

InternalMedicine118:304–309,1966.

McLellan,A.T.;Arndt,I.O.;Metzger,D.;Woody,G.E.;andO’Brien,C.P.The

effectsofpsychosocialservicesinsubstanceabusetreatment.TheJournalof

theAmericanMedicalAssociation269(15):1953–1959,1993.

TheRockerfellerUniversity.Thefirstpharmacologicaltreatmentfornarcotic

addiction:Methadonemaintenance.TheRockefellerUniversityHospital

Centennial,2010.Availableatcentennial.rucares.org/index.php?

page=Methadone_Maintenance.

Woody,G.E.;Luborsky,L.;McClellan,A.T.;O’Brien,C.P.;Beck,A.T.;Blaine,J.;

Herman,I.;andHole,A.Psychotherapyforopiateaddicts:Doesithelp?

ArchivesofGeneralPsychiatry40:639–645,1983.

Buprenorphine

Buprenorphineisasyntheticopioidmedicationthatactsasapartialagonistat

opioidreceptors—itdoesnotproducetheeuphoriaandsedationcausedby

heroinorotheropioidsbutisabletoreduceoreliminatewithdrawalsymptoms

associatedwithopioiddependenceandcarriesalowriskofoverdose.

Buprenorphineiscurrentlyavailableintwoformulationsthataretaken

sublingually:(1)apureformofthedrugand(2)amorecommonlyprescribed

formulationcalledSuboxone,whichcombinesbuprenorphinewiththedrug

naloxone,anantagonist(orblocker)atopioidreceptors.Naloxonehasnoeffect

36

whenSuboxoneistakenasprescribed,butifanaddictedindividualattemptsto

injectSuboxone,thenaloxonewillproduceseverewithdrawalsymptoms.Thus,

thisformulationlessensthelikelihoodthatthedrugwillbeabusedordivertedto

others.

Buprenorphinetreatmentfordetoxificationand/ormaintenancecanbeprovided

inoffice-basedsettingsbyqualifiedphysicianswhohavereceivedawaiver

fromtheDrugEnforcementAdministration(DEA),allowingthemtoprescribeit.

Theavailabilityofoffice-basedtreatmentforopioidaddictionisacost-effective

approachthatincreasesthereachoftreatmentandtheoptionsavailableto

patients.

Buprenorphineisalsoavailableasinanimplantandinjection.TheU.S.Food

andDrugAdministration(FDA)approveda6-monthsubdermalbuprenorphine

implantinMay2016andaonce-monthlybuprenorphineinjectioninNovember

2017.

FurtherReading:

Fiellin,D.A.;Pantalon,M.V.;Chawarski,M.C.;Moore,B.A.;Sullivan,L.E.;

O’Connor,P.G.;andSchottenfeld,R.S.Counselingplus

buprenorphine/naloxonemaintenancetherapyforopioiddependence.The

NewEnglandJournalofMedicine355(4):365–374,2006.

FudalaP.J.;Bridge,T.P.;Herbert,S.;Williford,W.O.;Chiang,C.N.;Jones,K.;

Collins,J.;Raisch,D.;Casadonte,P.;Goldsmith,R.J.;Ling,W.;Malkerneker,U.;

McNicholas,L.;Renner,J.;Stine,S.;andTusel,D.forthe

Buprenorphine/NaloxoneCollaborativeStudyGroup.Office-basedtreatmentof

opiateaddictionwithasublingual-tabletformulationofbuprenorphineand

naloxone.TheNewEnglandJournalofMedicine349(10):949–958,2003.

Kosten,T.R.;andFiellin,D.A.U.S.NationalBuprenorphineImplementation

Program:Buprenorphineforoffice-basedpractice.Consensusconference

overview.TheAmericanJournalonAddictions13(Suppl.1):S1–S7,2004.

37

McCance-Katz,E.F.Office-basedbuprenorphinetreatmentforopioid-

dependentpatients.HarvardReviewofPsychiatry12(6):321–338,2004.

Treatment,notSubstitution

Becausemethadoneandbuprenorphinearethemselvesopioids,some

peopleviewthesetreatmentsforopioiddependenceasjustsubstitutions

ofoneaddictivedrugforanother(seeQuestion19).Buttakingthese

medicationsasprescribedallowspatientstoholdjobs,avoidstreetcrime

andviolence,andreducetheirexposuretoHIVbystoppingordecreasing

injectiondruguseanddrug-relatedhigh-risksexualbehavior.Patients

stabilizedonthesemedicationscanalsoengagemorereadilyin

counselingandotherbehavioralinterventionsessentialtorecovery.

Naltrexone

Naltrexoneisasyntheticopioidantagonist—itblocksopioidsfrombindingto

theirreceptorsandtherebypreventstheireuphoricandothereffects.Ithas

beenusedformanyyearstoreverseopioidoverdoseandisalsoapprovedfor

treatingopioidaddiction.Thetheorybehindthistreatmentisthattherepeated

absenceofthedesiredeffectsandtheperceivedfutilityofabusingopioidswill

graduallydiminishcravingandaddiction.Naltrexoneitselfhasnosubjective

effectsfollowingdetoxification(thatis,apersondoesnotperceiveanyparticular

drugeffect),ithasnopotentialforabuse,anditisnotaddictive.

Naltrexoneasatreatmentforopioidaddictionisusuallyprescribedinoutpatient

medicalsettings,althoughthetreatmentshouldbeginaftermedical

detoxificationinaresidentialsettinginordertopreventwithdrawalsymptoms.

Naltrexonemustbetakenorally—eitherdailyorthreetimesaweek—but

noncompliancewithtreatmentisacommonproblem.Manyexperienced

clinicianshavefoundnaltrexonebestsuitedforhighlymotivated,recently

detoxifiedpatientswhodesiretotalabstinencebecauseofexternal

circumstances—forinstance,professionalsorparolees.Recently,along-acting

38

injectableversionofnaltrexone,calledVivitrol,wasapprovedtotreatopioid

addiction.Becauseitonlyneedstobedeliveredonceamonth,thisversionof

thedrugcanfacilitatecomplianceandoffersanalternativeforthosewhodonot

wishtobeplacedonagonist/partialagonistmedications.

FurtherReading:

Cornish,J.W.;Metzger,D.;Woody,G.E.;Wilson,D.;McClellan,A.T.;and

Vandergrift,B.Naltrexonepharmacotherapyforopioiddependentfederal

probationers.JournalofSubstanceAbuseTreatment14(6):529–534,1997.

Gastfriend,D.R.Intramuscularextended-releasenaltrexone:currentevidence.

AnnalsoftheNewYorkAcademyofSciences1216:144–166,2011.

Krupitsky,E.;Illerperuma,A.;Gastfriend,D.R.;andSilverman,B.L.Efficacyand

safetyofextended-releaseinjectablenaltrexone(XR-NTX)forthetreatmentof

opioiddependence.Paperpresentedatthe2010annualmeetingofthe

AmericanPsychiatricAssociation,NewOrleans,LA.

ComparingBuprenorphineandNaltrexone

ANIDAstudycomparingtheeffectivenessofabuprenorphine/naloxone

combinationandanextendedreleasenaltrexoneformulationontreatingopioid

usedisorderhasfoundthatbothmedicationsaresimilarlyeffectiveintreating

opioidusedisorderoncetreatmentisinitiated.Becausenaltrexonerequiresfull

detoxification,initiatingtreatmentamongactiveopioiduserswasmoredifficult

withthismedication.However,oncedetoxificationwascomplete,thenaltrexone

formulationhadasimilareffectivenessasthebuprenorphine/naloxone

combination.

TobaccoAddiction

NicotineReplacementTherapy(NRT)

Avarietyofformulationsofnicotinereplacementtherapies(NRTs)nowexist,

39

includingthetransdermalnicotinepatch,nicotinespray,nicotinegum,and

nicotinelozenges.Becausenicotineisthemainaddictiveingredientintobacco,

therationaleforNRTisthatstablelowlevelsofnicotinewillpreventwithdrawal

symptoms—whichoftendrivecontinuedtobaccouse—andhelpkeeppeople

motivatedtoquit.Researchshowsthatcombiningthepatchwithanother

replacementtherapyismoreeffectivethanasingletherapyalone.

Bupropion(Zyban )

Bupropionwasoriginallymarketedasanantidepressant(Wellbutrin).It

producesmildstimulanteffectsbyblockingthereuptakeofcertain

neurotransmitters,especiallynorepinephrineanddopamine.Aserendipitous

observationamongdepressedpatientswasthatthemedicationwasalso

effectiveinsuppressingtobaccocraving,helpingthemquitsmokingwithout

alsogainingweight.Althoughbupropion’sexactmechanismsofactionin

facilitatingsmokingcessationareunclear,ithasFDAapprovalasasmoking

cessationtreatment.

Varenicline(Chantix )

VareniclineisthemostrecentlyFDA-approvedmedicationforsmoking

cessation.Itactsonasubsetofnicotinicreceptorsinthebrainthoughttobe

involvedintherewardingeffectsofnicotine.Vareniclineactsasapartial

agonist/antagonistatthesereceptors—thismeansthatitmidlystimulatesthe

nicotinereceptorbutnotsufficientlytotriggerthereleaseofdopamine,whichis

importantfortherewardingeffectsofnicotine.Asanantagonist,vareniclinealso

blockstheabilityofnicotinetoactivatedopamine,interferingwiththereinforcing

effectsofsmoking,therebyreducingcravingsandsupportingabstinencefrom

smoking.

CombinedWithBehavioralTreatment

Eachoftheabovepharmacotherapiesisrecommendedforuseincombination

withbehavioralinterventions,includinggroupandindividualtherapies,aswell

astelephonequitlines.Behavioralapproachescomplementmosttobacco

addictiontreatmentprograms.Theycanamplifytheeffectsofmedicationsby

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teachingpeoplehowtomanagestress,recognizeandavoidhigh-risksituations

forsmokingrelapse,anddevelopalternativecopingstrategies(e.g.,cigarette

refusalskills,assertiveness,andtimemanagementskills)thattheycanpractice

intreatment,social,andworksettings.Combinedtreatmentisurgedbecause

behavioralandpharmacologicaltreatmentsarethoughttooperatebydifferent

yetcomplementarymechanismsthatcanhaveadditiveeffects.

FurtherReading:

Alterman,A.I.;Gariti,P.;andMulvaney,F.Short-andlong-termsmoking

cessationforthreelevelsofintensityofbehavioraltreatment.Psychologyof

AddictiveBehaviors15:261-264,2001.

Hall,S.M.;Humfleet,G.L.;Muñoz,R.F.;V.I;Prochaska,J.J.;andRobbins,J.A.

Usingextendedcognitivebehavioraltreatmentandmedicationtotreat

dependentsmokers.AmericanJournalofPublicHealth101:2349–2356,2011.

Jorenby,D.E.;Hays,J.T.;Rigotti,N.A.;Azoulay,S.;Watsky,E.J.;Williams,K.E.;

Billing,C.B.;Gong,J.;andReeves,K.R.VareniclinePhase3StudyGroup.

Efficacyofvarenicline,an42nicotinicacetylcholinereceptorpartialagonistvs.

placeboorsustained-releasebupropionforsmokingcessation:Arandomized

controlledtrial.TheJournaloftheAmericanMedicalAssociation296(1):56–63,

2006.

King,D.P.;Paciqa,S.;Pickering,E.;Benowitz,N.L.;Bierut,L.J.;Conti,D.V.;

Kaprio,J.;Lerman,C.;andPark,P.W.Smokingcessationpharmacogenetics:

Analysisofvareniclineandbupropioninplacebo-controlledclinicaltrials.

Neuropsychopharmacology37:641–650,2012.

Raupach,T.;andvanSchayck,C.P.Pharmacotherapyforsmokingcessation:

Currentadvancesandresearchtopics.CNSDrugs25:371–382,2011.

Shah,S.D.;Wilken,L.A.;Winkler,S.R.;andLin,S.J.Systematicreviewand

meta-analysisofcombinationtherapyforsmokingcessation.Journalofthe

AmericanPharmaceuticalAssociation48(5):659–665,2008.

41

Smith,S.S;McCarthy,D.E.;JapuntichS.J.;Christiansen,B.;Piper,M.E.;

Jorenby,D.E.;Fraser,D.L.;Fiore,M.C.;Baker,T.B.;andJackson,T.C.

Comparativeeffectivenessof5smokingcessationpharmacotherapiesin

primarycareclinics.ArchivesofInternalMedicine169:2148–2155,2009.

Stitzer,M.Combinedbehavioralandpharmacologicaltreatmentsforsmoking

cessation.Nicotine&TobaccoResearch1:S181–S187,1999.

AlcoholAddiction

Naltrexone

Naltrexoneblocksopioidreceptorsthatareinvolvedintherewardingeffectsof

drinkingandthecravingforalcohol.Ithasbeenshowntoreducerelapseto

problemdrinkinginsomepatients.Anextendedreleaseversion,Vivitrol—

administeredonceamonthbyinjection—isalsoFDA-approvedfortreating

alcoholism,andmayofferbenefitsregardingcompliance.

Acamprosate

Acamprosate(Campral )actsonthegamma-aminobutyricacid(GABA)and

glutamateneurotransmittersystemsandisthoughttoreducesymptomsof

protractedwithdrawal,suchasinsomnia,anxiety,restlessness,anddysphoria.

Acamprosatehasbeenshowntohelpdependentdrinkersmaintainabstinence

forseveralweekstomonths,anditmaybemoreeffectiveinpatientswith

severedependence.

Disulfiram

Disulfiram(Antabuse )interfereswithdegradationofalcohol,resultinginthe

accumulationofacetaldehyde,which,inturn,producesaveryunpleasant

reactionthatincludesflushing,nausea,andplapitationsifapersondrinks

alcohol.Theutilityandeffectivenessofdisulfiramareconsideredlimited

becausecomplianceisgenerallypoor.However,amongpatientswhoare

highlymotivated,disulfiramcanbeeffective,andsomepatientsuseit

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42

episodicallyforhigh-risksituations,suchassocialoccasionswherealcoholis

present.Itcanalsobeadministeredinamonitoredfashion,suchasinaclinic

orbyaspouse,improvingitsefficacy.

Topiramate

Topiramateisthoughttoworkbyincreasinginhibitory(GABA)

neurotransmissionandreducingstimulatory(glutamate)neurotransmission,

althoughitsprecisemechanismofactionisnotknown.Althoughtopiramatehas

notyetreceivedFDAapprovalfortreatingalcoholaddiction,itissometimes

usedoff-labelforthispurpose.Topiramatehasbeenshowninstudiesto

significantlyimprovemultipledrinkingoutcomes,comparedwithaplacebo.

CombinedWithBehavioralTreatment

Whileanumberofbehavioraltreatmentshavebeenshowntobeeffectiveinthe

treatmentofalcoholaddiction,itdoesnotappearthatanadditiveeffectexists

betweenbehavioraltreatmentsandpharmacotherapy.Studieshaveshownthat

justgettinghelpisoneofthemostimportantfactorsintreatingalcohol

addiction;theprecisetypeoftreatmentreceivedisnotasimportant.

FurtherReading:

Anton,R.F.;O’Malley,S.S.;Ciraulo,D.A.;Cisler,R.A.;Couper,D.;Donovan,

D.M.;Gastfriend,D.R.;Hosking,J.D.;Johnson,B.A.;LoCastro,J.S.;

Longabaugh,R.;Mason,B.J.;Mattson,M.E.;Miller,W.R.;Pettinati,H.M.;

Randall,C.L.;Swift,R.;Weiss,R.D.;Williams,L.D.;andZweben,A.,forthe

COMBINEStudyResearchGroup.Combinedpharmacotherapiesand

behavioralinterventionsforalcoholdependence:TheCOMBINEstudy:A

randomizedcontrolledtrial.TheJournaloftheAmericanMedicalAssociation

295(17):2003–2017,2006.

NationalInstituteonAlcoholAbuseandAlcoholism.HelpingPatientsWho

DrinkTooMuch:AClinician’sGuide,Updated2005Edition.Bethesda,MD:

NIAAA,updated2005.Availableat

pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm

43

BehavioralTherapies

Behavioralapproacheshelpengagepeopleindrugabusetreatment,provide

incentivesforthemtoremainabstinent,modifytheirattitudesandbehaviors

relatedtodrugabuse,andincreasetheirlifeskillstohandlestressful

circumstancesandenvironmentalcuesthatmaytriggerintensecravingfor

drugsandpromptanothercycleofcompulsiveabuse.Belowareanumberof

behavioraltherapiesshowntobeeffectiveinaddressingsubstanceabuse

(effectivenesswithparticulardrugsofabuseisdenotedinparentheses).

Cognitive-BehavioralTherapy(Alcohol,Marijuana,

Cocaine,Methamphetamine,Nicotine)

Cognitive-BehavioralTherapy(CBT)wasdevelopedasamethodtoprevent

relapsewhentreatingproblemdrinking,andlateritwasadaptedforcocaine-

addictedindividuals.Cognitive-behavioralstrategiesarebasedonthetheory

thatinthedevelopmentofmaladaptivebehavioralpatternslikesubstance

abuse,learningprocessesplayacriticalrole.IndividualsinCBTlearnto

identifyandcorrectproblematicbehaviorsbyapplyingarangeofdifferentskills

thatcanbeusedtostopdrugabuseandtoaddressarangeofotherproblems

thatoftenco-occurwithit.

AcentralelementofCBTisanticipatinglikelyproblemsandenhancingpatients’

self-controlbyhelpingthemdevelopeffectivecopingstrategies.Specific

techniquesincludeexploringthepositiveandnegativeconsequencesof

continueddruguse,self-monitoringtorecognizecravingsearlyandidentify

situationsthatmightputoneatriskforuse,anddevelopingstrategiesforcoping

withcravingsandavoidingthosehigh-risksituations.

Researchindicatesthattheskillsindividualslearnthroughcognitive-behavioral

approachesremainafterthecompletionoftreatment.Currentresearchfocuses

onhowtoproduceevenmorepowerfuleffectsbycombiningCBTwith

medicationsfordrugabuseandwithothertypesofbehavioraltherapies.A

computer-basedCBTsystemhasalsobeendevelopedandhasbeenshownto

beeffectiveinhelpingreducedrugusefollowingstandarddrugabuse

44

treatment.

FurtherReading:

Carroll,K.M.,Easton,C.J.;Nich,C.;Hunkele,K.A.;Neavins,T.M.;Sinha,R.;

Ford,H.L.;Vitolo,S.A;Doebrick,C.A.;andRounsaville,B.J.Theuseof

contingencymanagementandmotivational/skills-buildingtherapytotreat

youngadultswithmarijuanadependence.JournalofConsultingandClinical

Psychology74(5):955–966,2006.

Carroll,K.M.;andOnken,L.S.Behavioraltherapiesfordrugabuse.The

AmericanJournalofPsychiatry168(8):1452–1460,2005.

Carroll,K.M.;Sholomskas,D.;Syracuse,G.;Ball,S.A.;Nuro,K.;andFenton,

L.R.Wedon’ttraininvain:Adisseminationtrialofthreestrategiesoftraining

cliniciansincognitive-behavioraltherapy.JournalofConsultingandClinical

Psychology73(1):106–115,2005.

Carroll,K.;Fenton,L.R.;Ball,S.A.;Nich,C.;Frankforter,T.L.;Shi,J.;and

Rounsaville,B.J.Efficacyofdisulfiramandcognitivebehaviortherapyin

cocaine-dependentoutpatients:Arandomizedplacebo-controlledtrial.Archives

ofGeneralPsychiatry61(3):264–272,2004.

Carroll,K.M.;Ball,S.A.;Martino,S.;Nich,C.;Babuscio,T.A.;Nuro,K.F.;Gordon,

M.A.;Portnoy,G.A.;andRounsaville,B.J.Computer-assisteddeliveryof

cognitive-behavioraltherapyforaddiction:arandomizedtrialofCBT4CBT.The

AmericanJournalofPsychiatry165(7):881–888,2008.

ContingencyManagement

Interventions/MotivationalIncentives(Alcohol,

Stimulants,Opioids,Marijuana,Nicotine)

Researchhasdemonstratedtheeffectivenessoftreatmentapproachesusing

contingencymanagement(CM)principles,whichinvolvegivingpatients

45

tangiblerewardstoreinforcepositivebehaviorssuchasabstinence.Studies

conductedinbothmethadoneprogramsandpsychosocialcounselingtreatment

programsdemonstratethatincentive-basedinterventionsarehighlyeffectivein

increasingtreatmentretentionandpromotingabstinencefromdrugs.

Voucher-BasedReinforcement(VBR)augmentsothercommunity-based

treatmentsforadultswhoprimarilyabuseopioids(especiallyheroin)or

stimulants(especiallycocaine)orboth.InVBR,thepatientreceivesavoucher

foreverydrug-freeurinesampleprovided.Thevoucherhasmonetaryvaluethat

canbeexchangedforfooditems,moviepasses,orothergoodsorservicesthat

areconsistentwithadrug-freelifestyle.Thevouchervaluesarelowatfirst,but

increaseasthenumberofconsecutivedrug-freeurinesamplesincreases;

positiveurinesamplesresetthevalueofthevoucherstotheinitiallowvalue.

VBRhasbeenshowntobeeffectiveinpromotingabstinencefromopioidsand

cocaineinpatientsundergoingmethadonedetoxification.

PrizeIncentivesCMappliessimilarprinciplesasVBRbutuseschancestowin

cashprizesinsteadofvouchers.Overthecourseoftheprogram(atleast3

months,oneormoretimesweekly),participantssupplyingdrug-negativeurine

orbreathtestsdrawfromabowlforthechancetowinaprizeworthbetween$1

and$100.Participantsmayalsoreceivedrawsforattendingcounseling

sessionsandcompletingweeklygoal-relatedactivities.Thenumberofdraws

startsatoneandincreaseswithconsecutivenegativedrugtestsand/or

counselingsessionsattendedbutresetstoonewithanydrug-positivesample

orunexcusedabsence.Thepractitionercommunityhasraisedconcernsthat

thisinterventioncouldpromotegambling—asitcontainsanelementofchance

—andthatpathologicalgamblingandsubstanceusedisorderscanbe

comorbid.However,studiesexaminingthisconcernfoundthatPrizeIncentives

CMdidnotpromotegamblingbehavior.

FurtherReading:

Budney,A.J.;Moore,B.A.;Rocha,H.L.;andHiggins,S.T.Clinicaltrialof

abstinence-basedvouchersandcognitivebehavioraltherapyforcannabis

dependence.JournalofConsultingandClinicalPsychology74(2):307–316,

2006.

46

Budney,A.J.;Roffman,R.;Stephens,R.S.;andWalker,D.Marijuana

dependenceanditstreatment.AddictionScience&ClinicalPractice4(1):4–16,

2007.

Elkashef,A.;Vocci,F.;Huestis,M.;Haney,M.;Budney,A.;Gruber,A.;andel-

Guebaly,N.Marijuananeurobiologyandtreatment.SubstanceAbuse

29(3):17–29,2008.

Peirce,J.M.;Petry,N.M.;Stitzer,M.L.;Blaine,J.;Kellogg,S.;Satterfield,F.;

Schwartz,M.;Krasnansky,J.;Pencer,E.;Silva-Vazquez,L.;Kirby,K.C.;Royer-

Malvestuto,C.;Cohen,A.;Copersino,M.L.;Kolodner,K.;andLi,R.Effectsof

lower-costincentivesonstimulantabstinenceinmethadonemaintenance

treatment:ANationalDrugAbuseTreatmentClinicalTrialsNetworkstudy.

ArchivesofGeneralPsychiatry63(2):201–208,2006.

Petry,N.M.;Peirce,J.M.;Stitzer,M.L.;Blaine,J.;Roll,J.M.;Cohen,A.;Obert,J.;

Killeen,T.;Saladin,M.E.;Cowell,M.;Kirby,K.C.;Sterling,R.;Royer-Malvestuto,

C.;Hamilton,J.;Booth,R.E.;Macdonald,M.;Liebert,M.;Rader,L.;Burns,R;

DiMaria,J.;Copersino,M.;Stabile,P.Q.;Kolodner,K.;andLi,R.Effectof

prizebasedincentivesonoutcomesinstimulantabusersinoutpatient

psychosocialtreatmentprograms:ANationalDrugAbuseTreatmentClinical

TrialsNetworkstudy.ArchivesofGeneralPsychiatry62(10):1148–1156,2005.

Petry,N.M.;Kolodner,K.B.;Li,R.;Peirce,J.M.;Roll,J.M.;Stitzer,M.L.;and

Hamilton,J.A.Prize-basedcontingencymanagementdoesnotincrease

gambling.DrugandAlcoholDependence83(3):269–273,2006.

Prendergast,M.;Podus,D.;Finney,J.;Greenwell,L.;andRoll,J.Contingency

managementfortreatmentofsubstanceusedisorders:Ameta-analysis.

Addiction101(11):1546–1560,2006.

Roll,J.M.;Petry,N.M.;Stitzer,M.L.;Brecht,M.L.;Peirce,J.M.;McCann,M.J.;

Blaine,J.;MacDonald,M.;DiMaria,J.;Lucero,L.;andKellogg,S.Contingency

managementforthetreatmentofmethamphetamineusedisorders.The

AmericanJournalofPsychiatry163(11):1993–1999,2006.

47

CommunityReinforcementApproachPlus

Vouchers(Alcohol,Cocaine,Opioids)

CommunityReinforcementApproach(CRA)PlusVouchersisanintensive24-

weekoutpatienttherapyfortreatingpeopleaddictedtococaineandalcohol.It

usesarangeofrecreational,familial,social,andvocationalreinforcers,along

withmaterialincentives,tomakeanon-drug-usinglifestylemorerewarding

thansubstanceuse.Thetreatmentgoalsaretwofold:

Tomaintainabstinencelongenoughforpatientstolearnnewlifeskillsto

helpsustainit;and

Toreducealcoholconsumptionforpatientswhosedrinkingisassociated

withcocaineuse

Patientsattendoneortwoindividualcounselingsessionseachweek,where

theyfocusonimprovingfamilyrelations,learnavarietyofskillstominimize

druguse,receivevocationalcounseling,anddevelopnewrecreational

activitiesandsocialnetworks.Thosewhoalsoabusealcoholreceiveclinic-

monitoreddisulfiram(Antabuse)therapy.Patientssubmiturinesamplestwoor

threetimeseachweekandreceivevouchersforcocaine-negativesamples.As

inVBR,thevalueofthevouchersincreaseswithconsecutivecleansamples,

andthevouchersmaybeexchangedforretailgoodsthatareconsistentwitha

drug-freelifestyle.Studiesinbothurbanandruralareashavefoundthatthis

approachfacilitatespatients’engagementintreatmentandsuccessfullyaids

themingainingsubstantialperiodsofcocaineabstinence.

Acomputer-basedversionofCRAPlusVoucherscalledtheTherapeutic

EducationSystem(TES)wasfoundtobenearlyaseffectiveastreatment

administeredbyatherapistinpromotingabstinencefromopioidsandcocaine

amongopioid-dependentindividualsinoutpatienttreatment.AversionofCRA

foradolescentsaddressesproblem-solving,coping,andcommunicationskills

andencouragesactiveparticipationinpositivesocialandrecreationalactivities.

FurtherReading:

48

Brooks,A.C.;Ryder,D.;Carise,D.;andKirby,K.C.Feasibilityandeffectiveness

ofcomputer-basedtherapyincommunitytreatment.JournalofSubstance

AbuseTreatment39(3):227–235,2010.

Higgins,S.T.;Sigmon,S.C.;Wong,C.J.;Heil,S.H.;Badger,G.J.;Donham,R.;

Dantona,R.L.;andAnthony,S.Communityreinforcementtherapyforcocaine-

dependentoutpatients.ArchivesofGeneralPsychiatry60(10):1043–1052,

2003.

Roozen,H.G.;Boulogne,J.J.;vanTulder,M.W.;vandenBrink,W.;DeJong,

C.A.J.;andKerhof,J.F.M.Asystemicreviewoftheeffectivenessofthe

communityreinforcementapproachinalcohol,cocaineandopioidaddiction.

DrugandAlcoholDependence74(1):1–13,2004.

Silverman,K.;Higgins,S.T.;Brooner,R.K.;Montoya,I.D.;Cone,E.J.;Schuster,

C.R.;andPreston,K.L.Sustainedcocaineabstinenceinmethadone

maintenancepatientsthroughvoucher-basedreinforcementtherapy.Archives

ofGeneralPsychiatry53(5):409–415,1996.

Smith,J.E.;Meyers,R.J.;andDelaney,H.D.Thecommunityreinforcement

approachwithhomelessalcohol-dependentindividuals.JournalofConsulting

andClinicalPsychology66(3):541–548,1998.

Stahler,G.J.;Shipley,T.E.;Kirby,K.C.;Godboldte,C.;Kerwin,M.E;Shandler,I.;

andSimons,L.Developmentandinitialdemonstrationofacommunity-based

interventionforhomeless,cocaine-using,African-Americanwomen.Journalof

SubstanceAbuseTreatment28(2):171–179,2005.

MotivationalEnhancementTherapy(Alcohol,

Marijuana,Nicotine)

MotivationalEnhancementTherapy(MET)isacounselingapproachthathelps

individualsresolvetheirambivalenceaboutengagingintreatmentandstopping

theirdruguse.Thisapproachaimstoevokerapidandinternallymotivated

change,ratherthanguidethepatientstepwisethroughtherecoveryprocess.

49

Thistherapyconsistsofaninitialassessmentbatterysession,followedbytwoto

fourindividualtreatmentsessionswithatherapist.Inthefirsttreatmentsession,

thetherapistprovidesfeedbacktotheinitialassessment,stimulatingdiscussion

aboutpersonalsubstanceuseandelicitingself-motivationalstatements.

Motivationalinterviewingprinciplesareusedtostrengthenmotivationandbuild

aplanforchange.Copingstrategiesforhigh-risksituationsaresuggestedand

discussedwiththepatient.Insubsequentsessions,thetherapistmonitors

change,reviewscessationstrategiesbeingused,andcontinuestoencourage

commitmenttochangeorsustainedabstinence.Patientssometimesare

encouragedtobringasignificantothertosessions.

ResearchonMETsuggeststhatitseffectsdependonthetypeofdrugusedby

participantsandonthegoaloftheintervention.Thisapproachhasbeenused

successfullywithpeopleaddictedtoalcoholtobothimprovetheirengagement

intreatmentandreducetheirproblemdrinking.METhasalsobeenused

successfullywithmarijuana-dependentadultswhencombinedwithcognitive-

behavioraltherapy,constitutingamorecomprehensivetreatmentapproach.

TheresultsofMETaremixedforpeopleabusingotherdrugs(e.g.,heroin,

cocaine,nicotine)andforadolescentswhotendtousemultipledrugs.In

general,METseemstobemoreeffectiveforengagingdrugabusersin

treatmentthanforproducingchangesindruguse.

FurtherReading:

Baker,A.;Lewin,T.;Reichler,H.;Clancy,R.;Carr,V.;Garrett,R.;Sly,K.;Devir,

H.;andTerry,M.Evaluationofamotivationalinterviewforsubstanceusewith

psychiatricin-patientservices.Addiction97(10):1329-1337,2002.

Haug,N.A.;Svikis,D.S.;andDiclemente,C.Motivationalenhancementtherapy

fornicotinedependenceinmethadone-maintainedpregnantwomen.

PsychologyofAddictiveBehaviors18(3):289-292,2004.

MarijuanaTreatmentProjectResearchGroup.Brieftreatmentsforcannabis

dependence:Findingsfromarandomizedmultisitetrial.JournalofConsulting

andClinicalPsychology72(3):455-466,2004.

50

Miller,W.R.;Yahne,C.E.;andTonigan,J.S.Motivationalinterviewingindrug

abuseservices:Arandomizedtrial.JournalofConsultingandClinical

Psychology71(4):754-763,2003.

Stotts,A.L.;Diclemente,C.C.;andDolan-Mullen,P.One-to-one:Amotivational

interventionforresistantpregnantsmokers.AddictiveBehaviors27(2):275-292,

2002.

TheMatrixModel(Stimulants)

TheMatrixModelprovidesaframeworkforengagingstimulant(e.g.,

methamphetamineandcocaine)abusersintreatmentandhelpingthem

achieveabstinence.Patientslearnaboutissuescriticaltoaddictionand

relapse,receivedirectionandsupportfromatrainedtherapist,andbecome

familiarwithself-helpprograms.Patientsaremonitoredfordrugusethrough

urinetesting.

Thetherapistfunctionssimultaneouslyasteacherandcoach,fosteringa

positive,encouragingrelationshipwiththepatientandusingthatrelationshipto

reinforcepositivebehaviorchange.Theinteractionbetweenthetherapistand

thepatientisauthenticanddirectbutnotconfrontationalorparental.Therapists

aretrainedtoconducttreatmentsessionsinawaythatpromotesthepatient’s

self-esteem,dignity,andself-worth.Apositiverelationshipbetweenpatientand

therapistiscriticaltopatientretention.

Treatmentmaterialsdrawheavilyonothertestedtreatmentapproachesand,

thus,includeelementsofrelapseprevention,familyandgrouptherapies,drug

education,andself-helpparticipation.Detailedtreatmentmanualscontain

worksheetsforindividualsessions;othercomponentsincludefamilyeducation

groups,earlyrecoveryskillsgroups,relapsepreventiongroups,combined

sessions,urinetests,12-stepprograms,relapseanalysis,andsocialsupport

groups.

Anumberofstudieshavedemonstratedthatparticipantstreatedusingthe

MatrixModelshowstatisticallysignificantreductionsindrugandalcoholuse,

improvementsinpsychologicalindicators,andreducedriskysexualbehaviors

51

associatedwithHIVtransmission.

FurtherReading:

Huber,A.;Ling,W.;Shoptaw,S.;Gulati,V.;Brethen,P.;andRawson,R.

Integratingtreatmentsformethamphetamineabuse:Apsychosocial

perspective.JournalofAddictiveDiseases16(4):41-50,1997.

Rawson,R.;Shoptaw,S.J.;Obert,J.L.;McCann,M.J.;Hasson,A.L.;Marinelli-

Casey,P.J.;Brethen,P.R.;andLing,W.Anintensiveoutpatientapproachfor

cocaineabuse:TheMatrixmodel.JournalofSubstanceAbuseTreatment

12(2):117-127,1995.

Rawson,R.A.;Huber,A.;McCann,M.;Shoptaw,S.;Farabee,D.;Reiber,C.;and

Ling,W.Acomparisonofcontingencymanagementandcognitive-behavioral

approachesduringmethadonemaintenancetreatmentforcocaine

dependence.ArchivesofGeneralPsychiatry59(9):817-824,2002.

12-StepFacilitationTherapy(Alcohol,Stimulants,

Opiates)

Twelve-stepfacilitationtherapyisanactiveengagementstrategydesignedto

increasethelikelihoodofasubstanceabuserbecomingaffiliatedwithand

activelyinvolvedin12-stepself-helpgroups,therebypromotingabstinence.

Threekeyideaspredominate:(1)acceptance,whichincludestherealization

thatdrugaddictionisachronic,progressivediseaseoverwhichonehasno

control,thatlifehasbecomeunmanageablebecauseofdrugs,thatwillpower

aloneisinsufficienttoovercometheproblem,andthatabstinenceistheonly

alternative;(2)surrender,whichinvolvesgivingoneselfovertoahigherpower,

acceptingthefellowshipandsupportstructureofotherrecoveringaddicted

individuals,andfollowingtherecoveryactivitieslaidoutbythe12-step

program;and(3)activeinvolvementin12-stepmeetingsandrelatedactivities.

Whiletheefficacyof12-stepprograms(and12-stepfacilitation)intreating

alcoholdependencehasbeenestablished,theresearchonitsusefulnessfor

otherformsofsubstanceabuseismorepreliminary,butthetreatmentappears

52

promisingforhelpingdrugabuserssustainrecovery.

FurtherReading:

Carroll,K.M.;Nich,C.;Ball,S.A.;McCance,E.;Frankforter,T.L.;and

Rounsaville,B.J.One-yearfollow-upofdisulfiramandpsychotherapyfor

cocaine-alcoholusers:Sustainedeffectsoftreatment.Addiction95(9):1335-

1349,2000.

DonovanD.M.,andWellsE.A."Tweaking12-step":Thepotentialroleof12-Step

self-helpgroupinvolvementinmethamphetaminerecovery.Addiction

102(Suppl.1):121-129,2007.

ProjectMATCHResearchGroup.Matchingalcoholismtreatmentstoclient

heterogeneity:ProjectMATCHposttreatmentdrinkingoutcomes.Journalof

StudiesonAlcohol58(1)7-29,1997.

FamilyBehaviorTherapy

FamilyBehaviorTherapy(FBT),whichhasdemonstratedpositiveresultsinboth

adultsandadolescents,isaimedataddressingnotonlysubstanceuse

problemsbutotherco-occurringproblemsaswell,suchasconductdisorders,

childmistreatment,depression,familyconflict,andunemployment.FBT

combinesbehavioralcontractingwithcontingencymanagement.

FBTinvolvesthepatientalongwithatleastonesignificantothersuchasa

cohabitingpartneroraparent(inthecaseofadolescents).Therapistsseekto

engagefamiliesinapplyingthebehavioralstrategiestaughtinsessionsandin

acquiringnewskillstoimprovethehomeenvironment.Patientsareencouraged

todevelopbehavioralgoalsforpreventingsubstanceuseandHIVinfection,

whichareanchoredtoacontingencymanagementsystem.Substance-abusing

parentsarepromptedtosetgoalsrelatedtoeffectiveparentingbehaviors.

Duringeachsession,thebehavioralgoalsarereviewed,withrewardsprovided

bysignificantotherswhengoalsareaccomplished.Patientsparticipatein

treatmentplanning,choosingspecificinterventionsfromamenuofevidence-

53

basedtreatmentoptions.Inaseriesofcomparisonsinvolvingadolescentswith

andwithoutconductdisorder,FBTwasfoundtobemoreeffectivethan

supportivecounseling.

FurtherReading:

Azrin,N.H.;Donohue,B.;Besalel,V.A.;Kogan,E.S.;andAcierno,R.Youthdrug

abusetreatment:acontrolledoutcomestudy.JournalofChildandAdolescent

SubstanceAbuse3:1–16,1994.

Carroll,K.M.;andOnken,L.S.Behavioraltherapiesfordrugabuse.American

JournalofPsychiatry168(8):1452–1460,2005.

Donohue,B.;Azrin,N.;Allen,D.N.;Romero,V.;Hill,H.H.;Tracy,K.;Lapota,H.;

Gorney,S.;Abdel-al,R.;Caldas,D.;Herdzik,K.;Bradshaw,K.;Valdez,R.;and

VanHasselt,V.B.FamilyBehaviorTherapyforsubstanceabuse:Areviewofits

interventioncomponentsandapplicability.BehaviorModification33:495–519,

2009.

LaPota,H.B.;Donohue,B.;Warren,C.S.;andAllen,D.N.Integrationofa

HealthyLivingcurriculumwithinFamilyBehaviorTherapy:Aclinicalcase

exampleinawomanwithahistoryofdomesticviolence,childneglect,drug

abuse,andobesity.JournalofFamilyViolence26:227–234,2011.

BehavioralTherapiesPrimarilyforAdolescents

Drug-abusingandaddictedadolescentshaveuniquetreatmentneeds.

Researchhasshownthattreatmentsdesignedforandtestedinadult

populationsoftenneedtobemodifiedtobeeffectiveinadolescents.Family

involvementisaparticularlyimportantcomponentforinterventionstargeting

youth.Belowareexamplesofbehavioralinterventionsthatemploythese

principlesandhaveshownefficacyfortreatingaddictioninyouth.

MultisystemicTherapy

54

MultisystemicTherapy(MST)addressesthefactorsassociatedwithserious

antisocialbehaviorinchildrenandadolescentswhoabusealcoholandother

drugs.Thesefactorsincludecharacteristicsofthechildoradolescent(e.g.,

favorableattitudestowarddruguse),thefamily(poordiscipline,familyconflict,

parentaldrugabuse),peers(positiveattitudestowarddruguse),school

(dropout,poorperformance),andneighborhood(criminalsubculture).By

participatinginintensivetreatmentinnaturalenvironments(homes,schools,

andneighborhoodsettings),mostyouthsandfamiliescompleteafullcourseof

treatment.MSTsignificantlyreducesadolescentdruguseduringtreatmentand

foratleast6monthsaftertreatment.Fewerincarcerationsandout-of-home

juvenileplacementsoffsetthecostofprovidingthisintensiveserviceand

maintainingtheclinicians’lowcaseloads.

FurtherReading:

Henggeler,S.W.;Clingempeel,W.G.;Brondino,M.J.;andPickrel,S.G.Four-

yearfollow-upofmultisystemictherapywithsubstance-abusingandsubstance-

dependentjuvenileoffenders.JournaloftheAmericanAcademyofChildand

AdolescentPsychiatry41(7):868-874,2002.

Henggeler,S.W.;Rowland,M.D.;Randall,J.;Ward,D.M.;Pickrel,S.G.;

Cunningham,P.B.;Miller,S.L.;Edwards,J.;Zealberg,J.J.;Hand,L.D.;and

Santos,A.B.Home-basedmultisystemictherapyasanalternativetothe

hospitalizationofyouthsinpsychiatriccrisis:Clinicaloutcomes.Journalofthe

AmericanAcademyofChildandAdolescentPsychiatry38(11):1331-1339,

1999.

Henggeler,S.W.;Halliday-Boykins,C.A.;Cunningham,P.B.;Randall,J.;

Shapiro,S.B.;andChapman,J.E.Juveniledrugcourt:Enhancingoutcomesby

integratingevidence-basedtreatments.JournalofConsultingandClinical

Psychology74(1):42–54,2006.

Henggeler,S.W.;Pickrel,S.G.;Brondino,M.J.;andCrouch,J.L.Eliminating

(almost)treatmentdropoutofsubstance-abusingordependentdelinquents

throughhome-basedmultisystemictherapy.TheAmericanJournalof

Psychiatry153(3):427–428,1996.

55

Huey,S.J.;Henggeler,S.W.;Brondino,M.J.;andPickrel,S.G.Mechanismsof

changeinmultisystemictherapy:Reducingdelinquentbehaviorthrough

therapistadherenceandimprovedfamilyfunctioning.JournalofConsultingand

ClinicalPsychology68(3):451–467,2000.

MultidimensionalFamilyTherapy

MultidimensionalFamilyTherapy(MDFT)foradolescentsisanoutpatient,

family-basedtreatmentforteenagerswhoabusealcoholorotherdrugs.MDFT

viewsadolescentdruguseintermsofanetworkofinfluences(individual,

family,peer,community)andsuggeststhatreducingunwantedbehaviorand

increasingdesirablebehavioroccurinmultiplewaysindifferentsettings.

Treatmentincludesindividualandfamilysessionsheldintheclinic,inthe

home,orwithfamilymembersatthefamilycourt,school,orothercommunity

locations.

Duringindividualsessions,thetherapistandadolescentworkonimportant

developmentaltasks,suchasdevelopingdecision-making,negotiation,and

problem-solvingskills.Teenagersacquirevocationalskillsandskillsin

communicatingtheirthoughtsandfeelingstodealbetterwithlifestressors.

Parallelsessionsareheldwithfamilymembers.Parentsexaminetheir

particularparentingstyles,learningtodistinguishinfluencefromcontrolandto

haveapositiveanddevelopmentallyappropriateinfluenceontheirchildren.

FurtherReading:

Dennis,M.;Godley,S.H.;Diamond,G.;Tims,F.M.;Babor,T.;Donaldson,J.;

Liddle,H.;Titus,J.C.;Kaminer,Y.;Webb,C.;Hamilton,N.;andFunk,R.The

CannabisYouthTreatment(CYT)Study:Mainfindingsfromtworandomized

clinicaltrials.JournalofSubstanceAbuseTreatment27(3):197-213,2004.

Liddle,H.A.;Dakof,G.A.;Parker,K.;Diamond,G.S.;Barrett,K;,andTejeda,M.

Multidimensionalfamilytherapyforadolescentdrugabuse:Resultsofa

randomizedclinicaltrial.TheAmericanJournalofDrugandAlcoholAbuse

27(4):651-688,2001.

56

Liddle,H.A.,andHogue,A.Multidimensionalfamilytherapyforadolescent

substanceabuse.InE.F.WagnerandH.B.Waldron(eds.),Innovationsin

AdolescentSubstanceAbuseInterventions.London:Pergamon/Elsevier

Science,pp.227-261,2001.

Liddle,H.A.;Rowe,C.L.;Dakof,G.A.;Ungaro,R.A.;andHenderson,C.E.Early

interventionforadolescentsubstanceabuse:Pretreatmenttoposttreatment

outcomesofarandomizedclinicaltrialcomparingmultidimensionalfamily

therapyandpeergrouptreatment.JournalofPsychoactiveDrugs36(1):49-63,

2004.

Schmidt,S.E.;Liddle,H.A.;andDakof,G.A.Effectsofmultidimensionalfamily

therapy:Relationshipofchangesinparentingpracticestosymptomreductionin

adolescentsubstanceabuse.JournalofFamilyPsychology10(1):1-16,1996.

BriefStrategicFamilyTherapy

BriefStrategicFamilyTherapy(BSFT)targetsfamilyinteractionsthatare

thoughttomaintainorexacerbateadolescentdrugabuseandotherco-

occurringproblembehaviors.Suchproblembehaviorsincludeconduct

problemsathomeandatschool,oppositionalbehavior,delinquency,

associatingwithantisocialpeers,aggressiveandviolentbehavior,andrisky

sexualbehavior.BSFTisbasedonafamilysystemsapproachtotreatment,in

whichfamilymembers’behaviorsareassumedtobeinterdependentsuchthat

thesymptomsofonemember(thedrug-abusingadolescent,forexample)are

indicative,atleastinpart,ofwhatelseisoccurringinthefamilysystem.Therole

oftheBSFTcounseloristoidentifythepatternsoffamilyinteractionthatare

associatedwiththeadolescent’sbehaviorproblemsandtoassistinchanging

thoseproblem-maintainingfamilypatterns.BSFTismeanttobeaflexible

approachthatcanbeadaptedtoabroadrangeoffamilysituationsinvarious

settings(mentalhealthclinics,drugabusetreatmentprograms,othersocial

servicesettings,andfamilies’homes)andinvarioustreatmentmodalities(asa

primaryoutpatientintervention,incombinationwithresidentialordaytreatment,

andasanaftercare/continuing-careservicefollowingresidentialtreatment).

FurtherReading:

57

Coatsworth,J.D.;Santisteban,D.A.;McBride,C.K.;andSzapocznik,J.Brief

StrategicFamilyTherapyversuscommunitycontrol:Engagement,retention,

andanexplorationofthemoderatingroleofadolescentseverity.Family

Process40(3):313-332,2001.

Kurtines,W.M.;Murray,E.J.;andLaperriere,A.Efficacyofinterventionfor

engagingyouthandfamiliesintotreatmentandsomevariablesthatmay

contributetodifferentialeffectiveness.JournalofFamilyPsychology10(1):35–

44,1996.

Santisteban,D.A.;Coatsworth,J.D.;Perez-Vidal,A.;Mitrani,V.;Jean-Gilles,M.;

andSzapocznik,J.BriefStructural/StrategicFamilyTherapywithAfrican-

AmericanandHispanichigh-riskyouth.JournalofCommunityPsychology

25(5):453-471,1997.

Santisteban,D.A.;Suarez-Morales,L.;Robbins,M.S.;andSzapocznik,J.Brief

strategicfamilytherapy:Lessonslearnedinefficacyresearchandchallengesto

blendingresearchandpractice.FamilyProcess45(2):259-271,2006.

Santisteban,D.A.;Szapocznik,J.;Perez-Vidal,A.;Mitrani,V.;Jean-Gilles,M.;

andSzapocznik,J.BriefStructural/StrategicFamilyTherapywithAfrican-

AmericanandHispanichigh-riskyouth.JournalofCommunity

Psychology25(5):453–471,1997.

Szapocznik,J.,etal.Engagingadolescentdrugabusersandtheirfamiliesin

treatment:Astrategicstructuralsystemsapproach.JournalofConsultingand

ClinicalPsychology56(4):552-557,1988.

FunctionalFamilyTherapy

FunctionalFamilyTherapy(FFT)isanothertreatmentbasedonafamily

systemsapproach,inwhichanadolescent’sbehaviorproblemsareseenas

beingcreatedormaintainedbyafamily’sdysfunctionalinteractionpatterns.FFT

aimstoreduceproblembehaviorsbyimprovingcommunication,problem-

solving,conflictresolution,andparentingskills.Theinterventionalways

58

includestheadolescentandatleastonefamilymemberineachsession.

Principaltreatmenttacticsinclude(1)engagingfamiliesinthetreatment

processandenhancingtheirmotivationforchangeand(2)bringingabout

changesinfamilymembers’behaviorusingcontingencymanagement

techniques,communicationandproblem-solving,behavioralcontracts,and

otherbehavioralinterventions.

FurtherReading:

Waldron,H.B.;Slesnick,N.;Brody,J.L.;Turner,C.W.;andPeterson,T.R.

Treatmentoutcomesforadolescentsubstanceabuseat4-and7-month

assessments.JournalofConsultingandClinicalPsychology69:802–813,

2001.

Waldron,H.B.;Turner,C.W.;andOzechowski,T.J.Profilesofdruguse

behaviorchangeforadolescentsintreatment.AddictiveBehaviors30:1775–

1796,2005.

AdolescentCommunityReinforcementApproachand

AssertiveContinuingCare

TheAdolescentCommunityReinforcementApproach(A-CRA)isanother

comprehensivesubstanceabusetreatmentinterventionthatinvolvesthe

adolescentandhisorherfamily.Itseekstosupporttheindividual’srecoveryby

increasingfamily,social,andeducational/vocationalreinforcers.After

assessingtheadolescent’sneedsandlevelsoffunctioning,thetherapist

choosesfromamong17A-CRAprocedurestoaddressproblem-solving,

coping,andcommunicationskillsandtoencourageactiveparticipationin

positivesocialandrecreationalactivities.A-CRAskillstraininginvolvesrole-

playingandbehavioralrehearsal.

AssertiveContinuingCare(ACC)isahome-basedcontinuing-careapproachto

preventingrelapse.Weeklyhomevisitstakeplaceovera12-to14-weekperiod

afteranadolescentisdischargedfromresidential,intensiveoutpatient,or

regularoutpatienttreatment.Usingpositiveandnegativereinforcementto

shapebehaviors,alongwithtraininginproblem-solvingandcommunication

59

skills,ACCcombinesA-CRAandassertivecasemanagementservices(e.g.,

useofamultidisciplinaryteamofprofessionals,round-the-clockcoverage,

assertiveoutreach)tohelpadolescentsandtheircaregiversacquiretheskillsto

engageinpositivesocialactivities.

FurtherReading:

Dennis,M.;Godley,S.H.;Diamond,G.;Tims,F.M.;Babor,T.;Donaldson,J.;

Liddle,H.;Titus,J.C.;Kamier,Y.;Webb,C.;Hamilton,N.;andFunkR.The

CannabisYouthTreatment(CYT)Study:Mainfindingsfromtworandomized

trials.JournalofSubstanceAbuseTreatment27:197–213,2004.

Godley,S.H.;Garner,B.R.;Passetti,L.L.;Funk,R.R.;Dennis,M.L.;andGodley,

M.D.Adolescentoutpatienttreatmentandcontinuingcare:Mainfindingsfroma

randomizedclinicaltrial.DrugandAlcoholDependenceJul1;110(1-2):44–54,

2010.

Godley,M.D.;Godley,S.H.;Dennis,M.L.;Funk,R.;andPassetti,L.L.

Preliminaryoutcomesfromtheassertivecontinuingcareexperimentfor

adolescentsdischargedfromresidentialtreatment.JournalofSubstanceAbuse

Treatment23:21–32,2002.

“This course was developed from the public domain document: Principles of Drug Addiction Treatment: A

Research-Based Guide (Third Edition) – National Institute on Drug Abuse (NIDA) - NIH (2018).”