ADDICTION TREATMENT GOALS
GENERAL ADDICTION TREATMENT PRINCIPLES
Individuals with substance use disorders are heterogeneous with regard to a number of clinically important features and domains of functioning. Consequently, a multimodal approach to treatment is typically required. Care of individuals with substance use disorders includes conducting a complete assessment, treating intoxication and withdrawal syndromes when necessary, addressing co-occurring psychiatric and general medical conditions, and developing and implementing an overall treatment plan. The goals of treatment include the achievement of abstinence or reduction in the use and effects of substances, reduction in the frequency and severity of relapse to substance use, and improvement in psychological and social functioning.
PSYCHOSOCIAL ADDICTION TREATMENTS
Psychosocial treatments are essential components of a comprehensive treatment program [I].
Evidence-based psychosocial treatments include cognitive-behavioral therapies (CBTs, e.g., relapse prevention, social skills training), motivational enhancement therapy (MET), behavioral therapies (e.g., community reinforcement, contingency management), 12-step facilitation (TSF), psychodynamic therapy/interpersonal therapy (IPT), self-help manuals, behavioral self-control, brief interventions, case management, and group, marital, and family therapies. There is evidence to support the efficacy of integrated treatment for patients with a co-occurring substance use and psychiatric disorder; such treatment includes blending psychosocial therapies used to treat specific substance use disorders with psychosocial treatment approaches for other psychiatric diagnoses (e.g., CBT for depression).
ADDICTION TREATMENT SETTINGS
Treatment settings vary with regard to the availability of specific treatment modalities, the degree of restricted access to substances that are likely to be abused, the availability of general medical and psychiatric care, and the overall milieu and treatment philosophy. Patients should be treated in the least restrictive setting that is likely to be safe and effective. Commonly available treatment settings include hospitals, residential treatment facilities, partial hospitalization and intensive outpatient programs, and outpatient programs. Decisions regarding the site of care should be based on the patient’s ability to cooperate with and benefit from the treatment offered, refrain from illicit use of substances, and avoid high-risk behaviors as well as the patient’s need for structure and support or particular treatments that may be available only in certain settings. Patients move from one level of care to another based on these factors and an assessment of their ability to safely benefit from a different level of care.
HOSPITALIZATION; ADDICTION DETOXIFICATION AND INPATIENT TREATMENT
Hospitalization is appropriate for patients who 1) have a substance overdose who cannot be safely treated in an outpatient or emergency department setting; 2) are at risk for severe or medically complicated withdrawal syndromes (e.g., history of delirium tremens, documented history of very heavy alcohol use and high tolerance); 3) have co-occurring general medical conditions that make ambulatory detoxification unsafe; 4) have a documented history of not engaging in or benefiting from treatment in a less intensive setting (e.g., residential, outpatient); 5) have a level of psychiatric comorbidity that would markedly impair their ability to participate in, adhere to, or benefit from treatment or have a co-occurring disorder that by itself would require hospital level care (e.g., depression with suicidal thoughts, acute psychosis); 6) manifest substance use or other behaviors that constitute an acute danger to themselves or others; or 7) have not responded to or were unable to adhere to less intensive treatment efforts and have a substance use disorder(s) that endangers others or poses an ongoing threat to their physical and mental health.
ADDICTION RESIDENTIAL TREATMENT
Residential treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, who lack sufficient social and vocational skills, and who lack substance-free social supports to maintain abstinence in an outpatient setting. Residential treatment of ≥3 months is associated with better long-term outcomes in such patients. For patients with an
opioid use disorder, therapeutic communities have been found effective.
ADDICTION PARTIAL HOSPITALIZATION AND INTENSIVE OUTPATIENT TREATMENT
Partial hospitalization should be considered for patients who require intensive care but have a reasonable probability of refraining from illicit use of substances outside a restricted setting. Partial hospitalization settings are frequently used for patients leaving hospitals or residential settings who remain at high risk for relapse. These include patients who are thought to lack sufficient motivation to continue in treatment, have severe psychiatric co-morbidity and/or a history of relapse to substance use in the immediate post-hospitalization or post-residential period, and are returning to a high-risk environment and have limited psychosocial supports for abstaining from substance use. Partial hospitalization programs are also indicated for patients who are doing poorly despite intensive outpatient treatment.
Partial hospitalization and intensive outpatient programs can provide an intensive, structured treatment experience for individuals with substance use disorders who require more services than those generally available in traditional outpatient settings. Although the terms “partial hospitalization,” “day treatment,” and “intensive outpatient” programs may be used nearly interchangeably in different parts of the country, the ASAM patient placement criteria define structured programming in partial hospitalization programs as 20 hours per week and in intensive outpatient programs as 9 hours per week. Partial hospitalization programs provide ancillary medical and psychiatric services, whereas intensive outpatient programs may be more variable in the accessibility of these services. Some patients enter these programs directly from the community. Alternatively, these programs are sometimes used as “step-down” programs for individuals leaving hospital or residential settings who are at a high risk of relapsing because of problems with motivation, the presence of frequent cravings or urges to use a substance, poor social supports, immediate environmental cues for relapse and/or availability of substances, and co-occurring medical and/or psychiatric disorders. The goal of such a “step-down” approach is to stabilize patients by retaining them in treatment and providing more extended intensive outpatient monitoring of relapse potential and co-occurring disorders. Partial hospitalization and intensive outpatient programs may also be used as a brief “step-up” in treatment for an outpatient who has had a relapse but who does not require medical detoxification or who has entered into a high-risk period for relapse because of life circumstances or recurrence of a co-occurring medical and/or psychiatric symptom (e.g., depressed mood, increased pain).
The treatment components of partial hospitalization programs may include some combination of individual and group therapy, vocational and educational counseling, family meetings, medically supervised use of adjunctive medications (e.g., opioid antagonists, antidepressants), random urine screening for substances of abuse, and treatment for any co-occurring psychiatric disorders. Intensive outpatient programs use individual therapy, group therapy, family therapy, and urine toxicology but vary in the amount of other therapeutic components used. An advantage of intensive outpatient programs is the availability of evening programs that accommodate day-shift employees. The availability of weekend programs varies for both partial hospitalization and intensive outpatient programs. Both kinds of programs aim to prepare the individual for transition to less intensive outpatient services and increased self-reliance through the practice and mastery of relapse prevention skills and the active use of self-help programs.
Limited data are available for the efficacy of partial hospitalization and intensive outpatient programs. Randomized, controlled trials have demonstrated that some individuals who would ordinarily be referred for residential- or hospital-level care do just as well in partial hospitalization care. One study comparing a more time-intensive day hospital program to an intensive outpatient program that was actually less time intensive found no differences in outcome for cocaine-dependent individuals, and another study comparing intensive with traditional outpatient treatment of the same population found no differences in outcome.
ADDICTION OUTPATIENT TREATMENT
Outpatient treatment of substance use disorders is appropriate for patients whose clinical condition or environmental circumstances do not require a more intensive level of care [I]. As in other treatment settings, a comprehensive approach is optimal, using, where indicated, a variety of psychotherapeutic and pharmacological interventions along with behavioral monitoring [I]. Most treatment for patients with alcohol dependence or abuse can be successfully conducted outside the hospital (e.g., in outpatient or partial hospitalization settings) [II], although patients with alcohol withdrawal must be detoxified in a setting that provides frequent clinical assessment and any necessary treatments [I]. For many patients with a cocaine use disorder, clinical and research experience suggests the effectiveness of intensive outpatient treatment in which a variety of treatment modalities are simultaneously used and in which the focus is the maintenance of abstinence [II]. The treatment of patients with nicotine dependence or a marijuana use disorder.
Outpatient treatment settings include but are not limited to mental health clinics, integrated
dual-diagnosis programs, private practice settings, primary care clinics, and substance abuse treatment centers, including opioid treatment programs. For individuals with primary nicotine dependence or a marijuana use disorder, treatment is always provided in an outpatient setting. For individuals with other substance use disorders, outpatient treatment is appropriate when clinical conditions or environmental and social circumstances do not require a more intensive level of care.
As in other treatment settings, the optimal outpatient approach is a comprehensive one that includes a variety of psychotherapeutic and pharmacological interventions along with behavioral monitoring, where indicated. The evidence base for empirically supported outpatient treatments is larger for alcohol, nicotine, and opioid dependence treatments than for other substance dependence treatments. In addition to medication therapies, outpatient treatments with strong evidence of effectiveness include CBTs (e.g., relapse prevention, social skills training), MET, behavioral therapies (e.g., community reinforcement, contingency management), TSF, psychodynamic therapies/IPT, self-help manuals, behavioral self-control, brief interventions, case management, and group, marital, and family therapies.
Many specific outpatient treatments have been designed to enhance an individual’s participation in treatment and sense of self-efficacy regarding the reduction or cessation of problematic substance use. As in the case of residential and partial hospitalization programs, high rates of attrition can be problematic in outpatient settings, particularly in the early phase (i.e., the first 6 months). Because intermediate and long-term outcomes are highly correlated with retention in treatment, individuals should be strongly encouraged to remain in treatment. Clinicians should also encourage and attempt to integrate into treatment a patient’s participation in self-help programs where appropriate.
Aftercare occurs after an intense treatment intervention (e.g., hospital or partial hospitalization program) and generally includes outpatient care, involvement in self-help approaches, or both.
The clinician should consider the possibility that cognitive impairment may be present in recently detoxified patients when determining their next level of care. Research on aftercare has examined different treatment models, including eclectic, medically oriented, motivational, 12- step, cognitive-behavioral, group, and marital strategies. Given the chronic, relapsing nature of many types of substance use disorders, especially those requiring hospitalization, it is expected that aftercare will be recommended with few exceptions. In fact, if addiction is reconceptualized along the lines of a chronic rather than an acute disease model, as recommended by McLellan et al., the distinction between a “treatment episode” and “aftercare” should be removed and the different modalities of care (e.g., inpatient, outpatient) be reconsidered as part of a continuous, long-term treatment plan.
ADDICTION CASE MANAGEMENT
Case management, by definition, exists as an adjunctive treatment. The goals of case management interventions are to provide advocacy and coordination of care and social services and to improve patient adherence to prescribed treatment and follow-up care. Case management initially provides psycho-education about the patient’s diagnosis and treatment as well as assessment and stabilization of basic necessities required for the individual to actively participate in treatment (e.g., housing, utilities, income, health insurance, transportation). Beyond this, case managers aid individuals in maintaining stability and understanding and adhering to prescribed treatment. The variability in case management models has complicated research on the effectiveness of this approach. Nevertheless, studies show that case management interventions are effective for individuals with an alcohol use disorder or co-occurring psychiatric and substance use disorders and for adolescents with substance use disorders.
LEGALLY MANDATED ADDICTION TREATMENT
Treatment of substance use disorders may be legally mandated under a variety of circumstances, including substance-related criminal offenses such as driving under the influence of alcohol or drugs. Drug court programs recognize the effectiveness of diverting offenders with lesser drug related convictions from correctional facilities into court-mandated community programs for the treatment of substance use disorders. Standard procedures for drug court programs include 1) assessment of individual substance use treatment needs, 2) appropriate referral for treatment after arrest, 3) periodic monitoring of adherence to treatment through the use of clinician report and mandatory drug testing, 4) reduction in the severity of charges contingent on successful utilization of programs for the treatment of substance use disorders, and 5) aftercare planning for maintaining sobriety in the community. For offenses related to driving under the influence of alcohol or drugs, state and community sanctions include incarceration, license suspension, driver’s education, and community service requirements. Some evidence indicates that more severe sanctions lead to less recidivism for intoxicated drivers with high blood alcohol content readings.
Despite the high frequency at which substance use disorders and criminal behaviors co-occur, it has been estimated that only 1%–20% of substance abusers receive adequate treatment while incarcerated. The most studied effective treatment programs for incarcerated individuals are therapeutic communities.
EMPLOYEE ASSISTANCE PROGRAMS
Employee assistance programs (EAPs) provide an employment-based treatment setting and referral platform for employees with substance use disorders. EAPs differ according to workplace size and location. A critical difference for substance use treatment received through an EAP versus through an alternate community outpatient setting is the definition of successful intervention outcome. Whereas most community settings define successful outcome as a reduction of substance use and related medical and social problems, an EAP defines and measures success primarily through job performance. This reflects the employer’s need to serve and retain an employee while simultaneously protecting the workplace from inadequate job performance and attributable losses. EAPs are cost-effective in the short term, but post-treatment follow-up rates are poor.
RELAPSE PREVENTION AND TREATMENT COMPLIANCE
Because individuals with substance use disorders are often ambivalent about giving up their substance use, it can be useful to monitor their attitudes about participating in treatment and adhering to specific recommendations. These patients often deny or minimize the negative consequences attributable to their substance use; this tendency is often erroneously interpreted by clinicians and significant others as evidence of dishonesty. Even patients entering treatment with high motivation to achieve abstinence will struggle with the reemergence of craving for a substance or preoccupation with thoughts about attaining or using a substance. Moreover, social influences (e.g., substance-using family or friends), economic influences (e.g., unemployment), medical conditions (e.g., chronic pain, fatigue), and psychological influences (e.g., hopelessness, despair) may make an individual more vulnerable to a relapse episode even when he or she adheres to prescribed treatment. For these reasons, it can be helpful for clinicians and patients to anticipate the possibility that the patient may return to substance use and to agree on a corrective plan of action should this occur. If the patient is willing, it can be helpful to involve significant others in preventing the patient’s relapse and prepare significant others to manage relapses should they occur.
Supporting patients in their efforts to reduce or abstain from substance use positively reinforces their progress. Overt recognition of patient efforts and successes helps to motivate patients to remain in treatment despite setbacks. Clinicians can optimize patient engagement and retention in treatment through the use of motivational enhancement strategies and by encouraging patients to actively partake in self-help strategies. Monitoring programs, such as EAPs and impaired-physician programs, can sometimes help patients adhere to treatment.
Early in treatment a clinician may educate patients about cue-, stress-, and substance-induced relapse triggers. Patients benefit from being educated in a supportive manner about relapse risk situations, thoughts, or emotions; they must learn to recognize these as triggers for relapse and learn to manage unavoidable triggers without resorting to substance-using behaviors.
Participation in AA or similar self-help group meetings can also support patients’ sobriety and help them avoid relapse. Many other strategies can also help prevent relapse. Social skills training is targeted at improving individual responsibility within family relationships, work related interactions, and social relationships. During the early recovery phase, it can be helpful to encourage patients to seek new experiences and roles consistent with a substance-free existence (e.g., greater involvement in vocational, social, or religious activities) and to discourage them from instituting major life changes that might increase the risk of relapse. Facilitating treatment of co-occurring psychiatric and medical conditions that significantly interact with substance relapse is a long-term intervention for maintaining sobriety
Therapeutic strategies to prevent relapse have been well studied and include teaching individuals to anticipate and avoid substance-related cues (e.g., assessing individual capacity to avoid relapse in the presence of substance-using peers), training individuals how to monitor their affective or cognitive states associated with increased craving and substance use, behavioral contingency contracting, training individuals in cue extinction and relaxation therapies to reduce the potency of substance-related stimuli and modulate craving intensity, and supporting patients in the development of coping skills and lifestyle changes that support sobriety. Behavioral techniques that enhance the availability and perceived value of social reinforcement as an alternative to substance use or reward for remaining abstinent have also been used.