Transcript Moral / Temperance Model

MODELS OF ADDICTION:
A SUMMARY
Moral / Temperance Model *
Addiction as Sin or Crime
Personal Irresponsibility
Disease Model *
Genetic and Biological Factors **
12-Step Framework; Abstinence
Education as Treatment
Behavioral and CognitiveBehavioral Models *
Conditioning and Reinforcement
Social Learning and Modeling
Drug Expectancies and other
Cognitive Factors / RP
Family Models
Family Disease
Family Systems
Behavioral Marital/Family Tx
MODELS OF ADDICTION:
A SUMMARY
Psychological / Psychoanalytic
Disordered /Addictive Personality
Sociocultural Models
Cultural Factors
Socioeconomics/ Social Policy
Drug Subcultures
Public Health Model
Agent, Host, Environment
Interactions
THE BIOPSYCHOSOCIAL MODEL:
AN INTEGRATION
MODELS OF ADDICTION
Assumptions of Disease Model
addiction seen as a “primary” disease process
alcoholics qualitatively different from non
alcoholics: can’t drink in moderation
central symptom of addiction is loss of control
(e.g., one drink, one drunk)
addiction is chronic and progressive; no cure,
can only be arrested with total abstinence
(e.g. progression models - Johnson…learning &
seeking the mood swing; harmful dependence;
drinking to feel normal)
Disease Model - Treatment
• Early identification
• Education about diagnosis
• Acceptance of disease and
overcoming “denial”
• Abstinence
• 12-steps essential for real recovery
12 Steps of Alcoholics
Anonymous
1. We admitted we were powerless over alcohol - that
our lives had become unmanageable.
2. Came to believe that a Power greater than ourselves could
restore us to sanity.
3. Made a decision to turn our will and our lives over to the
care of God as we understood Him.
4. Made a searching and fearless moral inventory of
ourselves.
5. Admitted to God, to ourselves, and to another human being
the exact nature of our wrongs.
12 Steps of AA
(con’t)
6. Were entirely ready to have God remove all these
defects of character.
7. Humbly asked Him to remove our shortcomings.
8. Made a list of all persons we had harmed and became
willing to make amends to them all.
9. Made direct amends to such people wherever
possible, except when to do so would injure them or
others.
10. Continued to take moral inventory and when we
were wrong promptly admitted to it.
12 Steps of AA
(con’t)
11. Sought through prayer and meditation to improve
our conscious contact with God as we understood
Him, praying only for knowledge of His will for
us and the power to carry that out.
12. Having had a spiritual awakening as the result of
these steps, we tried to carry this message to
alcoholics, and to practice these principles in all
our affairs.
Disease Model - Research Support
• Adoption study of Goodwin
• 18% probands alcoholic vs. 5% controls
• Twin Studies
• male vs. female twin pairs
• Metabolic Studies – an error in
metabolism? Genetic variation does exist
but…does it predispose or protect? The Asian
and Native American flushing response
• P3 Wave Studies
Data on Assumptions of Disease Model
• addiction as “primary”
• loss of control
• chronic / progressive
• alcoholics qualitatively different
CRITIQUE OF DISEASE MODEL
Strengths
- perception shift: from sin to TX
- eases guilt, self-blame
- disease is a good metaphor that fits the
experience
- 12-step support and framework works for
many (prevalence of meetings; 24-hour
support…)
- Other strengths?
_______________________
CRITIQUE OF DISEASE MODEL
Limitations
- not all data-based
- dichotomous thinking dangerous; no middle
ground (you’re an alcoholic or not)
- loss of control and responsibility paradox
- Other flaws?
SUBSTANCE USE DISORDERS
GENERAL METHODS OF TREATMENT
Inpatient Detoxification and Rehabilitation
Outpatient Individual, Couple, or Family
Counseling
Self-help Groups (Alcoholics Anonymous;
NA, CA, OA, GA, Al-Anon etc.)
Residential Facilities & Therapeutic
Communities
Medications
TREATMENT OF SUBSTANCE USE DISORDERS
Addictive Behavior Meds
• ETOH: antabuse, naltrexone, acomprosate;
benzodiazepines
• Opiates:
• Methadone; LAAM
• narcan/naltrexone; depot naltrexone
• buprenophine
• Nicotine:
• Nicotine Replacement Therapies
• Zyban, Wellbutrin (bupropion)
• Effexor (venlafaxine)
Strength of Evidence of Pharmacotherapies
for Alcohol Dependence
• Naltrexone - Grade A: strong and consistent
•
•
•
•
evidence of efficacy of studies of large size and/or
high quality
Acomprosate – A: strong and consistent
evidence of efficacy of studies of large size and/or
high quality
Disulfiram – B: mixed evidence of efficacy
Serotonergic drugs – I: insufficient evidence
Lithium – C: evidence of lack of efficacy
Psychiatric Medications
• Psychiatric Medications
– The 3 revolutions in psychiatry
• Schizophrenia & antipsychotic drugs
– typical vs. atypical
• Anxiety disorders and benzodiazepines
• Mood disorders and antidepressants
– (MAOIs; tricyclics; SSRIs; others -Wellbutrin)
– Bipolar disorder: Lithium and anticonvulsants (Depakote,
Tegretol, Lamictal)
TREATMENT OF SUBSTANCE USE DISORDERS
TX myths
1. Nothing works
2. One approach is superior to all others (“one true light”
tradition)
3. All treatment approaches work equally well for everyone
- measuring outcomes
- good studies use:________________________
TREATMENT OF SUBSTANCE USE DISORDERS
• Outcome Studies
• Hazeldon study:
• N = 1,083 (71% retained)…53% abstinent at 1 yr. f/u
• Drug Abuse Treatment Outcome Study (DATOS) –
• natural tx in 4 settings: outpt. methadone clinics,
outpatient drug-free, short-term inpatient, long-term
residential:
1 year f/u data for outpt. methadone group
•
Pre
F/U
• N = 727 / 1,203
(60 %)
*weekly or more drug use
89.4%  27.8 heroin use
41.9%  21.7 cocaine use
17.1%  13.9 marijuana use
14.8%  16.3 alcohol use, 5+ drinks
28.6%  13.7 pred legal activity
25.2%  12.9 sexual behavior risk
Project MATCH Treatment Conditions
Type of
Treatment
Goal of
Treatment
Description
Frequency
CBT
(Cognitive
Behavioral
Therapy)
Learn skills to
achieve and
maintain sobriety
Coping and drink-refusal
skills taught by therapist to
handle states and situations
known to precipitate relapse
12 weekly
sessions
TSF
(Twelve Step
Facilitation)
Acceptance of the
disease of
alcoholism and
loss of control
over drinking
Patients introduced by
therapist to the first steps of
Alcoholics Anonymous and
encouraged to attend meetings
12 weekly
sessions
MET
(Motivational
Enhancement
Therapy)
Mobilize the
person’s own
commitment and
motivation to
change
Therapist applies motivational 4 sessions
psychology to examine effect in 12 weeks
of drinking on patient’s life,
and develop and implement a
plan to stop drinking
Project MATCH Results:
• N = 1,726 outpatients (n=952) and aftercare (n=774) at 5
sites (one of largest clinical trials ever)
• 25% were women; 15% were minority group members
• 10 client characteristics studied: severity etoh, sociopathy,
cognitive impairment, gender, meaning seeking, motivation,
psych severity, etc.
• 90% of the participants were assessed at 1-year follow-up
• pre-post differences in drinking days per month (25  6)
and drinks per “drinking” day (15  3)
• each of the 3 treatments worked about equally well in
reducing drinking
• TSF outpatients more likely to remain sober (24%)
at 1 yr. than outpatients in CBT or MET (about
15%)
• only 1 “matching” prediction supported:
outpatients with few or no psychiatric problems had
more abstinent days in TSF tx than in CBT
• At 3-yr. follow-up: 36% of TSF clients abstinent vs.
27% MET and 24% CBT clients
• *** strong correlation between
abstinence rates and compliance with
aftercare (“recovery” is a PROCESS).
Principles of Effective Treatment
http://www.nida.nih.gov/PODAT/PODAT1.html
• No single treatment is appropriate for all individuals.
• Treatment needs to be readily available.
• Effective treatment attends to multiple needs of the
individual, not just his or her drug use. Clients with
coexisting mental disorders should have both
disorders treated in an integrated way.
• In order to meet the changing needs of the client, the
treatment plan must be continually assessed and
modified.
• Remaining in treatment for an adequate period of
time is critical for treatment effectiveness.
• Counseling (individual, couple, and/or group) and
other behavioral therapies are critical components of
effective treatment for addiction...
Medical detoxification is only the first stage of
addiction treatment and by itself does little to
change long-term drug use.
• Medications are an important element of treatment
for many patients, especially when combined with
counseling and other behavioral therapies.
• Treatment does not need to be voluntary to be
effective
• Possible drug use during treatment must be
monitored continuously.
• Treatment programs should provide assessment
and counseling for HIV/AIDS, hepatitis B and C,
tuberculosis and other infectious diseases to help
patients modify or change behaviors that place
themselves or others at risk of infection.
• Recovery from drug addiction can be a long-term
process and frequently requires multiple episodes
of treatment.