Transcript TREATMENT OF SUBSTANCE USE DISORDERS Outcome Studies

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
Disease Model - Treatment
• Early identification
• Education about diagnosis
• Acceptance of disease and
overcoming “denial”
• Abstinence
• 12-steps essential for real recovery
TREATMENT OF SUBSTANCE USE DISORDERS
Addictive Behavior Meds
• ETOH: antabuse, naltrexone, acomprosate;
benzodiazepines
• Opiates:
• Methadone; LAAM
• narcan/naltrexone; depot naltrexone
• buprenorphine
• Cocaine: Modafinil (mechanism unknown, but does inc.
glutamate, DA, NE; decrease of GABA)
• Nicotine:
• Nicotine Replacement Therapies
• Zyban, Wellbutrin (bupropion)
• Effexor (venlafaxine)
Strength of Evidence of
Pharmacotherapies for Alcohol
Dependence
• Naltrexone –
• Acomprosate –
• Disulfiram –
• Serotonergic drugs –
• Lithium –
Strength of Evidence of
Pharmacotherapies
• 208 randomly assigned to 1 of 4 11-week
protocols for etoh and cocaine dependence:
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Naltrexone and Antabuse
Antabuse and placebo
Naltrexone and placebo
Double placebo
• Results:
TREATMENT OF SUBSTANCE USE DISORDERS
TX myths
1.
2.
3.
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
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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 predatory illegal 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
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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.
TREATMENT OF SUBSTANCE
USE DISORDERS
MOTIVATION AND STAGES OF CHANGE
• Pre-Contemplation
____________
• Contemplation
____________
• Preparation
_________________________
• Action
_________________________
• Maintenance _________________________
Specific Treatment Approaches
to Engage Substance Misusers
• Intervention
• Motivational Interviewing
– Assessment
– Cost-benefit analysis
– Feedback; focusing on discrepancies and
change talk
• Working with Concerned Significant Others
(CRAFT Program)
OUTLINE OF SERVICES
A.
B.
Chemical Dependence Treatment Program
Adolescent (ages 13-18)
Adults
Additional Specialty Areas
A. Specialized Chronic Pain Tract
B. Native American Program
Treatment Options
A.
B.
C.
D.
E.
F.
Detoxification 7 Medical Stabilization
In-Patient Rehabilitiation
Residential
Partial Residential
Intensive Out-Patient
Chronic Pain Stabilization
OUTLINE OF SERVICES
A.
B.
C.
D.
E.
F.
General Services
Free, Confidential Assessments
Emergency Consultation Services
24 Hour Crisis Line
Intervention Services
Referrals
Educational Programs
Counseling Services
A.
B.
C.
D.
E.
F.
G.
H.
I.
Individualized Treatment Plans
Group Therapy
Individual Therapy
Family Program
Art Therapy
Spiritual Counseling
Recreational Therapy
ROPES Course
Relapse Prevention Program
Family members and patients participate in an intensive family
program designed to help the patient and family members learn
about chemical dependency and co-dependency.
The Family Program is held each Sunday and Monday and begins with
a group facilitated by a Licensed or Masters Level Counselor entitled
“What to Expect from Treatment”.
• Learn the Neurobiology of Addiction and Relapse
• Change old behaviors that the family has employed in
responding to the alcoholic/chemically dependent family
member; develop new adaptive strategies
• Learn about co-dependency and enabling
• Improve family communication by learning how to
express emotions in an effective and appropriate way
• Share with and draw support from other family members
experiencing similar feelings, thoughts, and fears
• Learn how to become open and honest in
communicating emotions
• Enjoy relationships free from chemical dependency
• Provides a therapeutic outlet that does not solely rely on
verbal ability
• Teaches skills and lends insights which have beneficial
application to daily life to include:
– A more positive self-image and enhance self-esteem
– Effective teamwork and cooperative abilities
– Improved communication and listening skills
– Willingness to take appropriate risks
– An ability to set and achieve goals
– Improved problem-solving skills
– Feelings of accomplishment and success