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
12 Steps of Alcoholics
Anonymous
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 –
Acomprosate –
Disulfiram –
Serotonergic drugs –
Lithium –
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:
• 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 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
• *** 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.