Chapter 7:Preventing & Treating Drug Use

PSY 302: Substance Abuse

PreventionPrevention

Protective Factors◦ Emphasis put on enhancing these

Risk Factors◦ Emphasis put on reducing these

Models for PreventionModels for PreventionInformation Model The underlying assumption is that the presentation of factual information about drugs and the biological, social and psychological effects, the risk and dangers of drug use and its consequences would have sufficient preventive impact

Ellickson (1995)

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Models for PreventionModels for Prevention

Affective ModelDrug abuse has its main cause in the shortcomings of young personalities low level self-esteem, inability to make rational decisions and express feelings and inadequate problem-solving skillsThe main goal of prevention should be enhancing self-esteem, improvement of decision-making and problem-solving skills

Ellickson (1995)

Affective ModelAffective Model

Reconnecting Youth ProgramSelf-esteem EnhancementDecision MakingPersonal Control Interpersonal Communication

Models for PreventionModels for Prevention

Social Influence Model Behavior is the result of positive or negative influencesPrograms designed within the framework of this model should be based on a negative influence resisting

Ellickson (1995)

Social Influence ModelSocial Influence Model

LifeSkills Training (LST) ProgramSubstance abuse and violence prevention program that targets the social and psychological factors that promote the initiation of substance use and other risky behaviorsDesigned to provide information relevant to the important life transitions that adolescents and young teens face

Social Influence ModelSocial Influence Model

LifeSkills Training (LST) ProgramMathias (2003)Positive effects extended beyond the typical low-risk youths to those who were at higher than average riskLST “significantly reduced initiation of drug use among urban, middle school students who were doing poorly academically and had substance-abusing friends

Prevention ResearchPrevention Research

Technical Problems and CriticismsDifficulty in implementation of prevention programsSchool staff are usually more enthusiastic about their programs than the empirical data indicatesPrevention programs need to make goals explicit from the start

Drug TestingSeveral methods used to test for drugs:UrinalysisHair AnalysisSweat Patch Drug Residues LimitationsCannot determine exact time or how muchTests cannot distinguish the casual user from a chronic userFalse readingsSeveral ways to avoid detection

See next slide

METHODS TO AVOID METHODS TO AVOID DETECTIONDETECTIONAbstentionDilution (Hydration)AdulterationSubstitution

Professor David Cowan (right), head of the London 2012 lab, shows UK Olympics minister Hugh Robertson around the drug-testing facility in east London

ABSTENTIONABSTENTION

Stop using prior to the test

Switch to a different drug that is not part of the testing panel

Pre-employment tests most vulnerable

DILUTION (HYDRATION) DILUTION (HYDRATION)

Most popular method to avoid detection“Water-loading”, “Flushing”, “Detoxing”Use of diuretics, Lasix, vitaminsAdding water to the sample

ADULTERATIONADULTERATION A urine specimen that has been alteredNot a normal constituent for that type of specimen Shows an abnormal concentration of an endogenous substance

OXIDIZING ADULTERANTA substance that acts alone or in combination with other substances to oxidize drugs or drug metabolites to prevent the detection of the drug

SUBSTITUTIONSUBSTITUTION Substituting human or animal urine via a variety of ways, etc.

Desperate people do desperate things

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CHEATERS GETTING CHEATERS GETTING CREATIVECREATIVE

asdfsadf

Cane

Binoculars Books

Cell Phone FlaskBooks

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Man got shot to avoid drug test

Microwaving urine, blew up (man hospitalized)

Leaves found in urine

Man claimed to be positive due to bedbugs

Man faked heart attack during testing

DESPERATE PEOPLE

Treatment concernsTreatment concerns

There is no one gold-standard approach to treating addiction.

Anyone can start a treatment center or SA therapy without credentials or scientific research to back up their methods.

Options vary widely in price and relapse rates (the latter of which is rarely reported).

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Treatment concernsTreatment concerns

People should seek out treatment plans that include a reliable and valid diagnosis and a valid way of reducing their relapse rates.

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The Cure Industry

ScreeningIdentifies individuals with hazardous or harmful drug use or dependence and associated risk behaviorsDiagnosisReferences common to the mental healthTreatmentBased on a plan developed with the client and establishes goals in accord with identified needs and sets interventions to meet those goals

Diagnosing Substance Diagnosing Substance DependenceDependence

A variety of scales exist to document:◦ Physical health (no standardized instrument for

this)◦ Alcohol and drug use◦ Psychiatric Disturbance◦ Personality◦ Cognition◦ Family Adjustment◦ Social Adjustment◦ Legal problems◦ Financial history◦ Risk (suicidal? Violent?)

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Determination of abuse or dependency

Determination whether detoxification is needed Medical Social

Treatment Plan most appropriate for severity of use and type of drug Detoxification

Residential or outpatient Outpatient

Group, individual, family Residential

28-90 days Psychiatric referral Combination

Risk Management Plan for managing medical or psychiatric crises

Medication-Assisted Medication-Assisted TreatmentTreatmentNicotineNicotine gum and the transdermal nicotine patch are used in conjunction with behavioral support to relieve withdrawal symptomsElectric cigarettes provide nicotine without the attendant fire and smoke of a regular cigarette.

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Medication-Assisted Medication-Assisted TreatmentTreatmentAlcoholAntabuseNaltrexoneCampral

AntabuseMost studies suggest that Antabuse has been only moderately effectiveWhen effective, it supplements the alcoholic’s own commitment to quitDaily routine of pill ingestion may reaffirm commitment not to drinkMany quit taking the pill and continue to drink

Medications for Alcohol Abuse

CampralReduces the physical distress and emotional discomfort people usually experience when they quit drinking, apparently by reducing excitatory neurotransmittersShould be used as part of a complete treatment program that includes both counseling and psychological supportRestores the natural balance of chemicals in the brain (neurotransmitters)

Medications for Alcohol AbuseMedications for Alcohol Abuse

Opioid Addiction Opioid Addiction TreatmentsTreatmentsAntagonist Maintenance

◦ Naloxone ◦ Naltrexone◦ Ultra-rapid opioid detox

Agonists Maintenance◦ Methadone◦ Buprenorphine◦ Combination treatments

Abstinence-based◦ Residential (with or after

detox)◦ 12 Step Programs

Medication-Assisted Medication-Assisted TreatmentTreatmentOpioid AntagonistsBlock or counteract the effects of opioidsBind with opiate receptor sites and prevents stimulation; displaces an opiate already at the siteAn opiate similar to heroin and morphine but is absorbed and metabolized slowlyPerceived to be less harmful than other drugsAssumed to satisfy the cravings associated with the previous drug use and allow the person to carry on with their life

Antagonist MaintenanceAntagonist Maintenance

Naloxone Used for testing for opiate dependence before admission to a methadone programNo effect on non-dependent person

Antagonist Maintenance NaloxoneEmergency Treatment

◦Used to counter the effects of opiate overdose, for example heroin or morphine overdose

◦Specifically used to counteract life-threatening depression of the central nervous system and respiratory system

◦Naloxone has been distributed as part of emergency overdose response kits to heroin and other opioid drug users, and this has been shown to reduce rates of fatal overdose

Antagonist MaintenanceNaltrexone (ReVia)Blocks opioid receptorsReduce cravingTablets or implantable

pelletsReduces alcohol slipsUsed for opioids as well

as alcohol

Injectable Naltrexone Injectable Naltrexone (Vivitrol)(Vivitrol)Intramuscular injection of depot naltrexone given monthlyRecently FDA approved for alcoholAdminister in physician office, not at home

Naltrexone Implant

Oral naltrexone compounded by pharmacy into pellet◦Inserted subcutaneously (minor

surgery)◦Lasts for 1-3 months, may be replaced

Antagonist maintenance◦Similar to oral/intramuscular naltrexone

therapyRequires detoxification from

opioids firstNot approved by FDA

Opiod Agonists Maintenance Pharmacotherapy for OpioidsLong-acting medication in

controlled setting◦ Counseling◦ Social services

Avoid withdrawal & craving

Reduce disease & crimeMaintenance vs.

detoxification issues

MethadoneMethadoneOpioid substitution therapyHarm reduction

◦Individual◦Society

Highly regulated◦Narcotic treatment programs must

be licensedVery effective but controversial

Methadone MaintenanceSingle daily dose of the long-acting

opioid in a controlled settingUse of methadone for >180 days (6 mo.)Counseling and social servicesReferral for primary medical services

Methadone An opiate similar to heroin and morphine but is absorbed and metabolized slowlyPerceived to be less harmful than other drugsAssumed to satisfy the cravings associated with the previous drug use and allow the person to carry on with their life

Medications for Opiate Abuse

Blocking DoseMajority of opioid receptors are

blocked by methadone◦Can’t “feel” heroin effects

However, some typical opioid effects◦Sedation◦Reassuring feeling

Less side effects◦ No withdrawal symptoms◦ No craving

Beneficial EffectsEnhanced recoveryReduced mortality

◦ 70% reduction in each of the following: Overdose Trauma Homicide Medical illnesses

Improved health◦ Medical◦ Psychiatric

Improved psychosocial functioning◦ Employment◦ Criminal activity◦ Family responsibilities

Methadone Forever? No federal limit for time on methadone Some states restrict time

◦ Virginia: evaluate every 2 years to see if can come off the treatment within that time frame

Individual variability◦ Time required to stabilize (use, housing, family, job)◦ Long-term clients (decades)

Initial: can’t imagine life without something Stable: able to consider coming off

◦ Taper off comfortably over months/years

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Buprenorphine

Alternative to methadone for opioid addiction treatment

Long-acting partial opioid agonistMultiple forms available

◦ Combined with naloxone (Suboxone): most common

◦ Buprenorphine only (Subtex)◦ Used for treatment of acute pain

(Buprenex)Used for detox or maintenance

◦ Only mildly addictive

Buprenorphine

Binds to opioid receptors in bodyOnly activates receptor around

40%, not 100% like other opioids (heroin, methadone)◦If already in withdrawal, 40% is pretty good

◦If not in withdrawal, dropping from 100% to 40% receptor activation causes withdrawal

Very low risk of overdose

Buprenorphine/Naloxone

This combination of drugs helps reduce abuse

Naloxone only active when Suboxone is injected

Results in withdrawal for users trying to get high

Buprenorphine alone has similar effect when injected by those who are opioid dependent and not in withdrawal already

Buprenorphine:Office-based opioid therapyBuprenorphine is less restricted

than methadone Get prescription from pharmacy

with refills (up to 6 months)◦Outpatient physician visits for

medication checks as neededAddiction counseling is separate,

patient may be referred to another provider for this service

Taking Buprenorphine

Sublingual tablet◦ Dissolve under tongue◦ Takes around 5 min. to dissolve◦ Won’t be active if swallowed

Comes in 2mg and 8mg tabletsTypical dose is 12-16 mg once dailyCan take 3 times a week

Methadone or Buprenorphine?Treatment efficacy equivalent Similar opioid side effectsAbuse potential

◦Slightly higher for buprenorphine in opioid non-dependent persons

Buprenorphine has fewer drug interactionsMethadone has no ceiling effectBuprenorphine more convenient (less

restricted)Methadone less expensive

◦Higher cost of buprenorphine, counseling separate cost

Buprenorphine not age-restricted (can use with teens)

Methadone Clinic Buprenorphine

• Criteria:

Withdrawal

12 months use

• Criteria:

DSM 5

No time criteria

• Dose regulated • MD sets dose

• Age > 18 • Age > 16

• Limited take homes • Take homes (30 days)

• Services “required” • Services must be “available”

Methadone Treatment Decreases Methadone Treatment Decreases HIV SeroincidenceHIV Seroincidence..

0

5

10

15

20

25

30

35

40

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Baseline 1 yr. 2 yr. 3 yr.

% s

erop

ositiv

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Methadone Out-of-treatment

Metzger et al. (1993)

Treatment for Cocaine and MethamphetamineCocaineCocaine agonists and antagonists that typically affect neurotransmitters playing a role in cocaine dependence have been tested as possible treatment agents, but no drug effectively treats the cocaine-dependent patient MethamphetamineNo approved drug for treating methamphetamine dependence

Chemical DetoxificationThe use of chemicals to facilitate drug withdrawal can serve to attract the drug dependent into treatment and increases the probability that they will complete detoxification

Rapid Detox•Addicted patient is strapped down, anesthetized, and put on a respirator. •Patient then receives intravenous doses of naltrexone that dislodge opiate molecules from their receptor sites—the patient experiences instant withdrawal that is complete in about four to six hours

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Anesthesia Assisted Rapid Opioid Detoxification Induce acute withdrawal with naloxonePatient under deep sedation/anesthesiaShortens course, but still uncomfortableHigh riskHigh costNot recommended

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Psychological TreatmentPsychological Treatment• Psychoanalytic Approach

• Psychotherapy• Behavior Modification

• Aversion Treatment• Cognitive Behavior Therapy

• Contingency Management • Contingency Contracting

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Psychoanalytic ApproachPsychoanalytic ApproachStep 1: Take a detailed history of the

problems that have been caused by the patient’s use of drugs or alcohol.Inquire systematical about trouble in:

- Work- Medical health- Relationships with friends- Relationships with family- Legal problems- Mental health (depression, shame,

anxiety)53

Psychoanalytic ApproachPsychoanalytic Approach

Step 2: Diagnose client’s level of use and any comorbid disorders

Step 3: Select appropriate treatment plan

Step 4: Support clients’ attempts to change

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TherapyTherapyBehavior ModificationAversive Conditioning

Scene from “A Clockwork Orange”

Cognitive Behavioral Therapy (CBT)CBT focuses on changing the clients’

thoughts so that they do not support substance abuse behavior

Common Characteristics of CBT:• Emphasizes stoicism (calmness when

dealing with problems)• Has specific agendas for each

session, and the whole relationships is briefer and time-limited compared to other types of psychotherapy

• Homework is a central feature of CBT

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Cognitive Behavioral Therapy (CBT)

Strives to have drug abusers understand their cravings and to develop coping skills

•This may include detailed planning on how to get from one day to the next without using drugs•CBT is a short-term outpatient approach focused on helping patients to recognize, avoid, and cope

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Drug Treatment Programs

Drug Courts: PurposeWhy Do we Need A Specialized Court?Drug Offenders pose a unique challenge to our court system; they are different than offenders who break other criminal lawsTraditional Court Systems focus on determination of guilt and sanctions, not the addiction problemJudges need specialized training and courts need specialized services and supervision for drug offenders

How Do Drug Courts Operate?Drug courts represent the coordinated

efforts of justice and treatment professionals to actively intervene and break the cycle of substance abuse, addiction, and crime.

Drug Courts are an alternative to less effective interventions,

Drug courts quickly identify substance abusing offenders and place them under ongoing judicial monitoring and community supervision, coupled with effective, long-term treatment services.

Drug Types Vary by Location

Urban Drug Courts: cocaine/crack is the primary drug of choice for urban drug court clients

Suburban Drug Courts: marijuana is the primary drug of choice for suburban drug court clients

Rural Drug Courts: methamphetamine is the primary drug of choice for rural drug court clients

Impact of Drug Courts: Do They Work?

OVERALL IMPACT: According to over a decade of research, drug courts significantly improve substance abuse treatment outcomes, substantially reduce crime ,and produce greater cost benefits than any other justice strategy

Drug Treatment ProgramsTherapeutic Community (TC)Residential, self-help; drug-free treatment programAA model incorporated

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TC Philosophy and TC Philosophy and PerspectivesPerspectivesView of the “disorder”

View of the “person”

View of “recovery”

View of “healthy living”

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View of the “Disorder”View of the “Disorder”

The “problem” is the individual not the drug

Detox is a condition of entry

The GOAL is abstinence

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View of the “Person”View of the “Person”Dimensions of:

Psychological dysfunction Social deficits Vocational/educational deficits

Habilitative vs. rehabilitative needsPersonality disturbances either as a cause

or result of the substance use disorder

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View of “Recovery”View of “Recovery”

Change in lifestyle and personal identity

Motivation: pressure(s) to change

Treatment is through staff and peers

Social learning

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View of “Healthy Living”View of “Healthy Living”Clear “moral” positions are held

Right and wrong behaviors are identified

Specific values are stressed Guilt (as a central issue in recovery)

is addressed

Focus is on“here and now” The past is explored only to illustrate

current patterns and attitudes

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Usual Patient Usual Patient CharacteristicsCharacteristics

Who comes for treatment?Social profiles

Psychological profiles

Psychiatric diagnoses

Criteria for treatment

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Social ProfilesSocial Profiles70-75% maleMost from broken homes/disrupted

families<33% were employed full-time >66% have been arrested30-40% have prior treatment

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Psychological ProfilesPsychological Profiles

High anxiety/depression Poor socialization IQ = dull (70-84) to normal (85-115)Low self esteemDisturbed thinkingImmature/antisocial

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Psychiatric DiagnosesPsychiatric Diagnoses>70% lifetime psychiatric symptoms33% current serious mental disorderTemporary, substance-induced

conditionsIndependent disorders:

Antisocial personality disorder Bipolar disorder Anxiety disorders

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The TC Approach to The TC Approach to TreatmentTreatment

Structure and social organization of the TC Role of staff Role of the patient(s)

Treatment tools used via the social structure

Work as therapy Mutual self-help Peers as role models Staff as rationale authorities

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The Recovery The Recovery Process Process Typical Daily Regimen

Community meetingWork timeGroupsRecreational activities Individual counseling

Program stages I: Orientation (0-60 days) II: Primary treatment (2-12 months) III: Advanced treatment and aftercare (13-24 months)

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Effectiveness of the TC Effectiveness of the TC ApproachApproachSuccess reflected in improvements

in several variablesPost-treatment outcomes most

influenced by “time in program” (TIP)

Retention rates: predictors of this are important

Drop-out is expected, but there are some predictors of this

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Success RatesSuccess RatesSubstantial improvements 40-60% reduction in drug useUp to 40% in decreased arrest ratesUp to 40% in employment gainsTIP and outcomes (success = no drug use or criminality):90% for program graduates50% for drop-outs after 1 year of treatment25% for drop-outs prior to 1 year of treatment

NIDA (2001)

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RetentionRetention

Completion rate: 10-25% of all admissions

Dropout rates highest first 30 days (30-40%)

Retention very weakly predicted by client variables

Treatment entry variables stronger, more consistent predictors of retention

Chemical Dependency Chemical Dependency ProgramsPrograms

The Minnesota Model of TreatmentA period of residential or inpatient care (28days-6mo)A focus on the substance use disorder (little attention to psychological factors)Heavy emphasis on AA self-help concepts, resourcesReferral to AA or another self-help group on dischargeMinimal or no family therapy or counselingNegative attitudes towards ongoing psychotherapies and pharmacotherapies for SA disorders

12-step programs12-step programsAlcoholics Anonymous and Narcotics Alcoholics Anonymous and Narcotics AnonymousAnonymous

90-day induction period (daily attendance to meetings)

Sponsorship relationships (same-sex)Meeting attendance in which a leader

and 2-3 speakers share their experiences of how 12-step relates to their recovery

12-steps1. Admitting powerlessness2. Higher power can restore us to sanity

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12-step programs12-step programsAlcoholics Anonymous and Narcotics Alcoholics Anonymous and Narcotics AnonymouAnonymouss

12-steps cont’d3. Decide to turn our will and our lives over to the care of

God (as we understand him)

4. Make a fearless moral inventory of ourselves

5. Add to God, ourselves, and to another human being the exact nature of our groups

6. Are entirely ready to have God remove all these defects of character

7. Humbly ask God to remove our shortcomings

8. Make a list of all persons we have harmed

9. Make direct amends wherever possible

10. Continue to take personal inventory and admit errors

11. Improve conscious contact with God through prayer and mediation

12. Try to carry this message to other alcoholics 79

12-Step Effectiveness12-Step EffectivenessAlcoholics Anonymous Study (2008)The most recent survey of AA members, conducted in 2007, found that 33% had been continuously sober for more than 10 years, 12% had between 5 and 10 years of sobriety, 24% between 1 and 5 years, and 31% less than 1 yearComprehensively, the average length of sobriety for all members was more than 8 years, with 52% of the membership being between 41 and 60 years of age

12-Step Effectiveness12-Step EffectivenessResidential Use Studies

◦Alford (1980) Highly effective: Two years after discharge

50% still abstinent◦Alford (1991) AA/NA model inpatient treatment for

adolescents Mixed results: Over 70% remain abstinent

six months after completion of program; but this drops to about 40% after two years after completion of program

12-Step Effectiveness12-Step Effectiveness

AA contends that 75% of its members maintain abstinence

Little research because of members anonymity but indications are most don’t stick to it

Those with commitment to program leads to abstinence

CreditsCredits

Some slides prepared with the help of the following websites:hivaidsukraine.wikispaces.com/file/.../Module_5_2_ENG.pptwww1.appstate.edu/.../School-Based%20Drug%20Prevention....www.madisonpublicschools.org/.../lib/.../10_Toxicology.ppttransit-safety.volpe.dot.gov/DrugAndAlcohol/.../Final_Smith_...www.nvcc.edu/home/gstratton/Sum12.260/SA.Treatment.pptwww.alcoholmedicalscholars.org/web/presentations/ppt/tc.pptwww.vsias.org/presentations10/VSIASMAT.pptwww.aegisuniversity.com/powerpoint/CM%20final%20Portlanhttp://edition.cnn.com/2012/04/12/sport/drugs-london-2012-olympics-laboratory/index.html