Research Based Principles
of Drug Addiction Treatment
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Preface
Drugaddictionisacomplexillness.
Itischaracterizedbyintenseand,attimes,uncontrollabledrugcraving,along
withcompulsivedrugseekingandusethatpersisteveninthefaceof
devastatingconsequences.ThisupdateoftheNationalInstituteonDrug
Abuse’sPrinciplesofDrugAddictionTreatmentisintendedtoaddressaddiction
toawidevarietyofdrugs,includingnicotine,alcohol,andillicitandprescription
drugs.Itisdesignedtoserveasaresourceforhealthcareproviders,family
members,andotherstakeholderstryingtoaddressthemyriadproblemsfaced
bypatientsinneedoftreatmentfordrugabuseoraddiction.
Addictionaffectsmultiplebraincircuits,includingthoseinvolvedinrewardand
motivation,learningandmemory,andinhibitorycontroloverbehavior.Thatis
whyaddictionisabraindisease.Someindividualsaremorevulnerablethan
otherstobecomingaddicted,dependingontheinterplaybetweengenetic
makeup,ageofexposuretodrugs,andotherenvironmentalinfluences.Whilea
personinitiallychoosestotakedrugs,overtimetheeffectsofprolonged
exposureonbrainfunctioningcompromisethatabilitytochoose,andseeking
andconsumingthedrugbecomecompulsive,ofteneludingaperson’sself-
controlorwillpower.
Butaddictionismorethanjustcompulsivedrugtaking—itcanalsoproducefar-
reachinghealthandsocialconsequences.Forexample,drugabuseand
addictionincreaseaperson’sriskforavarietyofothermentalandphysical
illnessesrelatedtoadrug-abusinglifestyleorthetoxiceffectsofthedrugs
themselves.Additionally,thedysfunctionalbehaviorsthatresultfromdrug
abusecaninterferewithaperson’snormalfunctioninginthefamily,the
workplace,andthebroadercommunity.
Becausedrugabuseandaddictionhavesomanydimensionsanddisruptso
manyaspectsofanindividual’slife,treatmentisnotsimple.Effectivetreatment
programstypicallyincorporatemanycomponents,eachdirectedtoaparticular
aspectoftheillnessanditsconsequences.Addictiontreatmentmusthelpthe
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individualstopusingdrugs,maintainadrug-freelifestyle,andachieve
productivefunctioninginthefamily,atwork,andinsociety.Becauseaddiction
isadisease,mostpeoplecannotsimplystopusingdrugsforafewdaysandbe
cured.Patientstypicallyrequirelong-termorrepeatedepisodesofcareto
achievetheultimategoalofsustainedabstinenceandrecoveryoftheirlives.
Indeed,scientificresearchandclinicalpracticedemonstratethevalueof
continuingcareintreatingaddiction,withavarietyofapproacheshavingbeen
testedandintegratedinresidentialandcommunitysettings.
Aswelooktowardthefuture,wewillharnessnewresearchresultsonthe
influenceofgeneticsandenvironmentongenefunctionandexpression(i.e.,
epigenetics),whichareheraldingthedevelopmentofpersonalizedtreatment
interventions.Thesefindingswillbeintegratedwithcurrentevidencesupporting
themosteffectivedrugabuseandaddictiontreatmentsandtheir
implementation,whicharereflectedinthisguide.
NoraD.Volkow,M.D.
Director
NationalInstituteonDrugAbuse
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PrinciplesofEffectiveTreatment
1. Addictionisacomplexbuttreatablediseasethataffectsbrainfunction
andbehavior.Drugsofabusealterthebrain’sstructureandfunction,
resultinginchangesthatpersistlongafterdrugusehasceased.Thismay
explainwhydrugabusersareatriskforrelapseevenafterlongperiodsof
abstinenceanddespitethepotentiallydevastatingconsequences.
2. Nosingletreatmentisappropriateforeveryone.Treatmentvaries
dependingonthetypeofdrugandthecharacteristicsofthepatients.
Matchingtreatmentsettings,interventions,andservicestoanindividual’s
particularproblemsandneedsiscriticaltohisorherultimatesuccessin
returningtoproductivefunctioninginthefamily,workplace,andsociety.
3. Treatmentneedstobereadilyavailable.Becausedrug-addicted
individualsmaybeuncertainaboutenteringtreatment,takingadvantageof
availableservicesthemomentpeoplearereadyfortreatmentiscritical.
Potentialpatientscanbelostiftreatmentisnotimmediatelyavailableor
readilyaccessible.Aswithotherchronicdiseases,theearliertreatmentis
offeredinthediseaseprocess,thegreaterthelikelihoodofpositive
outcomes.
4. Effectivetreatmentattendstomultipleneedsoftheindividual,notjust
hisorherdrugabuse.Tobeeffective,treatmentmustaddressthe
individual’sdrugabuseandanyassociatedmedical,psychological,social,
vocational,andlegalproblems.Itisalsoimportantthattreatmentbe
appropriatetotheindividual’sage,gender,ethnicity,andculture.
5. Remainingintreatmentforanadequateperiodoftimeiscritical.The
appropriatedurationforanindividualdependsonthetypeanddegreeof
thepatient’sproblemsandneeds.Researchindicatesthatmostaddicted
individualsneedatleast3monthsintreatmenttosignificantlyreduceor
stoptheirdruguseandthatthebestoutcomesoccurwithlongerdurations
oftreatment.Recoveryfromdrugaddictionisalong-termprocessand
frequentlyrequiresmultipleepisodesoftreatment.Aswithotherchronic
illnesses,relapsestodrugabusecanoccurandshouldsignalaneedfor
treatmenttobereinstatedoradjusted.Becauseindividualsoftenleave
treatmentprematurely,programsshouldincludestrategiestoengageand
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keeppatientsintreatment.
6. Behavioraltherapies—includingindividual,family,orgroupcounseling—
arethemostcommonlyusedformsofdrugabusetreatment.
Behavioraltherapiesvaryintheirfocusandmayinvolveaddressinga
patient’smotivationtochange,providingincentivesforabstinence,building
skillstoresistdruguse,replacingdrug-usingactivitieswithconstructiveand
rewardingactivities,improvingproblem-solvingskills,andfacilitatingbetter
interpersonalrelationships.Also,participationingrouptherapyandother
peersupportprogramsduringandfollowingtreatmentcanhelpmaintain
abstinence.
7. Medicationsareanimportantelementoftreatmentformanypatients,
especiallywhencombinedwithcounselingandotherbehavioral
therapies.Forexample,methadone,buprenorphine,andnaltrexone
(includinganewlong-actingformulation)areeffectiveinhelpingindividuals
addictedtoheroinorotheropioidsstabilizetheirlivesandreducetheirillicit
druguse.Acamprosate,disulfiram,andnaltrexonearemedications
approvedfortreatingalcoholdependence.Forpersonsaddictedtonicotine,
anicotinereplacementproduct(availableaspatches,gum,lozenges,or
nasalspray)oranoralmedication(suchasbupropionorvarenicline)can
beaneffectivecomponentoftreatmentwhenpartofacomprehensive
behavioraltreatmentprogram.
8. Anindividual'streatmentandservicesplanmustbeassessed
continuallyandmodifiedasnecessarytoensurethatitmeetshisorher
changingneeds.Apatientmayrequirevaryingcombinationsofservices
andtreatmentcomponentsduringthecourseoftreatmentandrecovery.In
additiontocounselingorpsychotherapy,apatientmayrequiremedication,
medicalservices,familytherapy,parentinginstruction,vocational
rehabilitation,and/orsocialandlegalservices.Formanypatients,a
continuingcareapproachprovidesthebestresults,withthetreatment
intensityvaryingaccordingtoaperson’schangingneeds.
9. Manydrug-addictedindividualsalsohaveothermentaldisorders.
Becausedrugabuseandaddiction—bothofwhicharementaldisorders—
oftenco-occurwithothermentalillnesses,patientspresentingwithone
conditionshouldbeassessedfortheother(s).Andwhentheseproblemsco-
occur,treatmentshouldaddressboth(orall),includingtheuseof
medicationsasappropriate.
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10. Medicallyassisteddetoxificationisonlythefirststageofaddiction
treatmentandbyitselfdoeslittletochangelong-termdrugabuse.
Althoughmedicallyassisteddetoxificationcansafelymanagetheacute
physicalsymptomsofwithdrawalandcan,forsome,pavethewayfor
effectivelong-termaddictiontreatment,detoxificationaloneisrarely
sufficienttohelpaddictedindividualsachievelong-termabstinence.Thus,
patientsshouldbeencouragedtocontinuedrugtreatmentfollowing
detoxification.Motivationalenhancementandincentivestrategies,begunat
initialpatientintake,canimprovetreatmentengagement.
11. Treatmentdoesnotneedtobevoluntarytobeeffective.Sanctionsor
enticementsfromfamily,employmentsettings,and/orthecriminaljustice
systemcansignificantlyincreasetreatmententry,retentionrates,andthe
ultimatesuccessofdrugtreatmentinterventions.
12. Druguseduringtreatmentmustbemonitoredcontinuously,aslapses
duringtreatmentdooccur.Knowingtheirdruguseisbeingmonitoredcan
beapowerfulincentiveforpatientsandcanhelpthemwithstandurgesto
usedrugs.Monitoringalsoprovidesanearlyindicationofareturntodrug
use,signalingapossibleneedtoadjustanindividual’streatmentplanto
bettermeethisorherneeds.
13. TreatmentprogramsshouldtestpatientsforthepresenceofHIV/AIDS,
hepatitisBandC,tuberculosis,andotherinfectiousdiseasesaswellas
providetargetedrisk-reductioncounseling,linkingpatientstotreatment
ifnecessary.Typically,drugabusetreatmentaddressessomeofthedrug-
relatedbehaviorsthatputpeopleatriskofinfectiousdiseases.Targeted
counselingfocusedonreducinginfectiousdiseaseriskcanhelppatients
furtherreduceoravoidsubstance-relatedandotherhigh-riskbehaviors.
Counselingcanalsohelpthosewhoarealreadyinfectedtomanagetheir
illness.Moreover,engaginginsubstanceabusetreatmentcanfacilitate
adherencetoothermedicaltreatments.Substanceabusetreatmentfacilities
shouldprovideonsite,rapidHIVtestingratherthanreferralstooffsitetesting
—researchshowsthatdoingsoincreasesthelikelihoodthatpatientswillbe
testedandreceivetheirtestresults.Treatmentprovidersshouldalsoinform
patientsthathighlyactiveantiretroviraltherapy(HAART)hasproven
effectiveincombatingHIV,includingamongdrug-abusingpopulations,and
helplinkthemtoHIVtreatmentiftheytestpositive.
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FrequentlyAskedQuestions
Treatmentvariesdependingonthetypeofdrugandthecharacteristicsof
thepatient.Thebestprogramsprovideacombinationoftherapiesand
otherservices.
Whydodrug-addictedpersonskeep
usingdrugs?
Nearlyalladdictedindividualsbelieveattheoutsetthattheycanstopusing
drugsontheirown,andmosttrytostopwithouttreatment.Althoughsome
peoplearesuccessful,manyattemptsresultinfailuretoachievelong-term
abstinence.Researchhasshownthatlong-termdrugabuseresultsinchanges
inthebrainthatpersistlongafterapersonstopsusingdrugs.Thesedrug-
inducedchangesinbrainfunctioncanhavemanybehavioralconsequences,
includinganinabilitytoexertcontrolovertheimpulsetousedrugsdespite
adverseconsequences—thedefiningcharacteristicofaddiction.
Long-termdruguseresultsinsignificantchangesinbrainfunctionthatcan
persistlongaftertheindividualstopsusingdrugs.
Understandingthataddictionhassuchafundamentalbiologicalcomponent
mayhelpexplainthedifficultyofachievingandmaintainingabstinencewithout
treatment.Psychologicalstressfromwork,familyproblems,psychiatricillness,
painassociatedwithmedicalproblems,socialcues(suchasmeeting
individualsfromone’sdrug-usingpast),orenvironmentalcues(suchas
encounteringstreets,objects,orevensmellsassociatedwithdrugabuse)can
triggerintensecravingswithouttheindividualevenbeingconsciouslyawareof
thetriggeringevent.Anyoneofthesefactorscanhinderattainmentofsustained
abstinenceandmakerelapsemorelikely.Nevertheless,researchindicatesthat
activeparticipationintreatmentisanessentialcomponentforgoodoutcomes
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andcanbenefiteventhemostseverelyaddictedindividuals.
Whatisdrugaddictiontreatment?
Drugtreatmentisintendedtohelpaddictedindividualsstopcompulsivedrug
seekinganduse.Treatmentcanoccurinavarietyofsettings,takemany
differentforms,andlastfordifferentlengthsoftime.Becausedrugaddictionis
typicallyachronicdisordercharacterizedbyoccasionalrelapses,ashort-term,
one-timetreatmentisusuallynotsufficient.Formany,treatmentisalong-term
processthatinvolvesmultipleinterventionsandregularmonitoring.
Thereareavarietyofevidence-basedapproachestotreatingaddiction.Drug
treatmentcanincludebehavioraltherapy(suchascognitive-behavioraltherapy
orcontingencymanagement),medications,ortheircombination.Thespecific
typeoftreatmentorcombinationoftreatmentswillvarydependingonthe
patient’sindividualneedsand,often,onthetypesofdrugstheyuse.
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Drugaddictiontreatmentcanincludemedications,behavioraltherapies,or
theircombination.
Treatmentmedications,suchasmethadone,buprenorphine,andnaltrexone
(includinganewlong-actingformulation),areavailableforindividualsaddicted
toopioids,whilenicotinepreparations(patches,gum,lozenges,andnasal
spray)andthemedicationsvareniclineandbupropionareavailablefor
individualsaddictedtotobacco.Disulfiram,acamprosate,andnaltrexone
aremedicationsavailablefortreatingalcoholdependence, whichcommonly
co-occurswithotherdrugaddictions,includingaddictiontoprescription
medications.
Treatmentsforprescriptiondrugabusetendtobesimilartothoseforillicitdrugs
thataffectthesamebrainsystems.Forexample,buprenorphine,usedtotreat
heroinaddiction,canalsobeusedtotreataddictiontoopioidpainmedications.
Addictiontoprescriptionstimulants,whichaffectthesamebrainsystemsas
illicitstimulantslikecocaine,canbetreatedwithbehavioraltherapies,asthere
arenotyetmedicationsfortreatingaddictiontothesetypesofdrugs.
Behavioraltherapiescanhelpmotivatepeopletoparticipateindrugtreatment,
offerstrategiesforcopingwithdrugcravings,teachwaystoavoiddrugsand
preventrelapse,andhelpindividualsdealwithrelapseifitoccurs.Behavioral
therapiescanalsohelppeopleimprovecommunication,relationship,and
parentingskills,aswellasfamilydynamics.
Manytreatmentprogramsemploybothindividualandgrouptherapies.Group
therapycanprovidesocialreinforcementandhelpenforcebehavioral
contingenciesthatpromoteabstinenceandanon-drug-usinglifestyle.Someof
themoreestablishedbehavioraltreatments,suchascontingencymanagement
andcognitive-behavioraltherapy,arealsobeingadaptedforgroupsettingsto
improveefficiencyandcost-effectiveness.However,particularlyinadolescents,
therecanalsobeadangerofunintendedharmful(oriatrogenic)effectsof
grouptreatment—sometimesgroupmembers(especiallygroupsofhighly
delinquentyouth)canreinforcedruguseandtherebyderailthepurposeofthe
therapy.Thus,trainedcounselorsshouldbeawareofandmonitorforsuch
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effects.
Becausetheyworkondifferentaspectsofaddiction,combinationsofbehavioral
therapiesandmedications(whenavailable)generallyappeartobemore
effectivethaneitherapproachusedalone.
Finally,peoplewhoareaddictedtodrugsoftensufferfromotherhealth(e.g.,
depression,HIV),occupational,legal,familial,andsocialproblemsthatshould
beaddressedconcurrently.Thebestprogramsprovideacombinationof
therapiesandotherservicestomeetanindividualpatient’sneeds.
Psychoactivemedications,suchasantidepressants,anti-anxietyagents,mood
stabilizers,andantipsychoticmedications,maybecriticalfortreatmentsuccess
whenpatientshaveco-occurringmentaldisorderssuchasdepression,anxiety
disorders(includingpost-traumaticstressdisorder),bipolardisorder,or
schizophrenia.Inaddition,mostpeoplewithsevereaddictionabusemultiple
drugsandrequiretreatmentforallsubstancesabused.
Treatmentfordrugabuseandaddictionisdeliveredinmanydifferent
settingsusingavarietyofbehavioralandpharmacologicalapproaches.
Anotherdrug,topiramate,hasalsoshownpromiseinstudiesandissometimes
prescribed(off-label)forthispurposealthoughithasnotreceivedFDAapproval
asatreatmentforalcoholdependence.
Howeffectiveisdrugaddiction
treatment?
Inadditiontostoppingdrugabuse,thegoaloftreatmentistoreturnpeopleto
productivefunctioninginthefamily,workplace,andcommunity.Accordingto
researchthattracksindividualsintreatmentoverextendedperiods,most
peoplewhogetintoandremainintreatmentstopusingdrugs,decreasetheir
criminalactivity,andimprovetheiroccupational,social,andpsychological
functioning.Forexample,methadonetreatmenthasbeenshowntoincrease
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participationinbehavioraltherapyanddecreasebothdruguseandcriminal
behavior.However,individualtreatmentoutcomesdependontheextentand
natureofthepatient’sproblems,theappropriatenessoftreatmentandrelated
servicesusedtoaddressthoseproblems,andthequalityofinteractionbetween
thepatientandhisorhertreatmentproviders.
Relapseratesforaddictionresemblethoseofotherchronicdiseasessuch
asdiabetes,hypertension,andasthma.
Likeotherchronicdiseases,addictioncanbemanagedsuccessfully.Treatment
enablespeopletocounteractaddiction’spowerfuldisruptiveeffectsonthebrain
andbehaviorandtoregaincontroloftheirlives.Thechronicnatureofthe
diseasemeansthatrelapsingtodrugabuseisnotonlypossiblebutalsolikely,
withsymptomrecurrenceratessimilartothoseforotherwell-characterized
chronicmedicalillnesses—suchasdiabetes,hypertension,andasthma(see
figure,"ComparisonofRelapseRatesBetweenDrugAddictionandOther
ChronicIllnesses”)—thatalsohavebothphysiologicalandbehavioral
components.
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Unfortunately,whenrelapseoccursmanydeemtreatmentafailure.Thisisnot
thecase:Successfultreatmentforaddictiontypicallyrequirescontinual
evaluationandmodificationasappropriate,similartotheapproachtakenfor
otherchronicdiseases.Forexample,whenapatientisreceivingactive
treatmentforhypertensionandsymptomsdecrease,treatmentisdeemed
successful,eventhoughsymptomsmayrecurwhentreatmentisdiscontinued.
Fortheaddictedindividual,lapsestodrugabusedonotindicatefailure—rather,
theysignifythattreatmentneedstobereinstatedoradjusted,orthatalternate
treatmentisneeded(seefigure,"WhyisAddictionTreatmentEvaluated
Differently?").
Isdrugaddictiontreatmentworthits
cost?
SubstanceabusecostsourNationover$600billionannuallyandtreatmentcan
helpreducethesecosts.Drugaddictiontreatmenthasbeenshowntoreduce
associatedhealthandsocialcostsbyfarmorethanthecostofthetreatment
itself.Treatmentisalsomuchlessexpensivethanitsalternatives,suchas
incarceratingaddictedpersons.Forexample,theaveragecostfor1fullyearof
methadonemaintenancetreatmentisapproximately$4,700perpatient,
whereas1fullyearofimprisonmentcostsapproximately$24,000perperson.
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Drugaddictiontreatmentreducesdruguseanditsassociatedhealthand
socialcosts.
Accordingtoseveralconservativeestimates,everydollarinvestedinaddiction
treatmentprogramsyieldsareturnofbetween$4and$7inreduceddrug-
relatedcrime,criminaljusticecosts,andtheft.Whensavingsrelatedto
healthcareareincluded,totalsavingscanexceedcostsbyaratioof12to1.
Majorsavingstotheindividualandtosocietyalsostemfromfewer
interpersonalconflicts;greaterworkplaceproductivity;andfewerdrug-related
accidents,includingoverdosesanddeaths.
Howlongdoesdrugaddictiontreatment
usuallylast?
Individualsprogressthroughdrugaddictiontreatmentatvariousrates,sothere
isnopredeterminedlengthoftreatment.However,researchhasshown
unequivocallythatgoodoutcomesarecontingentonadequatetreatment
length.Generally,forresidentialoroutpatienttreatment,participationforless
than90daysisoflimitedeffectiveness,andtreatmentlastingsignificantly
longerisrecommendedformaintainingpositiveoutcomes.Formethadone
maintenance,12monthsisconsideredtheminimum,andsomeopioid-addicted
individualscontinuetobenefitfrommethadonemaintenanceformanyyears.
Goodoutcomesarecontingentonadequatetreatmentlength.
Treatmentdropoutisoneofthemajorproblemsencounteredbytreatment
programs;therefore,motivationaltechniquesthatcankeeppatientsengaged
willalsoimproveoutcomes.Byviewingaddictionasachronicdiseaseand
offeringcontinuingcareandmonitoring,programscansucceed,butthiswill
oftenrequiremultipleepisodesoftreatmentandreadilyreadmittingpatientsthat
haverelapsed.
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Whathelpspeoplestayintreatment?
Becausesuccessfuloutcomesoftendependonaperson’sstayingintreatment
longenoughtoreapitsfullbenefits,strategiesforkeepingpeopleintreatment
arecritical.Whetherapatientstaysintreatmentdependsonfactorsassociated
withboththeindividualandtheprogram.Individualfactorsrelatedto
engagementandretentiontypicallyincludemotivationtochangedrug-using
behavior;degreeofsupportfromfamilyandfriends;and,frequently,pressure
fromthecriminaljusticesystem,childprotectionservices,employers,orfamily.
Withinatreatmentprogram,successfulclinicianscanestablishapositive,
therapeuticrelationshipwiththeirpatients.Theclinicianshouldensurethata
treatmentplanisdevelopedcooperativelywiththepersonseekingtreatment,
thattheplanisfollowed,andthattreatmentexpectationsareclearlyunderstood.
Medical,psychiatric,andsocialservicesshouldalsobeavailable.
Whetherapatientstaysintreatmentdependsonfactorsassociatedwith
boththeindividualandtheprogram.
Becausesomeproblems(suchasseriousmedicalormentalillnessorcriminal
involvement)increasethelikelihoodofpatientsdroppingoutoftreatment,
intensiveinterventionsmayberequiredtoretainthem.Afteracourseof
intensivetreatment,theprovidershouldensureatransitiontolessintensive
continuingcaretosupportandmonitorindividualsintheirongoingrecovery.
Howdowegetmoresubstance-abusing
peopleintotreatment?
Ithasbeenknownformanyyearsthatthe"treatmentgap”ismassive—thatis,
amongthosewhoneedtreatmentforasubstanceusedisorder,fewreceiveit.In
2011,21.6millionpersonsaged12orolderneededtreatmentforanillicitdrug
oralcoholuseproblem,butonly2.3millionreceivedtreatmentataspecialty
substanceabusefacility.
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Reducingthisgaprequiresamultiprongedapproach.Strategiesinclude
increasingaccesstoeffectivetreatment,achievinginsuranceparity(nowinits
earliestphaseofimplementation),reducingstigma,andraisingawareness
amongbothpatientsandhealthcareprofessionalsofthevalueofaddiction
treatment.Toassistphysiciansinidentifyingtreatmentneedintheirpatients
andmakingappropriatereferrals,NIDAisencouragingwidespreaduseof
screening,briefintervention,andreferraltotreatment(SBIRT)toolsforusein
primarycaresettingsthroughitsNIDAMEDinitiative.SBIRT,whichevidence
showstobeeffectiveagainsttobaccoandalcoholuse—and,increasingly,
againstabuseofillicitandprescriptiondrugs—hasthepotentialnotonlyto
catchpeoplebeforeseriousdrugproblemsdevelop,butalsotoidentifypeople
inneedoftreatmentandconnectthemwithappropriatetreatmentproviders.
Howcanfamilyandfriendsmakea
differenceinthelifeofsomeoneneeding
treatment?
Familyandfriendscanplaycriticalrolesinmotivatingindividualswithdrug
problemstoenterandstayintreatment.Familytherapycanalsobeimportant,
especiallyforadolescents.Involvementofafamilymemberorsignificantother
inanindividual'streatmentprogramcanstrengthenandextendtreatment
benefits.
Wherecanfamilymembersgofor
informationontreatmentoptions?
Tryingtolocateappropriatetreatmentforalovedone,especiallyfindinga
programtailoredtoanindividual'sparticularneeds,canbeadifficultprocess.
However,therearesomeresourcestohelpwiththisprocess.Forexample,
NIDA’shandbookSeekingDrugAbuseTreatment:KnowWhattoAskoffers
guidanceinfindingtherighttreatmentprogram.Numerousonlineresources
canhelplocatealocalprogramorprovideotherinformation,including:
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TheSubstanceAbuseandMentalHealthServicesAdministration
(SAMHSA)maintainsaWebsite(www.findtreatment.samhsa.gov)that
showsthelocationofresidential,outpatient,andhospitalinpatienttreatment
programsfordrugaddictionandalcoholismthroughoutthecountry.This
informationisalsoaccessiblebycalling1-800-662-HELP.
TheNationalSuicidePreventionLifeline(1-800-273-TALK)offersmorethan
justsuicideprevention—itcanalsohelpwithahostofissues,includingdrug
andalcoholabuse,andcanconnectindividualswithanearbyprofessional.
TheNationalAllianceonMentalIllness(www.nami.org)andMentalHealth
America(www.mentalhealthamerica.net)arealliancesofnonprofit,self-help
supportorganizationsforpatientsandfamiliesdealingwithavarietyof
mentaldisorders.BothhaveStateandlocalaffiliatesthroughoutthecountry
andmaybeespeciallyhelpfulforpatientswithcomorbidconditions.
TheAmericanAcademyofAddictionPsychiatryandtheAmericanAcademy
ofChildandAdolescentPsychiatryeachhavephysicianlocatortools
postedontheirWebsitesataaap.organdaacap.org,respectively.
Faces&VoicesofRecovery(facesandvoicesofrecovery.org),foundedin
2001,isanadvocacyorganizationforindividualsinlong-termrecoverythat
strategizesonwaystoreachouttothemedical,publichealth,criminal
justice,andothercommunitiestopromoteandcelebraterecoveryfrom
addictiontoalcoholandotherdrugs.
ThePartnershipatDrugfree.org(drugfree.org)isanorganizationthat
providesinformationandresourcesonteendruguseandaddictionfor
parents,tohelpthempreventandinterveneintheirchildren’sdruguseor
findtreatmentforachildwhoneedsit.Theyofferatoll-freehelplinefor
parents(1-855-378-4373).
TheAmericanSocietyofAddictionMedicine(asam.org)isasocietyof
physiciansaimedatincreasingaccesstoaddictiontreatment.TheirWeb
sitehasanationwidedirectoryofaddictionmedicineprofessionals.
NIDA’sNationalDrugAbuseTreatmentClinicalTrialsNetwork
(drugabuse.gov/about-nida/organization/cctn/ctn)providesinformationfor
thoseinterestedinparticipatinginaclinicaltrialtestinga
promisingsubstanceabuseintervention;orvisitclinicaltrials.gov.
NIDA’sDrugPubsResearchDisseminationCenter
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(drugpubs.drugabuse.gov)providesbooklets,pamphlets,factsheets,and
otherinformationalresourcesondrugs,drugabuse,andtreatment.
TheNationalInstituteonAlcoholAbuseandAlcoholism(niaaa.nih.gov)
providesinformationonalcohol,alcoholuse,andtreatmentofalcohol-
relatedproblems(niaaa.nih.gov/search/node/treatment).
Howcantheworkplaceplayarolein
substanceabusetreatment?
ManyworkplacessponsorEmployeeAssistancePrograms(EAPs)thatoffer
short-termcounselingand/orassistanceinlinkingemployeeswithdrugor
alcoholproblemstolocaltreatmentresources,includingpeersupport/recovery
groups.Inaddition,therapeuticworkenvironmentsthatprovideemploymentfor
drug-abusingindividualswhocandemonstrateabstinencehavebeenshown
notonlytopromoteacontinueddrug-freelifestylebutalsotoimprovejobskills,
punctuality,andotherbehaviorsnecessaryforactiveemploymentthroughout
life.Urinetestingfacilities,trainedpersonnel,andworkplacemonitorsare
neededtoimplementthistypeoftreatment.
Whatrolecanthecriminaljusticesystem
playinaddressingdrugaddiction?
Itisestimatedthataboutone-halfofStateandFederalprisonersabuseorare
addictedtodrugs,butrelativelyfewreceivetreatmentwhileincarcerated.
Initiatingdrugabusetreatmentinprisonandcontinuingituponreleaseisvital
tobothindividualrecoveryandtopublichealthandsafety.Variousstudieshave
shownthatcombiningprison-andcommunity-basedtreatmentforaddicted
offendersreducestheriskofbothrecidivismtodrug-relatedcriminalbehavior
andrelapsetodruguse—which,inturn,netshugesavingsinsocietalcosts.A
2009studyinBaltimore,Maryland,forexample,foundthatopioid-addicted
prisonerswhostartedmethadonetreatment(alongwithcounseling)inprison
andthencontinueditafterreleasehadbetteroutcomes(reduceddruguseand
criminalactivity)thanthosewhoonlyreceivedcounselingwhileinprisonor
thosewhoonlystartedmethadonetreatmentaftertheirrelease.
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Individualswhoentertreatmentunderlegalpressurehaveoutcomesas
favorableasthosewhoentertreatmentvoluntarily.
Themajorityofoffendersinvolvedwiththecriminaljusticesystemarenotin
prisonbutareundercommunitysupervision.Forthosewithknowndrug
problems,drugaddictiontreatmentmayberecommendedormandatedasa
conditionofprobation.Researchhasdemonstratedthatindividualswhoenter
treatmentunderlegalpressurehaveoutcomesasfavorableasthosewhoenter
treatmentvoluntarily.
Thecriminaljusticesystemrefersdrugoffendersintotreatmentthrougha
varietyofmechanisms,suchasdivertingnonviolentoffenderstotreatment;
stipulatingtreatmentasaconditionofincarceration,probation,orpretrial
release;andconveningspecializedcourts,ordrugcourts,thathandledrug
offensecases.Thesecourtsmandateandarrangefortreatmentasan
alternativetoincarceration,activelymonitorprogressintreatment,andarrange
forotherservicesfordrug-involvedoffenders.
Themosteffectivemodelsintegratecriminaljusticeanddrugtreatmentsystems
andservices.Treatmentandcriminaljusticepersonnelworktogetheron
treatmentplanning—includingimplementationofscreening,placement,testing,
monitoring,andsupervision—aswellasonthesystematicuseofsanctionsand
rewards.Treatmentforincarcerateddrugabusersshouldincludecontinuing
care,monitoring,andsupervisionafterincarcerationandduringparole.
Methodstoachievebettercoordinationbetweenparole/probationofficersand
healthprovidersarebeingstudiedtoimproveoffenderoutcomes.(Formore
information,pleaseseeNIDA’sPrinciplesofDrugAbuseTreatmentforCriminal
JusticePopulations:AResearch-BasedGuide[revised2012].)
Whataretheuniqueneedsofwomenwith
substanceusedisorders?
Gender-relateddrugabusetreatmentshouldattendnotonlytobiological
20
differencesbutalsotosocialandenvironmentalfactors,allofwhichcan
influencethemotivationsfordruguse,thereasonsforseekingtreatment,the
typesofenvironmentswheretreatmentisobtained,thetreatmentsthataremost
effective,andtheconsequencesofnotreceivingtreatment.Manylife
circumstancespredominateinwomenasagroup,whichmayrequirea
specializedtreatmentapproach.Forexample,researchhasshownthatphysical
andsexualtraumafollowedbypost-traumaticstressdisorder(PTSD)ismore
commonindrug-abusingwomenthaninmenseekingtreatment.Otherfactors
uniquetowomenthatcaninfluencethetreatmentprocessincludeissues
aroundhowtheycomeintotreatment(aswomenaremorelikelythanmento
seektheassistanceofageneralormentalhealthpractitioner),financial
independence,andpregnancyandchildcare.
Whataretheuniqueneedsofpregnant
womenwithsubstanceusedisorders?
Usingdrugs,alcohol,ortobaccoduringpregnancyexposesnotjustthewoman
butalsoherdevelopingfetustothesubstanceandcanhavepotentially
deleteriousandevenlong-termeffectsonexposedchildren.Smokingduring
pregnancycanincreaseriskofstillbirth,infantmortality,suddeninfantdeath
syndrome,pretermbirth,respiratoryproblems,slowedfetalgrowth,andlow
birthweight.Drinkingduringpregnancycanleadtothechilddevelopingfetal
alcoholspectrumdisorders,characterizedbylowbirthweightandenduring
cognitiveandbehavioralproblems.
Prenataluseofsomedrugs,includingopioids,maycauseawithdrawal
syndromeinnewbornscalledneonatalabstinencesyndrome(NAS).Babies
withNASareatgreaterriskofseizures,respiratoryproblems,feeding
difficulties,lowbirthweight,andevendeath.
Researchhasestablishedthevalueofevidence-basedtreatmentsforpregnant
women(andtheirbabies),includingmedications.Forexample,althoughno
medicationshavebeenFDA-approvedtotreatopioiddependenceinpregnant
women,methadonemaintenancecombinedwithprenatalcareanda
comprehensivedrugtreatmentprogramcanimprovemanyofthedetrimental
21
outcomesassociatedwithuntreatedheroinabuse.However,newborns
exposedtomethadoneduringpregnancystillrequiretreatmentforwithdrawal
symptoms.Recently,anothermedicationoptionforopioiddependence,
buprenorphine,hasbeenshowntoproducefewerNASsymptomsinbabies
thanmethadone,resultinginshorterinfanthospitalstays.Ingeneral,itis
importanttocloselymonitorwomenwhoaretryingtoquitdruguseduring
pregnancyandtoprovidetreatmentasneeded.
Whataretheuniqueneedsofadolescents
withsubstanceusedisorders?
Adolescentdrugabusershaveuniqueneedsstemmingfromtheirimmature
neurocognitiveandpsychosocialstageofdevelopment.Researchhas
demonstratedthatthebrainundergoesaprolongedprocessofdevelopment
andrefinementfrombirththroughearlyadulthood.Overthecourseofthis
developmentalperiod,ayoungperson’sactionsgofrombeingmoreimpulsive
tobeingmorereasonedandreflective.Infact,thebrainareasmostclosely
associatedwithaspectsofbehaviorsuchasdecision-making,judgment,
planning,andself-controlundergoaperiodofrapiddevelopmentduring
adolescenceandyoungadulthood.
Adolescentdrugabuseisalsooftenassociatedwithotherco-occurringmental
healthproblems.Theseincludeattention-deficithyperactivitydisorder(ADHD),
oppositionaldefiantdisorder,andconductproblems,aswellasdepressiveand
anxietydisorders.
Adolescentsarealsoespeciallysensitivetosocialcues,withpeergroupsand
familiesbeinghighlyinfluentialduringthistime.Therefore,treatmentsthat
facilitatepositiveparentalinvolvement,integrateothersystemsinwhichthe
adolescentparticipates(suchasschoolandathletics),andrecognizethe
importanceofprosocialpeerrelationshipsareamongthemosteffective.Access
tocomprehensiveassessment,treatment,casemanagement,andfamily-
supportservicesthataredevelopmentally,culturally,andgender-appropriateis
alsointegralwhenaddressingadolescentaddiction.
22
Medicationsforsubstanceabuseamongadolescentsmayincertaincasesbe
helpful.Currently,theonlyaddictionmedicationsapprovedbyFDAforpeople
under18areover-the-countertransdermalnicotineskinpatches,chewinggum,
andlozenges(physicianadviceshouldbesoughtfirst).Buprenorphine,a
medicationfortreatingopioidaddictionthatmustbeprescribedbyspecially
trainedphysicians,hasnotbeenapprovedforadolescents,butrecentresearch
suggestsitcouldbeeffectiveforthoseasyoungas16.Studiesareunderway
todeterminethesafetyandefficacyofthisandothermedicationsforopioid-,
nicotine-,andalcohol-dependentadolescentsandforadolescentswithco-
occurringdisorders.
Aretherespecificdrugaddiction
treatmentsforolderadults?
Withtheagingofthebabyboomergeneration,thecompositionofthegeneral
populationischangingdramaticallywithrespecttothenumberofolderadults.
Suchachange,coupledwithagreaterhistoryoflifetimedruguse(than
previousoldergenerations),differentculturalnormsandgeneralattitudesabout
druguse,andincreasesintheavailabilityofpsychotherapeuticmedications,is
alreadyleadingtogreaterdrugusebyolderadultsandmayincrease
substanceuseproblemsinthispopulation.Whilesubstanceabuseinolder
adultsoftengoesunrecognizedandthereforeuntreated,researchindicatesthat
currentlyavailableaddictiontreatmentprogramscanbeaseffectiveforthemas
foryoungeradults.
Canapersonbecomeaddictedto
medicationsprescribedbyadoctor?
Yes.Peoplewhoabuseprescriptiondrugs—thatis,takingtheminamanneror
adoseotherthanprescribed,ortakingmedicationsprescribedforanother
person—riskaddictionandotherserioushealthconsequences.Suchdrugs
includeopioidpainrelievers,stimulantsusedtotreatADHD,and
benzodiazepinestotreatanxietyorsleepdisorders.Indeed,in2010,an
estimated2.4millionpeople12oroldermetcriteriaforabuseofordependence
23
onprescriptiondrugs,thesecondmostcommonillicitdruguseaftermarijuana.
Tominimizetheserisks,aphysician(orotherprescribinghealthprovider)
shouldscreenpatientsforpriororcurrentsubstanceabuseproblemsand
assesstheirfamilyhistoryofsubstanceabuseoraddictionbeforeprescribinga
psychoactivemedicationandmonitorpatientswhoareprescribedsuchdrugs.
Physiciansalsoneedtoeducatepatientsaboutthepotentialriskssothatthey
willfollowtheirphysician’sinstructionsfaithfully,safeguardtheirmedications,
anddisposeofthemappropriately.
Isthereadifferencebetweenphysical
dependenceandaddiction?
Yes.Addiction—orcompulsivedrugusedespiteharmfulconsequences—is
characterizedbyaninabilitytostopusingadrug;failuretomeetwork,social,or
familyobligations;and,sometimes(dependingonthedrug),toleranceand
withdrawal.Thelatterreflectphysicaldependenceinwhichthebodyadaptsto
thedrug,requiringmoreofittoachieveacertaineffect(tolerance)andeliciting
drug-specificphysicalormentalsymptomsifdruguseisabruptlyceased
(withdrawal).Physicaldependencecanhappenwiththechronicuseofmany
drugs—includingmanyprescriptiondrugs,eveniftakenasinstructed.Thus,
physicaldependenceinandofitselfdoesnotconstituteaddiction,butitoften
accompaniesaddiction.Thisdistinctioncanbedifficulttodiscern,particularly
withprescribedpainmedications,forwhichtheneedforincreasingdosages
canrepresenttoleranceoraworseningunderlyingproblem,asopposedtothe
beginningofabuseoraddiction.
Howdoothermentaldisorderscoexisting
withdrugaddictionaffectdrugaddiction
treatment?
Drugaddictionisadiseaseofthebrainthatfrequentlyoccurswithothermental
disorders.Infact,asmanyas6in10peoplewithanillicitsubstanceuse
disorderalsosufferfromanothermentalillness;andratesaresimilarforusers
oflicitdrugs—i.e.,tobaccoandalcohol.Fortheseindividuals,onecondition
24
becomesmoredifficulttotreatsuccessfullyasanadditionalconditionis
intertwined.Thus,peopleenteringtreatmenteitherforasubstanceusedisorder
orforanothermentaldisordershouldbeassessedfortheco-occurrenceofthe
othercondition.Researchindicatesthattreatingboth(ormultiple)illnesses
simultaneouslyinanintegratedfashionisgenerallythebesttreatment
approachforthesepatients.
Istheuseofmedicationslikemethadone
andbuprenorphinesimplyreplacingone
addictionwithanother?
No.Buprenorphineandmethadoneareprescribedoradministeredunder
monitored,controlledconditionsandaresafeandeffectivefortreatingopioid
addictionwhenusedasdirected.Theyareadministeredorallyorsublingually
(i.e.,underthetongue)inspecifieddoses,andtheireffectsdifferfromthoseof
heroinandotherabusedopioids.
Heroin,forexample,isofteninjected,snorted,orsmoked,causinganalmost
immediate"rush,"orbriefperiodofintenseeuphoria,thatwearsoffquicklyand
endsina"crash."Theindividualthenexperiencesanintensecravingtousethe
drugagaintostopthecrashandreinstatetheeuphoria.
Thecycleofeuphoria,crash,andcraving—sometimesrepeatedseveraltimesa
day—isahallmarkofaddictionandresultsinseverebehavioraldisruption.
Thesecharacteristicsresultfromheroin’srapidonsetandshortdurationof
actioninthebrain.
Asusedinmaintenancetreatment,methadoneandbuprenorphinearenot
heroin/opioidsubstitutes.
Incontrast,methadoneandbuprenorphinehavegradualonsetsofactionand
producestablelevelsofthedruginthebrain.Asaresult,patientsmaintained
25
onthesemedicationsdonotexperiencearush,whiletheyalsomarkedly
reducetheirdesiretouseopioids.
Ifanindividualtreatedwiththesemedicationstriestotakeanopioidsuchas
heroin,theeuphoriceffectsareusuallydampenedorsuppressed.Patients
undergoingmaintenancetreatmentdonotexperiencethephysiologicalor
behavioralabnormalitiesfromrapidfluctuationsindruglevelsassociatedwith
heroinuse.Maintenancetreatmentssavelives—theyhelptostabilize
individuals,allowingtreatmentoftheirmedical,psychological,andother
problemssotheycancontributeeffectivelyasmembersoffamiliesandof
society.
Wheredo12-steporself-helpprograms
fitintodrugaddictiontreatment?
Self-helpgroupscancomplementandextendtheeffectsofprofessional
treatment.Themostprominentself-helpgroupsarethoseaffiliatedwith
AlcoholicsAnonymous(AA),NarcoticsAnonymous(NA),andCocaine
Anonymous(CA),allofwhicharebasedonthe12-stepmodel.Mostdrug
addictiontreatmentprogramsencouragepatientstoparticipateinself-help
grouptherapyduringandafterformaltreatment.Thesegroupscanbe
particularlyhelpfulduringrecovery,offeringanaddedlayerofcommunity-level
socialsupporttohelppeopleachieveandmaintainabstinenceandother
healthylifestylebehaviorsoverthecourseofalifetime.
Canexerciseplayaroleinthetreatment
process?
Yes.Exerciseisincreasinglybecomingacomponentofmanytreatment
programsandhasproveneffective,whencombinedwithcognitive-behavioral
therapy,athelpingpeoplequitsmoking.Exercisemayexertbeneficialeffects
byaddressingpsychosocialandphysiologicalneedsthatnicotinereplacement
alonedoesnot,byreducingnegativefeelingsandstress,andbyhelping
preventweightgainfollowingcessation.Researchtodetermineifandhow
26
exerciseprogramscanplayasimilarroleinthetreatmentofotherformsofdrug
abuseisunderway.
Howdoesdrugaddictiontreatmenthelp
reducethespreadofHIV/AIDS,Hepatitis
C(HCV),andotherinfectiousdiseases?
Drug-abusingindividuals,includinginjectingandnon-injectingdrugusers,are
atincreasedriskofhumanimmunodeficiencyvirus(HIV),hepatitisCvirus
(HCV),andotherinfectiousdiseases.Thesediseasesaretransmittedby
sharingcontaminateddruginjectionequipmentandbyengaginginriskysexual
behaviorsometimesassociatedwithdruguse.Effectivedrugabusetreatmentis
HIV/HCVpreventionbecauseitreducesactivitiesthatcanspreaddisease,such
assharinginjectionequipmentandengaginginunprotectedsexualactivity.
CounselingthattargetsarangeofHIV/HCVriskbehaviorsprovidesanadded
levelofdiseaseprevention.
DrugabusetreatmentisHIVandHCVprevention.
Injectiondruguserswhodonotentertreatmentareuptosixtimesmorelikelyto
becomeinfectedwithHIVthanthosewhoenterandremainintreatment.
ParticipationintreatmentalsopresentsopportunitiesforHIVscreeningand
referraltoearlyHIVtreatment.Infact,recentresearchfromNIDA’sNational
DrugAbuseTreatmentClinicalTrialsNetworkshowedthatprovidingrapid
onsiteHIVtestinginsubstanceabusetreatmentfacilitiesincreasedpatients’
likelihoodofbeingtestedandofreceivingtheirtestresults.HIVcounselingand
testingarekeyaspectsofsuperiordrugabusetreatmentprogramsandshould
beofferedtoallindividualsenteringtreatment.Greateravailabilityof
inexpensiveandunobtrusiverapidHIVtestsshouldincreaseaccesstothese
importantaspectsofHIVpreventionandtreatment.
27
DrugAddictionTreatmentinthe
UnitedStates
Treatmentfordrugabuseandaddictionisdeliveredinmanydifferent
settings,usingavarietyofbehavioralandpharmacologicalapproaches.
Drugaddictionisacomplexdisorderthatcaninvolvevirtuallyeveryaspectof
anindividual'sfunctioning—inthefamily,atworkandschool,andinthe
community.
Becauseofaddiction'scomplexityandpervasiveconsequences,drugaddiction
treatmenttypicallymustinvolvemanycomponents.Someofthosecomponents
focusdirectlyontheindividual'sdruguse;others,likeemploymenttraining,
focusonrestoringtheaddictedindividualtoproductivemembershipinthe
familyandsociety(Seediagram"ComponentsofComprehensiveDrugAbuse
Treatment"),enablinghimorhertoexperiencetherewardsassociatedwith
abstinence.
Treatmentfordrugabuseandaddictionisdeliveredinmanydifferentsettings
usingavarietyofbehavioralandpharmacologicalapproaches.IntheUnited
States,morethan14,500specializeddrugtreatmentfacilitiesprovide
counseling,behavioraltherapy,medication,casemanagement,andothertypes
ofservicestopersonswithsubstanceusedisorders.
Alongwithspecializeddrugtreatmentfacilities,drugabuseandaddictionare
treatedinphysicians'officesandmentalhealthclinicsbyavarietyofproviders,
includingcounselors,physicians,psychiatrists,psychologists,nurses,and
socialworkers.Treatmentisdeliveredinoutpatient,inpatient,andresidential
settings.Althoughspecifictreatmentapproachesoftenareassociatedwith
particulartreatmentsettings,avarietyoftherapeuticinterventionsorservices
canbeincludedinanygivensetting.
28
Becausedrugabuseandaddictionaremajorpublichealthproblems,alarge
portionofdrugtreatmentisfundedbylocal,State,andFederalgovernments.
Privateandemployer-subsidizedhealthplansalsomayprovidecoveragefor
treatmentofaddictionanditsmedicalconsequences.Unfortunately,managed
carehasresultedinshorteraveragestays,whileahistoricallackofor
insufficientcoverageforsubstanceabusetreatmenthascurtailedthenumberof
operationalprograms.Therecentpassageofparityforinsurancecoverageof
mentalhealthandsubstanceabuseproblemswillhopefullyimprovethisstate
ofaffairs.HealthCareReform(i.e.,thePatientProtectionandAffordableCare
Actof2010,"ACA")alsostandstoincreasethedemandfordrugabuse
treatmentservicesandpresentsanopportunitytostudyhowinnovationsin
servicedelivery,organization,andfinancingcanimproveaccesstoanduseof
them.
TypesofTreatmentPrograms
Researchstudiesonaddictiontreatmenttypicallyhaveclassifiedprogramsinto
severalgeneraltypesormodalities.Treatmentapproachesandindividual
programscontinuetoevolveanddiversify,andmanyprogramstodaydonotfit
neatlyintotraditionaldrugadictiontreatmentclassifications.
Most,however,startwithdetoxificationandmedicallymanagedwithdrawal,
oftenconsideredthefirststageoftreatment.Detoxification,theprocessby
whichthebodyclearsitselfofdrugs,isdesignedtomanagetheacuteand
potentiallydangerousphysiologicaleffectsofstoppingdruguse.Asstated
previously,detoxificationalonedoesnotaddressthepsychological,social,and
behavioralproblemsassociatedwithaddictionandthereforedoesnottypically
producelastingbehavioralchangesnecessaryforrecovery.Detoxification
shouldthusbefollowedbyaformalassessmentandreferraltodrugaddiction
treatment.
Becauseitisoftenaccompaniedbyunpleasantandpotentiallyfatalsideeffects
stemmingfromwithdrawal,detoxificationisoftenmanagedwithmedications
administeredbyaphysicianinaninpatientoroutpatientsetting;therefore,itis
referredtoas"medicallymanagedwithdrawal.”Medicationsareavailableto
assistinthewithdrawalfromopioids,benzodiazepines,alcohol,nicotine,
29
barbiturates,andothersedatives.
FurtherReading:
Kleber,H.D.Outpatientdetoxificationfromopiates.PrimaryPsychiatry1:42-52,
1996.
Long-TermResidentialTreatment
Long-termresidentialtreatmentprovidescare24hoursaday,generallyinnon-
hospitalsettings.Thebest-knownresidentialtreatmentmodelisthetherapeutic
community(TC),withplannedlengthsofstayofbetween6and12months.TCs
focusonthe"resocialization"oftheindividualandusetheprogram’sentire
community—includingotherresidents,staff,andthesocialcontext—asactive
componentsoftreatment.Addictionisviewedinthecontextofanindividual’s
socialandpsychologicaldeficits,andtreatmentfocusesondeveloping
personalaccountabilityandresponsibilityaswellassociallyproductivelives.
Treatmentishighlystructuredandcanbeconfrontationalattimes,withactivities
designedtohelpresidentsexaminedamagingbeliefs,self-concepts,and
destructivepatternsofbehaviorandadoptnew,moreharmoniousand
constructivewaystointeractwithothers.ManyTCsoffercomprehensive
services,whichcanincludeemploymenttrainingandothersupportservices,
onsite.ResearchshowsthatTCscanbemodifiedtotreatindividualswith
specialneeds,includingadolescents,women,homelessindividuals,people
withseverementaldisorders,andindividualsinthecriminaljusticesystem(see
"TreatingCriminalJustice-InvolvedDrugAbusersandAddictedIndividuals").
FurtherReading:
Lewis,B.F.;McCusker,J.;Hindin,R.;Frost,R.;andGarfield,F.Fourresidential
drugtreatmentprograms:ProjectIMPACT.In:J.A.Inciardi,F.M.Tims,andB.W.
Fletcher(eds.),InnovativeApproachesintheTreatmentofDrugAbuse,
Westport,CT:GreenwoodPress,pp.45-60,1993.
Sacks,S.;Banks,S.;McKendrick,K.;andSacks,J.Y.Modifiedtherapeutic
communityforco-occurringdisorders:Asummaryoffourstudies.Journalof
30
SubstanceAbuseTreatment34(1):112-122,2008.
Sacks,S.;Sacks,J.;DeLeon,G.;Bernhardt,A.;andStaines,G.Modified
therapeuticcommunityformentallyillchemical"abusers":Background;
influences;programdescription;preliminaryfindings.SubstanceUseand
Misuse32(9):1217-1259,1997.
Stevens,S.J.,andGlider,P.J.Therapeuticcommunities:Substanceabuse
treatmentforwomen.In:F.M.Tims,G.DeLeon,andN.Jainchill(eds.),
TherapeuticCommunity:AdvancesinResearchandApplication,National
InstituteonDrugAbuseResearchMonograph144,NIHPub.No.94-3633,U.S.
GovernmentPrintingOffice,pp.162-180,1994.
Sullivan,C.J.;McKendrick,K.;Sacks,S.;andBanks,S.M.Modifiedtherapeutic
communityforoffenderswithMICAdisorders:Substanceuseoutcomes.
AmericanJournalofDrugandAlcoholAbuse33(6):823-832,2007.
Short-TermResidentialTreatment
Short-termresidentialprogramsprovideintensivebutrelativelybrieftreatment
basedonamodified12-stepapproach.Theseprogramswereoriginally
designedtotreatalcoholproblems,butduringthecocaineepidemicofthemid-
1980s,manybegantotreatothertypesofsubstanceusedisorders.Theoriginal
residentialtreatmentmodelconsistedofa3-to6-weekhospital-basedinpatient
treatmentphasefollowedbyextendedoutpatienttherapyandparticipationina
self-helpgroup,suchasAA.Followingstaysinresidentialtreatmentprograms,
itisimportantforindividualstoremainengagedinoutpatienttreatment
programsand/oraftercareprograms.Theseprogramshelptoreducetheriskof
relapseonceapatientleavestheresidentialsetting.
FurtherReading:
Hubbard,R.L.;Craddock,S.G.;Flynn,P.M.;Anderson,J.;andEtheridge,R.M.
Overviewof1-yearfollow-upoutcomesintheDrugAbuseTreatmentOutcome
Study(DATOS).PsychologyofAddictiveBehaviors11(4):291-298,1998.
31
Miller,M.M.Traditionalapproachestothetreatmentofaddiction.In:A.W.
GrahamandT.K.Schultz(eds.),PrinciplesofAddictionMedicine(2nded.).
Washington,D.C.:AmericanSocietyofAddictionMedicine,1998.
OutpatientTreatmentPrograms
Outpatienttreatmentvariesinthetypesandintensityofservicesoffered.Such
treatmentcostslessthanresidentialorinpatienttreatmentandoftenismore
suitableforpeoplewithjobsorextensivesocialsupports.Itshouldbenoted,
however,thatlow-intensityprogramsmayofferlittlemorethandrugeducation.
Otheroutpatientmodels,suchasintensivedaytreatment,canbecomparableto
residentialprogramsinservicesandeffectiveness,dependingontheindividual
patient’scharacteristicsandneeds.Inmanyoutpatientprograms,group
counselingcanbeamajorcomponent.Someoutpatientprogramsarealso
designedtotreatpatientswithmedicalorothermentalhealthproblemsin
additiontotheirdrugdisorders.
FurtherReading:
Hubbard,R.L.;Craddock,S.G.;Flynn,P.M.;Anderson,J.;andEtheridge,R.M.
Overviewof1-yearfollow-upoutcomesintheDrugAbuseTreatmentOutcome
Study(DATOS).PsychologyofAddictiveBehaviors11(4):291-298,1998.
InstituteofMedicine.TreatingDrugProblems.Washington,D.C.:National
AcademyPress,1990.
McLellan,A.T.;Grisson,G.;Durell,J.;Alterman,A.I.;Brill,P.;andO'Brien,C.P.
Substanceabusetreatmentintheprivatesetting:Aresomeprogramsmore
effectivethanothers?JournalofSubstanceAbuseTreatment10:243-254,
1993.
Simpson,D.D.,andBrown,B.S.Treatmentretentionandfollow-upoutcomesin
theDrugAbuseTreatmentOutcomeStudy(DATOS).PsychologyofAddictive
Behaviors11(4):294-307,1998.
32
IndividualizedDrugCounseling
Individualizeddrugcounselingnotonlyfocusesonreducingorstoppingillicit
drugoralcoholuse;italsoaddressesrelatedareasofimpairedfunctioning—
suchasemploymentstatus,illegalactivity,andfamily/socialrelations—aswell
asthecontentandstructureofthepatient’srecoveryprogram.Throughits
emphasisonshort-termbehavioralgoals,individualizedcounselinghelpsthe
patientdevelopcopingstrategiesandtoolstoabstainfromdruguseand
maintainabstinence.Theaddictioncounselorencourages12-stepparticipation
(atleastoneortwotimesperweek)andmakesreferralsforneeded
supplementalmedical,psychiatric,employment,andotherservices.
GroupCounseling
Manytherapeuticsettingsusegrouptherapytocapitalizeonthesocial
reinforcementofferedbypeerdiscussionandtohelppromotedrug-free
lifestyles.Researchhasshownthatwhengrouptherapyeitherisofferedin
conjunctionwithindividualizeddrugcounselingorisformattedtoreflectthe
principlesofcognitive-behavioraltherapyorcontingencymanagement,positive
outcomesareachieved.Currently,researchersaretestingconditionsinwhich
grouptherapycanbestandardizedandmademorecommunity-friendly.
TreatingCriminalJustice-InvolvedDrugAbusersand
AddictedIndividuals
Often,drugabuserscomeintocontactwiththecriminaljusticesystemearlier
thanotherhealthorsocialsystems,presentingopportunitiesforintervention
andtreatmentpriorto,during,after,orinlieuofincarceration.Researchhas
shownthatcombiningcriminaljusticesanctionswithdrugtreatmentcanbe
effectiveindecreasingdrugabuseandrelatedcrime.Individualsunderlegal
coerciontendtostayintreatmentlongeranddoaswellasorbetterthanthose
notunderlegalpressure.Studiesshowthatforincarceratedindividualswith
drugproblems,startingdrugabusetreatmentinprisonandcontinuingthesame
treatmentuponrelease—inotherwords,aseamlesscontinuumofservices—
resultsinbetteroutcomes:lessdruguseandlesscriminalbehavior.More
informationonhowthecriminaljusticesystemcanaddresstheproblemofdrug
33
addictioncanbefoundinPrinciplesofDrugAbuseTreatmentforCriminal
JusticePopulations:AResearch-BasedGuide(NationalInstituteonDrug
Abuse,revised2012).
TreatingCriminalJustice-InvolvedDrug
AbusersandAddictedIndividuals
Often,drugabuserscomeintocontactwiththecriminaljusticesystemearlier
thanotherhealthorsocialsystems,presentingopportunitiesforintervention
andtreatmentpriorto,during,after,orinlieuofincarceration.Researchhas
shownthatcombiningcriminaljusticesanctionswithdrugtreatmentcanbe
effectiveindecreasingdrugabuseandrelatedcrime.Individualsunderlegal
coerciontendtostayintreatmentlongeranddoaswellasorbetterthanthose
notunderlegalpressure.Studiesshowthatforincarceratedindividualswith
drugproblems,startingdrugabusetreatmentinprisonandcontinuingthesame
treatmentuponrelease—inotherwords,aseamlesscontinuumofservices—
resultsinbetteroutcomes:lessdruguseandlesscriminalbehavior.More
informationonhowthecriminaljusticesystemcanaddresstheproblemofdrug
addictioncanbefoundinPrinciplesofDrugAbuseTreatmentforCriminal
JusticePopulations:AResearch-BasedGuide(NationalInstituteonDrug
Abuse,revised2012).
34
Evidence-BasedApproachestoDrug
AddictionTreatment
Eachapproachtodrugtreatmentisdesignedtoaddresscertainaspectsof
drugaddictionanditsconsequencesfortheindividual,family,andsociety.
Thissectionpresentsexamplesoftreatmentapproachesandcomponentsthat
haveanevidencebasesupportingtheiruse.Eachapproachisdesignedto
addresscertainaspectsofdrugaddictionanditsconsequencesforthe
individual,family,andsociety.Someoftheapproachesareintendedto
supplementorenhanceexistingtreatmentprograms,andothersarefairly
comprehensiveinandofthemselves.
ThefollowingsectionisbrokendownintoPharmacotherapies,Behavioral
Therapies,andBehavioralTherapiesPrimarilyforAdolescents.Theyarefurther
subdividedaccordingtoparticularsubstanceusedisorders.Thislistisnot
exhaustive,andnewtreatmentsarecontinuallyunderdevelopment.
Pharmacotherapies
OpioidAddiction
Methadone
Methadoneisalong-actingsyntheticopioidagonistmedicationthatcanprevent
withdrawalsymptomsandreducecravinginopioid-addictedindividuals.Itcan
alsoblocktheeffectsofillicitopioids.Ithasalonghistoryofuseintreatmentof
opioiddependenceinadultsandistakenorally.Methadonemaintenance
treatmentisavailableinallbutthreeStatesthroughspeciallylicensedopioid
treatmentprogramsormethadonemaintenanceprograms.
35
Combinedwithbehavioraltreatment:Researchhasshownthatmethadone
maintenanceismoreeffectivewhenitincludesindividualand/orgroup
counseling,withevenbetteroutcomeswhenpatientsareprovidedwith,or
referredto,otherneededmedical/psychiatric,psychological,andsocial
services(e.g.,employmentorfamilyservices).
FurtherReading:
Dole,V.P.;Nyswander,M.;andKreek,M.J.Narcoticblockade.Archivesof
InternalMedicine118:304–309,1966.
McLellan,A.T.;Arndt,I.O.;Metzger,D.;Woody,G.E.;andO’Brien,C.P.The
effectsofpsychosocialservicesinsubstanceabusetreatment.TheJournalof
theAmericanMedicalAssociation269(15):1953–1959,1993.
TheRockerfellerUniversity.Thefirstpharmacologicaltreatmentfornarcotic
addiction:Methadonemaintenance.TheRockefellerUniversityHospital
Centennial,2010.Availableatcentennial.rucares.org/index.php?
page=Methadone_Maintenance.
Woody,G.E.;Luborsky,L.;McClellan,A.T.;O’Brien,C.P.;Beck,A.T.;Blaine,J.;
Herman,I.;andHole,A.Psychotherapyforopiateaddicts:Doesithelp?
ArchivesofGeneralPsychiatry40:639–645,1983.
Buprenorphine
Buprenorphineisasyntheticopioidmedicationthatactsasapartialagonistat
opioidreceptors—itdoesnotproducetheeuphoriaandsedationcausedby
heroinorotheropioidsbutisabletoreduceoreliminatewithdrawalsymptoms
associatedwithopioiddependenceandcarriesalowriskofoverdose.
Buprenorphineiscurrentlyavailableintwoformulationsthataretaken
sublingually:(1)apureformofthedrugand(2)amorecommonlyprescribed
formulationcalledSuboxone,whichcombinesbuprenorphinewiththedrug
naloxone,anantagonist(orblocker)atopioidreceptors.Naloxonehasnoeffect
36
whenSuboxoneistakenasprescribed,butifanaddictedindividualattemptsto
injectSuboxone,thenaloxonewillproduceseverewithdrawalsymptoms.Thus,
thisformulationlessensthelikelihoodthatthedrugwillbeabusedordivertedto
others.
Buprenorphinetreatmentfordetoxificationand/ormaintenancecanbeprovided
inoffice-basedsettingsbyqualifiedphysicianswhohavereceivedawaiver
fromtheDrugEnforcementAdministration(DEA),allowingthemtoprescribeit.
Theavailabilityofoffice-basedtreatmentforopioidaddictionisacost-effective
approachthatincreasesthereachoftreatmentandtheoptionsavailableto
patients.
Buprenorphineisalsoavailableasinanimplantandinjection.TheU.S.Food
andDrugAdministration(FDA)approveda6-monthsubdermalbuprenorphine
implantinMay2016andaonce-monthlybuprenorphineinjectioninNovember
2017.
FurtherReading:
Fiellin,D.A.;Pantalon,M.V.;Chawarski,M.C.;Moore,B.A.;Sullivan,L.E.;
O’Connor,P.G.;andSchottenfeld,R.S.Counselingplus
buprenorphine/naloxonemaintenancetherapyforopioiddependence.The
NewEnglandJournalofMedicine355(4):365–374,2006.
FudalaP.J.;Bridge,T.P.;Herbert,S.;Williford,W.O.;Chiang,C.N.;Jones,K.;
Collins,J.;Raisch,D.;Casadonte,P.;Goldsmith,R.J.;Ling,W.;Malkerneker,U.;
McNicholas,L.;Renner,J.;Stine,S.;andTusel,D.forthe
Buprenorphine/NaloxoneCollaborativeStudyGroup.Office-basedtreatmentof
opiateaddictionwithasublingual-tabletformulationofbuprenorphineand
naloxone.TheNewEnglandJournalofMedicine349(10):949–958,2003.
Kosten,T.R.;andFiellin,D.A.U.S.NationalBuprenorphineImplementation
Program:Buprenorphineforoffice-basedpractice.Consensusconference
overview.TheAmericanJournalonAddictions13(Suppl.1):S1–S7,2004.
37
McCance-Katz,E.F.Office-basedbuprenorphinetreatmentforopioid-
dependentpatients.HarvardReviewofPsychiatry12(6):321–338,2004.
Treatment,notSubstitution
Becausemethadoneandbuprenorphinearethemselvesopioids,some
peopleviewthesetreatmentsforopioiddependenceasjustsubstitutions
ofoneaddictivedrugforanother(seeQuestion19).Buttakingthese
medicationsasprescribedallowspatientstoholdjobs,avoidstreetcrime
andviolence,andreducetheirexposuretoHIVbystoppingordecreasing
injectiondruguseanddrug-relatedhigh-risksexualbehavior.Patients
stabilizedonthesemedicationscanalsoengagemorereadilyin
counselingandotherbehavioralinterventionsessentialtorecovery.
Naltrexone
Naltrexoneisasyntheticopioidantagonist—itblocksopioidsfrombindingto
theirreceptorsandtherebypreventstheireuphoricandothereffects.Ithas
beenusedformanyyearstoreverseopioidoverdoseandisalsoapprovedfor
treatingopioidaddiction.Thetheorybehindthistreatmentisthattherepeated
absenceofthedesiredeffectsandtheperceivedfutilityofabusingopioidswill
graduallydiminishcravingandaddiction.Naltrexoneitselfhasnosubjective
effectsfollowingdetoxification(thatis,apersondoesnotperceiveanyparticular
drugeffect),ithasnopotentialforabuse,anditisnotaddictive.
Naltrexoneasatreatmentforopioidaddictionisusuallyprescribedinoutpatient
medicalsettings,althoughthetreatmentshouldbeginaftermedical
detoxificationinaresidentialsettinginordertopreventwithdrawalsymptoms.
Naltrexonemustbetakenorally—eitherdailyorthreetimesaweek—but
noncompliancewithtreatmentisacommonproblem.Manyexperienced
clinicianshavefoundnaltrexonebestsuitedforhighlymotivated,recently
detoxifiedpatientswhodesiretotalabstinencebecauseofexternal
circumstances—forinstance,professionalsorparolees.Recently,along-acting
38
injectableversionofnaltrexone,calledVivitrol,wasapprovedtotreatopioid
addiction.Becauseitonlyneedstobedeliveredonceamonth,thisversionof
thedrugcanfacilitatecomplianceandoffersanalternativeforthosewhodonot
wishtobeplacedonagonist/partialagonistmedications.
FurtherReading:
Cornish,J.W.;Metzger,D.;Woody,G.E.;Wilson,D.;McClellan,A.T.;and
Vandergrift,B.Naltrexonepharmacotherapyforopioiddependentfederal
probationers.JournalofSubstanceAbuseTreatment14(6):529–534,1997.
Gastfriend,D.R.Intramuscularextended-releasenaltrexone:currentevidence.
AnnalsoftheNewYorkAcademyofSciences1216:144–166,2011.
Krupitsky,E.;Illerperuma,A.;Gastfriend,D.R.;andSilverman,B.L.Efficacyand
safetyofextended-releaseinjectablenaltrexone(XR-NTX)forthetreatmentof
opioiddependence.Paperpresentedatthe2010annualmeetingofthe
AmericanPsychiatricAssociation,NewOrleans,LA.
ComparingBuprenorphineandNaltrexone
ANIDAstudycomparingtheeffectivenessofabuprenorphine/naloxone
combinationandanextendedreleasenaltrexoneformulationontreatingopioid
usedisorderhasfoundthatbothmedicationsaresimilarlyeffectiveintreating
opioidusedisorderoncetreatmentisinitiated.Becausenaltrexonerequiresfull
detoxification,initiatingtreatmentamongactiveopioiduserswasmoredifficult
withthismedication.However,oncedetoxificationwascomplete,thenaltrexone
formulationhadasimilareffectivenessasthebuprenorphine/naloxone
combination.
TobaccoAddiction
NicotineReplacementTherapy(NRT)
Avarietyofformulationsofnicotinereplacementtherapies(NRTs)nowexist,
39
includingthetransdermalnicotinepatch,nicotinespray,nicotinegum,and
nicotinelozenges.Becausenicotineisthemainaddictiveingredientintobacco,
therationaleforNRTisthatstablelowlevelsofnicotinewillpreventwithdrawal
symptoms—whichoftendrivecontinuedtobaccouse—andhelpkeeppeople
motivatedtoquit.Researchshowsthatcombiningthepatchwithanother
replacementtherapyismoreeffectivethanasingletherapyalone.
Bupropion(Zyban )
Bupropionwasoriginallymarketedasanantidepressant(Wellbutrin).It
producesmildstimulanteffectsbyblockingthereuptakeofcertain
neurotransmitters,especiallynorepinephrineanddopamine.Aserendipitous
observationamongdepressedpatientswasthatthemedicationwasalso
effectiveinsuppressingtobaccocraving,helpingthemquitsmokingwithout
alsogainingweight.Althoughbupropion’sexactmechanismsofactionin
facilitatingsmokingcessationareunclear,ithasFDAapprovalasasmoking
cessationtreatment.
Varenicline(Chantix )
VareniclineisthemostrecentlyFDA-approvedmedicationforsmoking
cessation.Itactsonasubsetofnicotinicreceptorsinthebrainthoughttobe
involvedintherewardingeffectsofnicotine.Vareniclineactsasapartial
agonist/antagonistatthesereceptors—thismeansthatitmidlystimulatesthe
nicotinereceptorbutnotsufficientlytotriggerthereleaseofdopamine,whichis
importantfortherewardingeffectsofnicotine.Asanantagonist,vareniclinealso
blockstheabilityofnicotinetoactivatedopamine,interferingwiththereinforcing
effectsofsmoking,therebyreducingcravingsandsupportingabstinencefrom
smoking.
CombinedWithBehavioralTreatment
Eachoftheabovepharmacotherapiesisrecommendedforuseincombination
withbehavioralinterventions,includinggroupandindividualtherapies,aswell
astelephonequitlines.Behavioralapproachescomplementmosttobacco
addictiontreatmentprograms.Theycanamplifytheeffectsofmedicationsby
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teachingpeoplehowtomanagestress,recognizeandavoidhigh-risksituations
forsmokingrelapse,anddevelopalternativecopingstrategies(e.g.,cigarette
refusalskills,assertiveness,andtimemanagementskills)thattheycanpractice
intreatment,social,andworksettings.Combinedtreatmentisurgedbecause
behavioralandpharmacologicaltreatmentsarethoughttooperatebydifferent
yetcomplementarymechanismsthatcanhaveadditiveeffects.
FurtherReading:
Alterman,A.I.;Gariti,P.;andMulvaney,F.Short-andlong-termsmoking
cessationforthreelevelsofintensityofbehavioraltreatment.Psychologyof
AddictiveBehaviors15:261-264,2001.
Hall,S.M.;Humfleet,G.L.;Muñoz,R.F.;V.I;Prochaska,J.J.;andRobbins,J.A.
Usingextendedcognitivebehavioraltreatmentandmedicationtotreat
dependentsmokers.AmericanJournalofPublicHealth101:2349–2356,2011.
Jorenby,D.E.;Hays,J.T.;Rigotti,N.A.;Azoulay,S.;Watsky,E.J.;Williams,K.E.;
Billing,C.B.;Gong,J.;andReeves,K.R.VareniclinePhase3StudyGroup.
Efficacyofvarenicline,an42nicotinicacetylcholinereceptorpartialagonistvs.
placeboorsustained-releasebupropionforsmokingcessation:Arandomized
controlledtrial.TheJournaloftheAmericanMedicalAssociation296(1):56–63,
2006.
King,D.P.;Paciqa,S.;Pickering,E.;Benowitz,N.L.;Bierut,L.J.;Conti,D.V.;
Kaprio,J.;Lerman,C.;andPark,P.W.Smokingcessationpharmacogenetics:
Analysisofvareniclineandbupropioninplacebo-controlledclinicaltrials.
Neuropsychopharmacology37:641–650,2012.
Raupach,T.;andvanSchayck,C.P.Pharmacotherapyforsmokingcessation:
Currentadvancesandresearchtopics.CNSDrugs25:371–382,2011.
Shah,S.D.;Wilken,L.A.;Winkler,S.R.;andLin,S.J.Systematicreviewand
meta-analysisofcombinationtherapyforsmokingcessation.Journalofthe
AmericanPharmaceuticalAssociation48(5):659–665,2008.
41
Smith,S.S;McCarthy,D.E.;JapuntichS.J.;Christiansen,B.;Piper,M.E.;
Jorenby,D.E.;Fraser,D.L.;Fiore,M.C.;Baker,T.B.;andJackson,T.C.
Comparativeeffectivenessof5smokingcessationpharmacotherapiesin
primarycareclinics.ArchivesofInternalMedicine169:2148–2155,2009.
Stitzer,M.Combinedbehavioralandpharmacologicaltreatmentsforsmoking
cessation.Nicotine&TobaccoResearch1:S181–S187,1999.
AlcoholAddiction
Naltrexone
Naltrexoneblocksopioidreceptorsthatareinvolvedintherewardingeffectsof
drinkingandthecravingforalcohol.Ithasbeenshowntoreducerelapseto
problemdrinkinginsomepatients.Anextendedreleaseversion,Vivitrol—
administeredonceamonthbyinjection—isalsoFDA-approvedfortreating
alcoholism,andmayofferbenefitsregardingcompliance.
Acamprosate
Acamprosate(Campral )actsonthegamma-aminobutyricacid(GABA)and
glutamateneurotransmittersystemsandisthoughttoreducesymptomsof
protractedwithdrawal,suchasinsomnia,anxiety,restlessness,anddysphoria.
Acamprosatehasbeenshowntohelpdependentdrinkersmaintainabstinence
forseveralweekstomonths,anditmaybemoreeffectiveinpatientswith
severedependence.
Disulfiram
Disulfiram(Antabuse )interfereswithdegradationofalcohol,resultinginthe
accumulationofacetaldehyde,which,inturn,producesaveryunpleasant
reactionthatincludesflushing,nausea,andplapitationsifapersondrinks
alcohol.Theutilityandeffectivenessofdisulfiramareconsideredlimited
becausecomplianceisgenerallypoor.However,amongpatientswhoare
highlymotivated,disulfiramcanbeeffective,andsomepatientsuseit
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42
episodicallyforhigh-risksituations,suchassocialoccasionswherealcoholis
present.Itcanalsobeadministeredinamonitoredfashion,suchasinaclinic
orbyaspouse,improvingitsefficacy.
Topiramate
Topiramateisthoughttoworkbyincreasinginhibitory(GABA)
neurotransmissionandreducingstimulatory(glutamate)neurotransmission,
althoughitsprecisemechanismofactionisnotknown.Althoughtopiramatehas
notyetreceivedFDAapprovalfortreatingalcoholaddiction,itissometimes
usedoff-labelforthispurpose.Topiramatehasbeenshowninstudiesto
significantlyimprovemultipledrinkingoutcomes,comparedwithaplacebo.
CombinedWithBehavioralTreatment
Whileanumberofbehavioraltreatmentshavebeenshowntobeeffectiveinthe
treatmentofalcoholaddiction,itdoesnotappearthatanadditiveeffectexists
betweenbehavioraltreatmentsandpharmacotherapy.Studieshaveshownthat
justgettinghelpisoneofthemostimportantfactorsintreatingalcohol
addiction;theprecisetypeoftreatmentreceivedisnotasimportant.
FurtherReading:
Anton,R.F.;O’Malley,S.S.;Ciraulo,D.A.;Cisler,R.A.;Couper,D.;Donovan,
D.M.;Gastfriend,D.R.;Hosking,J.D.;Johnson,B.A.;LoCastro,J.S.;
Longabaugh,R.;Mason,B.J.;Mattson,M.E.;Miller,W.R.;Pettinati,H.M.;
Randall,C.L.;Swift,R.;Weiss,R.D.;Williams,L.D.;andZweben,A.,forthe
COMBINEStudyResearchGroup.Combinedpharmacotherapiesand
behavioralinterventionsforalcoholdependence:TheCOMBINEstudy:A
randomizedcontrolledtrial.TheJournaloftheAmericanMedicalAssociation
295(17):2003–2017,2006.
NationalInstituteonAlcoholAbuseandAlcoholism.HelpingPatientsWho
DrinkTooMuch:AClinician’sGuide,Updated2005Edition.Bethesda,MD:
NIAAA,updated2005.Availableat
pubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm
43
BehavioralTherapies
Behavioralapproacheshelpengagepeopleindrugabusetreatment,provide
incentivesforthemtoremainabstinent,modifytheirattitudesandbehaviors
relatedtodrugabuse,andincreasetheirlifeskillstohandlestressful
circumstancesandenvironmentalcuesthatmaytriggerintensecravingfor
drugsandpromptanothercycleofcompulsiveabuse.Belowareanumberof
behavioraltherapiesshowntobeeffectiveinaddressingsubstanceabuse
(effectivenesswithparticulardrugsofabuseisdenotedinparentheses).
Cognitive-BehavioralTherapy(Alcohol,Marijuana,
Cocaine,Methamphetamine,Nicotine)
Cognitive-BehavioralTherapy(CBT)wasdevelopedasamethodtoprevent
relapsewhentreatingproblemdrinking,andlateritwasadaptedforcocaine-
addictedindividuals.Cognitive-behavioralstrategiesarebasedonthetheory
thatinthedevelopmentofmaladaptivebehavioralpatternslikesubstance
abuse,learningprocessesplayacriticalrole.IndividualsinCBTlearnto
identifyandcorrectproblematicbehaviorsbyapplyingarangeofdifferentskills
thatcanbeusedtostopdrugabuseandtoaddressarangeofotherproblems
thatoftenco-occurwithit.
AcentralelementofCBTisanticipatinglikelyproblemsandenhancingpatients’
self-controlbyhelpingthemdevelopeffectivecopingstrategies.Specific
techniquesincludeexploringthepositiveandnegativeconsequencesof
continueddruguse,self-monitoringtorecognizecravingsearlyandidentify
situationsthatmightputoneatriskforuse,anddevelopingstrategiesforcoping
withcravingsandavoidingthosehigh-risksituations.
Researchindicatesthattheskillsindividualslearnthroughcognitive-behavioral
approachesremainafterthecompletionoftreatment.Currentresearchfocuses
onhowtoproduceevenmorepowerfuleffectsbycombiningCBTwith
medicationsfordrugabuseandwithothertypesofbehavioraltherapies.A
computer-basedCBTsystemhasalsobeendevelopedandhasbeenshownto
beeffectiveinhelpingreducedrugusefollowingstandarddrugabuse
44
treatment.
FurtherReading:
Carroll,K.M.,Easton,C.J.;Nich,C.;Hunkele,K.A.;Neavins,T.M.;Sinha,R.;
Ford,H.L.;Vitolo,S.A;Doebrick,C.A.;andRounsaville,B.J.Theuseof
contingencymanagementandmotivational/skills-buildingtherapytotreat
youngadultswithmarijuanadependence.JournalofConsultingandClinical
Psychology74(5):955–966,2006.
Carroll,K.M.;andOnken,L.S.Behavioraltherapiesfordrugabuse.The
AmericanJournalofPsychiatry168(8):1452–1460,2005.
Carroll,K.M.;Sholomskas,D.;Syracuse,G.;Ball,S.A.;Nuro,K.;andFenton,
L.R.Wedon’ttraininvain:Adisseminationtrialofthreestrategiesoftraining
cliniciansincognitive-behavioraltherapy.JournalofConsultingandClinical
Psychology73(1):106–115,2005.
Carroll,K.;Fenton,L.R.;Ball,S.A.;Nich,C.;Frankforter,T.L.;Shi,J.;and
Rounsaville,B.J.Efficacyofdisulfiramandcognitivebehaviortherapyin
cocaine-dependentoutpatients:Arandomizedplacebo-controlledtrial.Archives
ofGeneralPsychiatry61(3):264–272,2004.
Carroll,K.M.;Ball,S.A.;Martino,S.;Nich,C.;Babuscio,T.A.;Nuro,K.F.;Gordon,
M.A.;Portnoy,G.A.;andRounsaville,B.J.Computer-assisteddeliveryof
cognitive-behavioraltherapyforaddiction:arandomizedtrialofCBT4CBT.The
AmericanJournalofPsychiatry165(7):881–888,2008.
ContingencyManagement
Interventions/MotivationalIncentives(Alcohol,
Stimulants,Opioids,Marijuana,Nicotine)
Researchhasdemonstratedtheeffectivenessoftreatmentapproachesusing
contingencymanagement(CM)principles,whichinvolvegivingpatients
45
tangiblerewardstoreinforcepositivebehaviorssuchasabstinence.Studies
conductedinbothmethadoneprogramsandpsychosocialcounselingtreatment
programsdemonstratethatincentive-basedinterventionsarehighlyeffectivein
increasingtreatmentretentionandpromotingabstinencefromdrugs.
Voucher-BasedReinforcement(VBR)augmentsothercommunity-based
treatmentsforadultswhoprimarilyabuseopioids(especiallyheroin)or
stimulants(especiallycocaine)orboth.InVBR,thepatientreceivesavoucher
foreverydrug-freeurinesampleprovided.Thevoucherhasmonetaryvaluethat
canbeexchangedforfooditems,moviepasses,orothergoodsorservicesthat
areconsistentwithadrug-freelifestyle.Thevouchervaluesarelowatfirst,but
increaseasthenumberofconsecutivedrug-freeurinesamplesincreases;
positiveurinesamplesresetthevalueofthevoucherstotheinitiallowvalue.
VBRhasbeenshowntobeeffectiveinpromotingabstinencefromopioidsand
cocaineinpatientsundergoingmethadonedetoxification.
PrizeIncentivesCMappliessimilarprinciplesasVBRbutuseschancestowin
cashprizesinsteadofvouchers.Overthecourseoftheprogram(atleast3
months,oneormoretimesweekly),participantssupplyingdrug-negativeurine
orbreathtestsdrawfromabowlforthechancetowinaprizeworthbetween$1
and$100.Participantsmayalsoreceivedrawsforattendingcounseling
sessionsandcompletingweeklygoal-relatedactivities.Thenumberofdraws
startsatoneandincreaseswithconsecutivenegativedrugtestsand/or
counselingsessionsattendedbutresetstoonewithanydrug-positivesample
orunexcusedabsence.Thepractitionercommunityhasraisedconcernsthat
thisinterventioncouldpromotegambling—asitcontainsanelementofchance
—andthatpathologicalgamblingandsubstanceusedisorderscanbe
comorbid.However,studiesexaminingthisconcernfoundthatPrizeIncentives
CMdidnotpromotegamblingbehavior.
FurtherReading:
Budney,A.J.;Moore,B.A.;Rocha,H.L.;andHiggins,S.T.Clinicaltrialof
abstinence-basedvouchersandcognitivebehavioraltherapyforcannabis
dependence.JournalofConsultingandClinicalPsychology74(2):307–316,
2006.
46
Budney,A.J.;Roffman,R.;Stephens,R.S.;andWalker,D.Marijuana
dependenceanditstreatment.AddictionScience&ClinicalPractice4(1):4–16,
2007.
Elkashef,A.;Vocci,F.;Huestis,M.;Haney,M.;Budney,A.;Gruber,A.;andel-
Guebaly,N.Marijuananeurobiologyandtreatment.SubstanceAbuse
29(3):17–29,2008.
Peirce,J.M.;Petry,N.M.;Stitzer,M.L.;Blaine,J.;Kellogg,S.;Satterfield,F.;
Schwartz,M.;Krasnansky,J.;Pencer,E.;Silva-Vazquez,L.;Kirby,K.C.;Royer-
Malvestuto,C.;Cohen,A.;Copersino,M.L.;Kolodner,K.;andLi,R.Effectsof
lower-costincentivesonstimulantabstinenceinmethadonemaintenance
treatment:ANationalDrugAbuseTreatmentClinicalTrialsNetworkstudy.
ArchivesofGeneralPsychiatry63(2):201–208,2006.
Petry,N.M.;Peirce,J.M.;Stitzer,M.L.;Blaine,J.;Roll,J.M.;Cohen,A.;Obert,J.;
Killeen,T.;Saladin,M.E.;Cowell,M.;Kirby,K.C.;Sterling,R.;Royer-Malvestuto,
C.;Hamilton,J.;Booth,R.E.;Macdonald,M.;Liebert,M.;Rader,L.;Burns,R;
DiMaria,J.;Copersino,M.;Stabile,P.Q.;Kolodner,K.;andLi,R.Effectof
prizebasedincentivesonoutcomesinstimulantabusersinoutpatient
psychosocialtreatmentprograms:ANationalDrugAbuseTreatmentClinical
TrialsNetworkstudy.ArchivesofGeneralPsychiatry62(10):1148–1156,2005.
Petry,N.M.;Kolodner,K.B.;Li,R.;Peirce,J.M.;Roll,J.M.;Stitzer,M.L.;and
Hamilton,J.A.Prize-basedcontingencymanagementdoesnotincrease
gambling.DrugandAlcoholDependence83(3):269–273,2006.
Prendergast,M.;Podus,D.;Finney,J.;Greenwell,L.;andRoll,J.Contingency
managementfortreatmentofsubstanceusedisorders:Ameta-analysis.
Addiction101(11):1546–1560,2006.
Roll,J.M.;Petry,N.M.;Stitzer,M.L.;Brecht,M.L.;Peirce,J.M.;McCann,M.J.;
Blaine,J.;MacDonald,M.;DiMaria,J.;Lucero,L.;andKellogg,S.Contingency
managementforthetreatmentofmethamphetamineusedisorders.The
AmericanJournalofPsychiatry163(11):1993–1999,2006.
47
CommunityReinforcementApproachPlus
Vouchers(Alcohol,Cocaine,Opioids)
CommunityReinforcementApproach(CRA)PlusVouchersisanintensive24-
weekoutpatienttherapyfortreatingpeopleaddictedtococaineandalcohol.It
usesarangeofrecreational,familial,social,andvocationalreinforcers,along
withmaterialincentives,tomakeanon-drug-usinglifestylemorerewarding
thansubstanceuse.Thetreatmentgoalsaretwofold:
Tomaintainabstinencelongenoughforpatientstolearnnewlifeskillsto
helpsustainit;and
Toreducealcoholconsumptionforpatientswhosedrinkingisassociated
withcocaineuse
Patientsattendoneortwoindividualcounselingsessionseachweek,where
theyfocusonimprovingfamilyrelations,learnavarietyofskillstominimize
druguse,receivevocationalcounseling,anddevelopnewrecreational
activitiesandsocialnetworks.Thosewhoalsoabusealcoholreceiveclinic-
monitoreddisulfiram(Antabuse)therapy.Patientssubmiturinesamplestwoor
threetimeseachweekandreceivevouchersforcocaine-negativesamples.As
inVBR,thevalueofthevouchersincreaseswithconsecutivecleansamples,
andthevouchersmaybeexchangedforretailgoodsthatareconsistentwitha
drug-freelifestyle.Studiesinbothurbanandruralareashavefoundthatthis
approachfacilitatespatients’engagementintreatmentandsuccessfullyaids
themingainingsubstantialperiodsofcocaineabstinence.
Acomputer-basedversionofCRAPlusVoucherscalledtheTherapeutic
EducationSystem(TES)wasfoundtobenearlyaseffectiveastreatment
administeredbyatherapistinpromotingabstinencefromopioidsandcocaine
amongopioid-dependentindividualsinoutpatienttreatment.AversionofCRA
foradolescentsaddressesproblem-solving,coping,andcommunicationskills
andencouragesactiveparticipationinpositivesocialandrecreationalactivities.
FurtherReading:
48
Brooks,A.C.;Ryder,D.;Carise,D.;andKirby,K.C.Feasibilityandeffectiveness
ofcomputer-basedtherapyincommunitytreatment.JournalofSubstance
AbuseTreatment39(3):227–235,2010.
Higgins,S.T.;Sigmon,S.C.;Wong,C.J.;Heil,S.H.;Badger,G.J.;Donham,R.;
Dantona,R.L.;andAnthony,S.Communityreinforcementtherapyforcocaine-
dependentoutpatients.ArchivesofGeneralPsychiatry60(10):1043–1052,
2003.
Roozen,H.G.;Boulogne,J.J.;vanTulder,M.W.;vandenBrink,W.;DeJong,
C.A.J.;andKerhof,J.F.M.Asystemicreviewoftheeffectivenessofthe
communityreinforcementapproachinalcohol,cocaineandopioidaddiction.
DrugandAlcoholDependence74(1):1–13,2004.
Silverman,K.;Higgins,S.T.;Brooner,R.K.;Montoya,I.D.;Cone,E.J.;Schuster,
C.R.;andPreston,K.L.Sustainedcocaineabstinenceinmethadone
maintenancepatientsthroughvoucher-basedreinforcementtherapy.Archives
ofGeneralPsychiatry53(5):409–415,1996.
Smith,J.E.;Meyers,R.J.;andDelaney,H.D.Thecommunityreinforcement
approachwithhomelessalcohol-dependentindividuals.JournalofConsulting
andClinicalPsychology66(3):541–548,1998.
Stahler,G.J.;Shipley,T.E.;Kirby,K.C.;Godboldte,C.;Kerwin,M.E;Shandler,I.;
andSimons,L.Developmentandinitialdemonstrationofacommunity-based
interventionforhomeless,cocaine-using,African-Americanwomen.Journalof
SubstanceAbuseTreatment28(2):171–179,2005.
MotivationalEnhancementTherapy(Alcohol,
Marijuana,Nicotine)
MotivationalEnhancementTherapy(MET)isacounselingapproachthathelps
individualsresolvetheirambivalenceaboutengagingintreatmentandstopping
theirdruguse.Thisapproachaimstoevokerapidandinternallymotivated
change,ratherthanguidethepatientstepwisethroughtherecoveryprocess.
49
Thistherapyconsistsofaninitialassessmentbatterysession,followedbytwoto
fourindividualtreatmentsessionswithatherapist.Inthefirsttreatmentsession,
thetherapistprovidesfeedbacktotheinitialassessment,stimulatingdiscussion
aboutpersonalsubstanceuseandelicitingself-motivationalstatements.
Motivationalinterviewingprinciplesareusedtostrengthenmotivationandbuild
aplanforchange.Copingstrategiesforhigh-risksituationsaresuggestedand
discussedwiththepatient.Insubsequentsessions,thetherapistmonitors
change,reviewscessationstrategiesbeingused,andcontinuestoencourage
commitmenttochangeorsustainedabstinence.Patientssometimesare
encouragedtobringasignificantothertosessions.
ResearchonMETsuggeststhatitseffectsdependonthetypeofdrugusedby
participantsandonthegoaloftheintervention.Thisapproachhasbeenused
successfullywithpeopleaddictedtoalcoholtobothimprovetheirengagement
intreatmentandreducetheirproblemdrinking.METhasalsobeenused
successfullywithmarijuana-dependentadultswhencombinedwithcognitive-
behavioraltherapy,constitutingamorecomprehensivetreatmentapproach.
TheresultsofMETaremixedforpeopleabusingotherdrugs(e.g.,heroin,
cocaine,nicotine)andforadolescentswhotendtousemultipledrugs.In
general,METseemstobemoreeffectiveforengagingdrugabusersin
treatmentthanforproducingchangesindruguse.
FurtherReading:
Baker,A.;Lewin,T.;Reichler,H.;Clancy,R.;Carr,V.;Garrett,R.;Sly,K.;Devir,
H.;andTerry,M.Evaluationofamotivationalinterviewforsubstanceusewith
psychiatricin-patientservices.Addiction97(10):1329-1337,2002.
Haug,N.A.;Svikis,D.S.;andDiclemente,C.Motivationalenhancementtherapy
fornicotinedependenceinmethadone-maintainedpregnantwomen.
PsychologyofAddictiveBehaviors18(3):289-292,2004.
MarijuanaTreatmentProjectResearchGroup.Brieftreatmentsforcannabis
dependence:Findingsfromarandomizedmultisitetrial.JournalofConsulting
andClinicalPsychology72(3):455-466,2004.
50
Miller,W.R.;Yahne,C.E.;andTonigan,J.S.Motivationalinterviewingindrug
abuseservices:Arandomizedtrial.JournalofConsultingandClinical
Psychology71(4):754-763,2003.
Stotts,A.L.;Diclemente,C.C.;andDolan-Mullen,P.One-to-one:Amotivational
interventionforresistantpregnantsmokers.AddictiveBehaviors27(2):275-292,
2002.
TheMatrixModel(Stimulants)
TheMatrixModelprovidesaframeworkforengagingstimulant(e.g.,
methamphetamineandcocaine)abusersintreatmentandhelpingthem
achieveabstinence.Patientslearnaboutissuescriticaltoaddictionand
relapse,receivedirectionandsupportfromatrainedtherapist,andbecome
familiarwithself-helpprograms.Patientsaremonitoredfordrugusethrough
urinetesting.
Thetherapistfunctionssimultaneouslyasteacherandcoach,fosteringa
positive,encouragingrelationshipwiththepatientandusingthatrelationshipto
reinforcepositivebehaviorchange.Theinteractionbetweenthetherapistand
thepatientisauthenticanddirectbutnotconfrontationalorparental.Therapists
aretrainedtoconducttreatmentsessionsinawaythatpromotesthepatient’s
self-esteem,dignity,andself-worth.Apositiverelationshipbetweenpatientand
therapistiscriticaltopatientretention.
Treatmentmaterialsdrawheavilyonothertestedtreatmentapproachesand,
thus,includeelementsofrelapseprevention,familyandgrouptherapies,drug
education,andself-helpparticipation.Detailedtreatmentmanualscontain
worksheetsforindividualsessions;othercomponentsincludefamilyeducation
groups,earlyrecoveryskillsgroups,relapsepreventiongroups,combined
sessions,urinetests,12-stepprograms,relapseanalysis,andsocialsupport
groups.
Anumberofstudieshavedemonstratedthatparticipantstreatedusingthe
MatrixModelshowstatisticallysignificantreductionsindrugandalcoholuse,
improvementsinpsychologicalindicators,andreducedriskysexualbehaviors
51
associatedwithHIVtransmission.
FurtherReading:
Huber,A.;Ling,W.;Shoptaw,S.;Gulati,V.;Brethen,P.;andRawson,R.
Integratingtreatmentsformethamphetamineabuse:Apsychosocial
perspective.JournalofAddictiveDiseases16(4):41-50,1997.
Rawson,R.;Shoptaw,S.J.;Obert,J.L.;McCann,M.J.;Hasson,A.L.;Marinelli-
Casey,P.J.;Brethen,P.R.;andLing,W.Anintensiveoutpatientapproachfor
cocaineabuse:TheMatrixmodel.JournalofSubstanceAbuseTreatment
12(2):117-127,1995.
Rawson,R.A.;Huber,A.;McCann,M.;Shoptaw,S.;Farabee,D.;Reiber,C.;and
Ling,W.Acomparisonofcontingencymanagementandcognitive-behavioral
approachesduringmethadonemaintenancetreatmentforcocaine
dependence.ArchivesofGeneralPsychiatry59(9):817-824,2002.
12-StepFacilitationTherapy(Alcohol,Stimulants,
Opiates)
Twelve-stepfacilitationtherapyisanactiveengagementstrategydesignedto
increasethelikelihoodofasubstanceabuserbecomingaffiliatedwithand
activelyinvolvedin12-stepself-helpgroups,therebypromotingabstinence.
Threekeyideaspredominate:(1)acceptance,whichincludestherealization
thatdrugaddictionisachronic,progressivediseaseoverwhichonehasno
control,thatlifehasbecomeunmanageablebecauseofdrugs,thatwillpower
aloneisinsufficienttoovercometheproblem,andthatabstinenceistheonly
alternative;(2)surrender,whichinvolvesgivingoneselfovertoahigherpower,
acceptingthefellowshipandsupportstructureofotherrecoveringaddicted
individuals,andfollowingtherecoveryactivitieslaidoutbythe12-step
program;and(3)activeinvolvementin12-stepmeetingsandrelatedactivities.
Whiletheefficacyof12-stepprograms(and12-stepfacilitation)intreating
alcoholdependencehasbeenestablished,theresearchonitsusefulnessfor
otherformsofsubstanceabuseismorepreliminary,butthetreatmentappears
52
promisingforhelpingdrugabuserssustainrecovery.
FurtherReading:
Carroll,K.M.;Nich,C.;Ball,S.A.;McCance,E.;Frankforter,T.L.;and
Rounsaville,B.J.One-yearfollow-upofdisulfiramandpsychotherapyfor
cocaine-alcoholusers:Sustainedeffectsoftreatment.Addiction95(9):1335-
1349,2000.
DonovanD.M.,andWellsE.A."Tweaking12-step":Thepotentialroleof12-Step
self-helpgroupinvolvementinmethamphetaminerecovery.Addiction
102(Suppl.1):121-129,2007.
ProjectMATCHResearchGroup.Matchingalcoholismtreatmentstoclient
heterogeneity:ProjectMATCHposttreatmentdrinkingoutcomes.Journalof
StudiesonAlcohol58(1)7-29,1997.
FamilyBehaviorTherapy
FamilyBehaviorTherapy(FBT),whichhasdemonstratedpositiveresultsinboth
adultsandadolescents,isaimedataddressingnotonlysubstanceuse
problemsbutotherco-occurringproblemsaswell,suchasconductdisorders,
childmistreatment,depression,familyconflict,andunemployment.FBT
combinesbehavioralcontractingwithcontingencymanagement.
FBTinvolvesthepatientalongwithatleastonesignificantothersuchasa
cohabitingpartneroraparent(inthecaseofadolescents).Therapistsseekto
engagefamiliesinapplyingthebehavioralstrategiestaughtinsessionsandin
acquiringnewskillstoimprovethehomeenvironment.Patientsareencouraged
todevelopbehavioralgoalsforpreventingsubstanceuseandHIVinfection,
whichareanchoredtoacontingencymanagementsystem.Substance-abusing
parentsarepromptedtosetgoalsrelatedtoeffectiveparentingbehaviors.
Duringeachsession,thebehavioralgoalsarereviewed,withrewardsprovided
bysignificantotherswhengoalsareaccomplished.Patientsparticipatein
treatmentplanning,choosingspecificinterventionsfromamenuofevidence-
53
basedtreatmentoptions.Inaseriesofcomparisonsinvolvingadolescentswith
andwithoutconductdisorder,FBTwasfoundtobemoreeffectivethan
supportivecounseling.
FurtherReading:
Azrin,N.H.;Donohue,B.;Besalel,V.A.;Kogan,E.S.;andAcierno,R.Youthdrug
abusetreatment:acontrolledoutcomestudy.JournalofChildandAdolescent
SubstanceAbuse3:1–16,1994.
Carroll,K.M.;andOnken,L.S.Behavioraltherapiesfordrugabuse.American
JournalofPsychiatry168(8):1452–1460,2005.
Donohue,B.;Azrin,N.;Allen,D.N.;Romero,V.;Hill,H.H.;Tracy,K.;Lapota,H.;
Gorney,S.;Abdel-al,R.;Caldas,D.;Herdzik,K.;Bradshaw,K.;Valdez,R.;and
VanHasselt,V.B.FamilyBehaviorTherapyforsubstanceabuse:Areviewofits
interventioncomponentsandapplicability.BehaviorModification33:495–519,
2009.
LaPota,H.B.;Donohue,B.;Warren,C.S.;andAllen,D.N.Integrationofa
HealthyLivingcurriculumwithinFamilyBehaviorTherapy:Aclinicalcase
exampleinawomanwithahistoryofdomesticviolence,childneglect,drug
abuse,andobesity.JournalofFamilyViolence26:227–234,2011.
BehavioralTherapiesPrimarilyforAdolescents
Drug-abusingandaddictedadolescentshaveuniquetreatmentneeds.
Researchhasshownthattreatmentsdesignedforandtestedinadult
populationsoftenneedtobemodifiedtobeeffectiveinadolescents.Family
involvementisaparticularlyimportantcomponentforinterventionstargeting
youth.Belowareexamplesofbehavioralinterventionsthatemploythese
principlesandhaveshownefficacyfortreatingaddictioninyouth.
MultisystemicTherapy
54
MultisystemicTherapy(MST)addressesthefactorsassociatedwithserious
antisocialbehaviorinchildrenandadolescentswhoabusealcoholandother
drugs.Thesefactorsincludecharacteristicsofthechildoradolescent(e.g.,
favorableattitudestowarddruguse),thefamily(poordiscipline,familyconflict,
parentaldrugabuse),peers(positiveattitudestowarddruguse),school
(dropout,poorperformance),andneighborhood(criminalsubculture).By
participatinginintensivetreatmentinnaturalenvironments(homes,schools,
andneighborhoodsettings),mostyouthsandfamiliescompleteafullcourseof
treatment.MSTsignificantlyreducesadolescentdruguseduringtreatmentand
foratleast6monthsaftertreatment.Fewerincarcerationsandout-of-home
juvenileplacementsoffsetthecostofprovidingthisintensiveserviceand
maintainingtheclinicians’lowcaseloads.
FurtherReading:
Henggeler,S.W.;Clingempeel,W.G.;Brondino,M.J.;andPickrel,S.G.Four-
yearfollow-upofmultisystemictherapywithsubstance-abusingandsubstance-
dependentjuvenileoffenders.JournaloftheAmericanAcademyofChildand
AdolescentPsychiatry41(7):868-874,2002.
Henggeler,S.W.;Rowland,M.D.;Randall,J.;Ward,D.M.;Pickrel,S.G.;
Cunningham,P.B.;Miller,S.L.;Edwards,J.;Zealberg,J.J.;Hand,L.D.;and
Santos,A.B.Home-basedmultisystemictherapyasanalternativetothe
hospitalizationofyouthsinpsychiatriccrisis:Clinicaloutcomes.Journalofthe
AmericanAcademyofChildandAdolescentPsychiatry38(11):1331-1339,
1999.
Henggeler,S.W.;Halliday-Boykins,C.A.;Cunningham,P.B.;Randall,J.;
Shapiro,S.B.;andChapman,J.E.Juveniledrugcourt:Enhancingoutcomesby
integratingevidence-basedtreatments.JournalofConsultingandClinical
Psychology74(1):42–54,2006.
Henggeler,S.W.;Pickrel,S.G.;Brondino,M.J.;andCrouch,J.L.Eliminating
(almost)treatmentdropoutofsubstance-abusingordependentdelinquents
throughhome-basedmultisystemictherapy.TheAmericanJournalof
Psychiatry153(3):427–428,1996.
55
Huey,S.J.;Henggeler,S.W.;Brondino,M.J.;andPickrel,S.G.Mechanismsof
changeinmultisystemictherapy:Reducingdelinquentbehaviorthrough
therapistadherenceandimprovedfamilyfunctioning.JournalofConsultingand
ClinicalPsychology68(3):451–467,2000.
MultidimensionalFamilyTherapy
MultidimensionalFamilyTherapy(MDFT)foradolescentsisanoutpatient,
family-basedtreatmentforteenagerswhoabusealcoholorotherdrugs.MDFT
viewsadolescentdruguseintermsofanetworkofinfluences(individual,
family,peer,community)andsuggeststhatreducingunwantedbehaviorand
increasingdesirablebehavioroccurinmultiplewaysindifferentsettings.
Treatmentincludesindividualandfamilysessionsheldintheclinic,inthe
home,orwithfamilymembersatthefamilycourt,school,orothercommunity
locations.
Duringindividualsessions,thetherapistandadolescentworkonimportant
developmentaltasks,suchasdevelopingdecision-making,negotiation,and
problem-solvingskills.Teenagersacquirevocationalskillsandskillsin
communicatingtheirthoughtsandfeelingstodealbetterwithlifestressors.
Parallelsessionsareheldwithfamilymembers.Parentsexaminetheir
particularparentingstyles,learningtodistinguishinfluencefromcontrolandto
haveapositiveanddevelopmentallyappropriateinfluenceontheirchildren.
FurtherReading:
Dennis,M.;Godley,S.H.;Diamond,G.;Tims,F.M.;Babor,T.;Donaldson,J.;
Liddle,H.;Titus,J.C.;Kaminer,Y.;Webb,C.;Hamilton,N.;andFunk,R.The
CannabisYouthTreatment(CYT)Study:Mainfindingsfromtworandomized
clinicaltrials.JournalofSubstanceAbuseTreatment27(3):197-213,2004.
Liddle,H.A.;Dakof,G.A.;Parker,K.;Diamond,G.S.;Barrett,K;,andTejeda,M.
Multidimensionalfamilytherapyforadolescentdrugabuse:Resultsofa
randomizedclinicaltrial.TheAmericanJournalofDrugandAlcoholAbuse
27(4):651-688,2001.
56
Liddle,H.A.,andHogue,A.Multidimensionalfamilytherapyforadolescent
substanceabuse.InE.F.WagnerandH.B.Waldron(eds.),Innovationsin
AdolescentSubstanceAbuseInterventions.London:Pergamon/Elsevier
Science,pp.227-261,2001.
Liddle,H.A.;Rowe,C.L.;Dakof,G.A.;Ungaro,R.A.;andHenderson,C.E.Early
interventionforadolescentsubstanceabuse:Pretreatmenttoposttreatment
outcomesofarandomizedclinicaltrialcomparingmultidimensionalfamily
therapyandpeergrouptreatment.JournalofPsychoactiveDrugs36(1):49-63,
2004.
Schmidt,S.E.;Liddle,H.A.;andDakof,G.A.Effectsofmultidimensionalfamily
therapy:Relationshipofchangesinparentingpracticestosymptomreductionin
adolescentsubstanceabuse.JournalofFamilyPsychology10(1):1-16,1996.
BriefStrategicFamilyTherapy
BriefStrategicFamilyTherapy(BSFT)targetsfamilyinteractionsthatare
thoughttomaintainorexacerbateadolescentdrugabuseandotherco-
occurringproblembehaviors.Suchproblembehaviorsincludeconduct
problemsathomeandatschool,oppositionalbehavior,delinquency,
associatingwithantisocialpeers,aggressiveandviolentbehavior,andrisky
sexualbehavior.BSFTisbasedonafamilysystemsapproachtotreatment,in
whichfamilymembers’behaviorsareassumedtobeinterdependentsuchthat
thesymptomsofonemember(thedrug-abusingadolescent,forexample)are
indicative,atleastinpart,ofwhatelseisoccurringinthefamilysystem.Therole
oftheBSFTcounseloristoidentifythepatternsoffamilyinteractionthatare
associatedwiththeadolescent’sbehaviorproblemsandtoassistinchanging
thoseproblem-maintainingfamilypatterns.BSFTismeanttobeaflexible
approachthatcanbeadaptedtoabroadrangeoffamilysituationsinvarious
settings(mentalhealthclinics,drugabusetreatmentprograms,othersocial
servicesettings,andfamilies’homes)andinvarioustreatmentmodalities(asa
primaryoutpatientintervention,incombinationwithresidentialordaytreatment,
andasanaftercare/continuing-careservicefollowingresidentialtreatment).
FurtherReading:
57
Coatsworth,J.D.;Santisteban,D.A.;McBride,C.K.;andSzapocznik,J.Brief
StrategicFamilyTherapyversuscommunitycontrol:Engagement,retention,
andanexplorationofthemoderatingroleofadolescentseverity.Family
Process40(3):313-332,2001.
Kurtines,W.M.;Murray,E.J.;andLaperriere,A.Efficacyofinterventionfor
engagingyouthandfamiliesintotreatmentandsomevariablesthatmay
contributetodifferentialeffectiveness.JournalofFamilyPsychology10(1):35–
44,1996.
Santisteban,D.A.;Coatsworth,J.D.;Perez-Vidal,A.;Mitrani,V.;Jean-Gilles,M.;
andSzapocznik,J.BriefStructural/StrategicFamilyTherapywithAfrican-
AmericanandHispanichigh-riskyouth.JournalofCommunityPsychology
25(5):453-471,1997.
Santisteban,D.A.;Suarez-Morales,L.;Robbins,M.S.;andSzapocznik,J.Brief
strategicfamilytherapy:Lessonslearnedinefficacyresearchandchallengesto
blendingresearchandpractice.FamilyProcess45(2):259-271,2006.
Santisteban,D.A.;Szapocznik,J.;Perez-Vidal,A.;Mitrani,V.;Jean-Gilles,M.;
andSzapocznik,J.BriefStructural/StrategicFamilyTherapywithAfrican-
AmericanandHispanichigh-riskyouth.JournalofCommunity
Psychology25(5):453–471,1997.
Szapocznik,J.,etal.Engagingadolescentdrugabusersandtheirfamiliesin
treatment:Astrategicstructuralsystemsapproach.JournalofConsultingand
ClinicalPsychology56(4):552-557,1988.
FunctionalFamilyTherapy
FunctionalFamilyTherapy(FFT)isanothertreatmentbasedonafamily
systemsapproach,inwhichanadolescent’sbehaviorproblemsareseenas
beingcreatedormaintainedbyafamily’sdysfunctionalinteractionpatterns.FFT
aimstoreduceproblembehaviorsbyimprovingcommunication,problem-
solving,conflictresolution,andparentingskills.Theinterventionalways
58
includestheadolescentandatleastonefamilymemberineachsession.
Principaltreatmenttacticsinclude(1)engagingfamiliesinthetreatment
processandenhancingtheirmotivationforchangeand(2)bringingabout
changesinfamilymembers’behaviorusingcontingencymanagement
techniques,communicationandproblem-solving,behavioralcontracts,and
otherbehavioralinterventions.
FurtherReading:
Waldron,H.B.;Slesnick,N.;Brody,J.L.;Turner,C.W.;andPeterson,T.R.
Treatmentoutcomesforadolescentsubstanceabuseat4-and7-month
assessments.JournalofConsultingandClinicalPsychology69:802–813,
2001.
Waldron,H.B.;Turner,C.W.;andOzechowski,T.J.Profilesofdruguse
behaviorchangeforadolescentsintreatment.AddictiveBehaviors30:1775–
1796,2005.
AdolescentCommunityReinforcementApproachand
AssertiveContinuingCare
TheAdolescentCommunityReinforcementApproach(A-CRA)isanother
comprehensivesubstanceabusetreatmentinterventionthatinvolvesthe
adolescentandhisorherfamily.Itseekstosupporttheindividual’srecoveryby
increasingfamily,social,andeducational/vocationalreinforcers.After
assessingtheadolescent’sneedsandlevelsoffunctioning,thetherapist
choosesfromamong17A-CRAprocedurestoaddressproblem-solving,
coping,andcommunicationskillsandtoencourageactiveparticipationin
positivesocialandrecreationalactivities.A-CRAskillstraininginvolvesrole-
playingandbehavioralrehearsal.
AssertiveContinuingCare(ACC)isahome-basedcontinuing-careapproachto
preventingrelapse.Weeklyhomevisitstakeplaceovera12-to14-weekperiod
afteranadolescentisdischargedfromresidential,intensiveoutpatient,or
regularoutpatienttreatment.Usingpositiveandnegativereinforcementto
shapebehaviors,alongwithtraininginproblem-solvingandcommunication
59
skills,ACCcombinesA-CRAandassertivecasemanagementservices(e.g.,
useofamultidisciplinaryteamofprofessionals,round-the-clockcoverage,
assertiveoutreach)tohelpadolescentsandtheircaregiversacquiretheskillsto
engageinpositivesocialactivities.
FurtherReading:
Dennis,M.;Godley,S.H.;Diamond,G.;Tims,F.M.;Babor,T.;Donaldson,J.;
Liddle,H.;Titus,J.C.;Kamier,Y.;Webb,C.;Hamilton,N.;andFunkR.The
CannabisYouthTreatment(CYT)Study:Mainfindingsfromtworandomized
trials.JournalofSubstanceAbuseTreatment27:197–213,2004.
Godley,S.H.;Garner,B.R.;Passetti,L.L.;Funk,R.R.;Dennis,M.L.;andGodley,
M.D.Adolescentoutpatienttreatmentandcontinuingcare:Mainfindingsfroma
randomizedclinicaltrial.DrugandAlcoholDependenceJul1;110(1-2):44–54,
2010.
Godley,M.D.;Godley,S.H.;Dennis,M.L.;Funk,R.;andPassetti,L.L.
Preliminaryoutcomesfromtheassertivecontinuingcareexperimentfor
adolescentsdischargedfromresidentialtreatment.JournalofSubstanceAbuse
Treatment23:21–32,2002.
“This course was developed from the public domain document: Principles of Drug Addiction Treatment: A
Research-Based Guide (Third Edition) – National Institute on Drug Abuse (NIDA) - NIH (2018).”