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NationalInstituteonDrugAbuse(NIDA)

PrinciplesofDrugAddictionTreatment:AResearch-BasedGuide(ThirdEdition)

LastUpdatedJanuary2018

https://www.drugabuse.gov

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TableofContents

PrinciplesofDrugAddictionTreatment:AResearch-BasedGuide(ThirdEdition)

Preface

PrinciplesofEffectiveTreatment

FrequentlyAskedQuestions

DrugAddictionTreatmentintheUnitedStates

Evidence-BasedApproachestoDrugAddictionTreatment

Resources

Acknowledgments

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Preface

Drugaddictionisacomplexillness.

Itischaracterizedbyintenseand,attimes,uncontrollabledrugcraving,alongwithcompulsivedrugseekingandusethatpersisteveninthefaceofdevastatingconsequences.ThisupdateoftheNationalInstituteonDrugAbuse’sPrinciplesofDrugAddictionTreatmentisintendedtoaddressaddictiontoawidevarietyofdrugs,includingnicotine,alcohol,andillicitandprescriptiondrugs.Itisdesignedtoserveasaresourceforhealthcareproviders,familymembers,andotherstakeholderstryingtoaddressthemyriadproblemsfacedbypatientsinneedoftreatmentfordrugabuseoraddiction.

Addictionaffectsmultiplebraincircuits,includingthoseinvolvedinrewardandmotivation,learningandmemory,andinhibitorycontroloverbehavior.Thatiswhyaddictionisabraindisease.Someindividualsaremorevulnerablethanotherstobecomingaddicted,dependingontheinterplaybetweengeneticmakeup,ageofexposuretodrugs,andotherenvironmentalinfluences.Whileapersoninitiallychoosestotakedrugs,overtimetheeffectsofprolongedexposureonbrainfunctioningcompromisethatabilitytochoose,andseekingandconsumingthedrugbecomecompulsive,ofteneludingaperson’sself-controlorwillpower.

Butaddictionismorethanjustcompulsivedrugtaking—itcanalsoproducefar-reachinghealthandsocialconsequences.Forexample,drugabuseandaddictionincreaseaperson’sriskforavarietyofothermentalandphysicalillnessesrelatedtoadrug-abusinglifestyleorthetoxiceffectsofthedrugsthemselves.Additionally,thedysfunctionalbehaviorsthatresultfromdrugabusecaninterferewithaperson’snormalfunctioninginthefamily,theworkplace,andthebroadercommunity.

Becausedrugabuseandaddictionhavesomanydimensionsanddisruptsomanyaspectsofanindividual’slife,treatmentisnotsimple.Effectivetreatmentprogramstypicallyincorporatemanycomponents,eachdirectedtoaparticularaspectoftheillnessanditsconsequences.Addictiontreatmentmusthelpthe

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individualstopusingdrugs,maintainadrug-freelifestyle,andachieveproductivefunctioninginthefamily,atwork,andinsociety.Becauseaddictionisadisease,mostpeoplecannotsimplystopusingdrugsforafewdaysandbecured.Patientstypicallyrequirelong-termorrepeatedepisodesofcaretoachievetheultimategoalofsustainedabstinenceandrecoveryoftheirlives.Indeed,scientificresearchandclinicalpracticedemonstratethevalueofcontinuingcareintreatingaddiction,withavarietyofapproacheshavingbeentestedandintegratedinresidentialandcommunitysettings.

Aswelooktowardthefuture,wewillharnessnewresearchresultsontheinfluenceofgeneticsandenvironmentongenefunctionandexpression(i.e.,epigenetics),whichareheraldingthedevelopmentofpersonalizedtreatmentinterventions.Thesefindingswillbeintegratedwithcurrentevidencesupportingthemosteffectivedrugabuseandaddictiontreatmentsandtheirimplementation,whicharereflectedinthisguide.

NoraD.Volkow,M.D.DirectorNationalInstituteonDrugAbuse

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PrinciplesofEffectiveTreatment

1. Addictionisacomplexbuttreatablediseasethataffectsbrainfunctionandbehavior.Drugsofabusealterthebrain’sstructureandfunction,resultinginchangesthatpersistlongafterdrugusehasceased.Thismayexplainwhydrugabusersareatriskforrelapseevenafterlongperiodsofabstinenceanddespitethepotentiallydevastatingconsequences.

2. Nosingletreatmentisappropriateforeveryone.Treatmentvariesdependingonthetypeofdrugandthecharacteristicsofthepatients.Matchingtreatmentsettings,interventions,andservicestoanindividual’sparticularproblemsandneedsiscriticaltohisorherultimatesuccessinreturningtoproductivefunctioninginthefamily,workplace,andsociety.

3. Treatmentneedstobereadilyavailable.Becausedrug-addictedindividualsmaybeuncertainaboutenteringtreatment,takingadvantageofavailableservicesthemomentpeoplearereadyfortreatmentiscritical.Potentialpatientscanbelostiftreatmentisnotimmediatelyavailableorreadilyaccessible.Aswithotherchronicdiseases,theearliertreatmentisofferedinthediseaseprocess,thegreaterthelikelihoodofpositiveoutcomes.

4. Effectivetreatmentattendstomultipleneedsoftheindividual,notjusthisorherdrugabuse.Tobeeffective,treatmentmustaddresstheindividual’sdrugabuseandanyassociatedmedical,psychological,social,vocational,andlegalproblems.Itisalsoimportantthattreatmentbeappropriatetotheindividual’sage,gender,ethnicity,andculture.

5. Remainingintreatmentforanadequateperiodoftimeiscritical.Theappropriatedurationforanindividualdependsonthetypeanddegreeofthepatient’sproblemsandneeds.Researchindicatesthatmostaddictedindividualsneedatleast3monthsintreatmenttosignificantlyreduceorstoptheirdruguseandthatthebestoutcomesoccurwithlongerdurationsoftreatment.Recoveryfromdrugaddictionisalong-termprocessandfrequentlyrequiresmultipleepisodesoftreatment.Aswithotherchronicillnesses,relapsestodrugabusecanoccurandshouldsignalaneedfortreatmenttobereinstatedoradjusted.Becauseindividualsoftenleavetreatmentprematurely,programsshouldincludestrategiestoengageand

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keeppatientsintreatment.

6. Behavioraltherapies—includingindividual,family,orgroupcounseling—arethemostcommonlyusedformsofdrugabusetreatment.Behavioraltherapiesvaryintheirfocusandmayinvolveaddressingapatient’smotivationtochange,providingincentivesforabstinence,buildingskillstoresistdruguse,replacingdrug-usingactivitieswithconstructiveandrewardingactivities,improvingproblem-solvingskills,andfacilitatingbetterinterpersonalrelationships.Also,participationingrouptherapyandotherpeersupportprogramsduringandfollowingtreatmentcanhelpmaintainabstinence.

7. Medicationsareanimportantelementoftreatmentformanypatients,especiallywhencombinedwithcounselingandotherbehavioraltherapies.Forexample,methadone,buprenorphine,andnaltrexone(includinganewlong-actingformulation)areeffectiveinhelpingindividualsaddictedtoheroinorotheropioidsstabilizetheirlivesandreducetheirillicitdruguse.Acamprosate,disulfiram,andnaltrexonearemedicationsapprovedfortreatingalcoholdependence.Forpersonsaddictedtonicotine,anicotinereplacementproduct(availableaspatches,gum,lozenges,ornasalspray)oranoralmedication(suchasbupropionorvarenicline)canbeaneffectivecomponentoftreatmentwhenpartofacomprehensivebehavioraltreatmentprogram.

8. Anindividual'streatmentandservicesplanmustbeassessedcontinuallyandmodifiedasnecessarytoensurethatitmeetshisorherchangingneeds.Apatientmayrequirevaryingcombinationsofservicesandtreatmentcomponentsduringthecourseoftreatmentandrecovery.Inadditiontocounselingorpsychotherapy,apatientmayrequiremedication,medicalservices,familytherapy,parentinginstruction,vocationalrehabilitation,and/orsocialandlegalservices.Formanypatients,acontinuingcareapproachprovidesthebestresults,withthetreatmentintensityvaryingaccordingtoaperson’schangingneeds.

9. Manydrug-addictedindividualsalsohaveothermentaldisorders.Becausedrugabuseandaddiction—bothofwhicharementaldisorders—oftenco-occurwithothermentalillnesses,patientspresentingwithoneconditionshouldbeassessedfortheother(s).Andwhentheseproblemsco-occur,treatmentshouldaddressboth(orall),includingtheuseofmedicationsasappropriate.

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10. Medicallyassisteddetoxificationisonlythefirststageofaddictiontreatmentandbyitselfdoeslittletochangelong-termdrugabuse.Althoughmedicallyassisteddetoxificationcansafelymanagetheacutephysicalsymptomsofwithdrawalandcan,forsome,pavethewayforeffectivelong-termaddictiontreatment,detoxificationaloneisrarelysufficienttohelpaddictedindividualsachievelong-termabstinence.Thus,patientsshouldbeencouragedtocontinuedrugtreatmentfollowingdetoxification.Motivationalenhancementandincentivestrategies,begunatinitialpatientintake,canimprovetreatmentengagement.

11. Treatmentdoesnotneedtobevoluntarytobeeffective.Sanctionsorenticementsfromfamily,employmentsettings,and/orthecriminaljusticesystemcansignificantlyincreasetreatmententry,retentionrates,andtheultimatesuccessofdrugtreatmentinterventions.

12. Druguseduringtreatmentmustbemonitoredcontinuously,aslapsesduringtreatmentdooccur.Knowingtheirdruguseisbeingmonitoredcanbeapowerfulincentiveforpatientsandcanhelpthemwithstandurgestousedrugs.Monitoringalsoprovidesanearlyindicationofareturntodruguse,signalingapossibleneedtoadjustanindividual’streatmentplantobettermeethisorherneeds.

13. TreatmentprogramsshouldtestpatientsforthepresenceofHIV/AIDS,hepatitisBandC,tuberculosis,andotherinfectiousdiseasesaswellasprovidetargetedrisk-reductioncounseling,linkingpatientstotreatmentifnecessary.Typically,drugabusetreatmentaddressessomeofthedrug-relatedbehaviorsthatputpeopleatriskofinfectiousdiseases.Targetedcounselingfocusedonreducinginfectiousdiseaseriskcanhelppatientsfurtherreduceoravoidsubstance-relatedandotherhigh-riskbehaviors.Counselingcanalsohelpthosewhoarealreadyinfectedtomanagetheirillness.Moreover,engaginginsubstanceabusetreatmentcanfacilitateadherencetoothermedicaltreatments.Substanceabusetreatmentfacilitiesshouldprovideonsite,rapidHIVtestingratherthanreferralstooffsitetesting—researchshowsthatdoingsoincreasesthelikelihoodthatpatientswillbetestedandreceivetheirtestresults.Treatmentprovidersshouldalsoinformpatientsthathighlyactiveantiretroviraltherapy(HAART)hasproveneffectiveincombatingHIV,includingamongdrug-abusingpopulations,andhelplinkthemtoHIVtreatmentiftheytestpositive.

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FrequentlyAskedQuestions

Treatmentvariesdependingonthetypeofdrugandthecharacteristicsofthepatient.Thebestprogramsprovideacombinationoftherapiesandotherservices.

Whydodrug-addictedpersonskeepusingdrugs?

Nearlyalladdictedindividualsbelieveattheoutsetthattheycanstopusingdrugsontheirown,andmosttrytostopwithouttreatment.Althoughsomepeoplearesuccessful,manyattemptsresultinfailuretoachievelong-termabstinence.Researchhasshownthatlong-termdrugabuseresultsinchangesinthebrainthatpersistlongafterapersonstopsusingdrugs.Thesedrug-inducedchangesinbrainfunctioncanhavemanybehavioralconsequences,includinganinabilitytoexertcontrolovertheimpulsetousedrugsdespiteadverseconsequences—thedefiningcharacteristicofaddiction.

Long-termdruguseresultsinsignificantchangesinbrainfunctionthatcanpersistlongaftertheindividualstopsusingdrugs.

Understandingthataddictionhassuchafundamentalbiologicalcomponentmayhelpexplainthedifficultyofachievingandmaintainingabstinencewithouttreatment.Psychologicalstressfromwork,familyproblems,psychiatricillness,painassociatedwithmedicalproblems,socialcues(suchasmeetingindividualsfromone’sdrug-usingpast),orenvironmentalcues(suchasencounteringstreets,objects,orevensmellsassociatedwithdrugabuse)cantriggerintensecravingswithouttheindividualevenbeingconsciouslyawareofthetriggeringevent.Anyoneofthesefactorscanhinderattainmentofsustainedabstinenceandmakerelapsemorelikely.Nevertheless,researchindicatesthatactiveparticipationintreatmentisanessentialcomponentforgoodoutcomes

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andcanbenefiteventhemostseverelyaddictedindividuals.

Whatisdrugaddictiontreatment?

Drugtreatmentisintendedtohelpaddictedindividualsstopcompulsivedrugseekinganduse.Treatmentcanoccurinavarietyofsettings,takemanydifferentforms,andlastfordifferentlengthsoftime.Becausedrugaddictionistypicallyachronicdisordercharacterizedbyoccasionalrelapses,ashort-term,one-timetreatmentisusuallynotsufficient.Formany,treatmentisalong-termprocessthatinvolvesmultipleinterventionsandregularmonitoring.

Thereareavarietyofevidence-basedapproachestotreatingaddiction.Drugtreatmentcanincludebehavioraltherapy(suchascognitive-behavioraltherapyorcontingencymanagement),medications,ortheircombination.Thespecifictypeoftreatmentorcombinationoftreatmentswillvarydependingonthepatient’sindividualneedsand,often,onthetypesofdrugstheyuse.

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Drugaddictiontreatmentcanincludemedications,behavioraltherapies,ortheircombination.

Treatmentmedications,suchasmethadone,buprenorphine,andnaltrexone(includinganewlong-actingformulation),areavailableforindividualsaddictedtoopioids,whilenicotinepreparations(patches,gum,lozenges,andnasalspray)andthemedicationsvareniclineandbupropionareavailableforindividualsaddictedtotobacco.Disulfiram,acamprosate,andnaltrexonearemedicationsavailablefortreatingalcoholdependence, whichcommonlyco-occurswithotherdrugaddictions,includingaddictiontoprescriptionmedications.

Treatmentsforprescriptiondrugabusetendtobesimilartothoseforillicitdrugsthataffectthesamebrainsystems.Forexample,buprenorphine,usedtotreatheroinaddiction,canalsobeusedtotreataddictiontoopioidpainmedications.Addictiontoprescriptionstimulants,whichaffectthesamebrainsystemsasillicitstimulantslikecocaine,canbetreatedwithbehavioraltherapies,astherearenotyetmedicationsfortreatingaddictiontothesetypesofdrugs.

Behavioraltherapiescanhelpmotivatepeopletoparticipateindrugtreatment,offerstrategiesforcopingwithdrugcravings,teachwaystoavoiddrugsandpreventrelapse,andhelpindividualsdealwithrelapseifitoccurs.Behavioraltherapiescanalsohelppeopleimprovecommunication,relationship,andparentingskills,aswellasfamilydynamics.

Manytreatmentprogramsemploybothindividualandgrouptherapies.Grouptherapycanprovidesocialreinforcementandhelpenforcebehavioralcontingenciesthatpromoteabstinenceandanon-drug-usinglifestyle.Someofthemoreestablishedbehavioraltreatments,suchascontingencymanagementandcognitive-behavioraltherapy,arealsobeingadaptedforgroupsettingstoimproveefficiencyandcost-effectiveness.However,particularlyinadolescents,therecanalsobeadangerofunintendedharmful(oriatrogenic)effectsofgrouptreatment—sometimesgroupmembers(especiallygroupsofhighlydelinquentyouth)canreinforcedruguseandtherebyderailthepurposeofthetherapy.Thus,trainedcounselorsshouldbeawareofandmonitorforsuch

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effects.

Becausetheyworkondifferentaspectsofaddiction,combinationsofbehavioraltherapiesandmedications(whenavailable)generallyappeartobemoreeffectivethaneitherapproachusedalone.

Finally,peoplewhoareaddictedtodrugsoftensufferfromotherhealth(e.g.,depression,HIV),occupational,legal,familial,andsocialproblemsthatshouldbeaddressedconcurrently.Thebestprogramsprovideacombinationoftherapiesandotherservicestomeetanindividualpatient’sneeds.Psychoactivemedications,suchasantidepressants,anti-anxietyagents,moodstabilizers,andantipsychoticmedications,maybecriticalfortreatmentsuccesswhenpatientshaveco-occurringmentaldisorderssuchasdepression,anxietydisorders(includingpost-traumaticstressdisorder),bipolardisorder,orschizophrenia.Inaddition,mostpeoplewithsevereaddictionabusemultipledrugsandrequiretreatmentforallsubstancesabused.

Treatmentfordrugabuseandaddictionisdeliveredinmanydifferentsettingsusingavarietyofbehavioralandpharmacologicalapproaches.

Anotherdrug,topiramate,hasalsoshownpromiseinstudiesandissometimesprescribed(off-label)forthispurposealthoughithasnotreceivedFDAapprovalasatreatmentforalcoholdependence.

Howeffectiveisdrugaddictiontreatment?

Inadditiontostoppingdrugabuse,thegoaloftreatmentistoreturnpeopletoproductivefunctioninginthefamily,workplace,andcommunity.Accordingtoresearchthattracksindividualsintreatmentoverextendedperiods,mostpeoplewhogetintoandremainintreatmentstopusingdrugs,decreasetheircriminalactivity,andimprovetheiroccupational,social,andpsychologicalfunctioning.Forexample,methadonetreatmenthasbeenshowntoincrease

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participationinbehavioraltherapyanddecreasebothdruguseandcriminalbehavior.However,individualtreatmentoutcomesdependontheextentandnatureofthepatient’sproblems,theappropriatenessoftreatmentandrelatedservicesusedtoaddressthoseproblems,andthequalityofinteractionbetweenthepatientandhisorhertreatmentproviders.

Relapseratesforaddictionresemblethoseofotherchronicdiseasessuchasdiabetes,hypertension,andasthma.

Likeotherchronicdiseases,addictioncanbemanagedsuccessfully.Treatmentenablespeopletocounteractaddiction’spowerfuldisruptiveeffectsonthebrainandbehaviorandtoregaincontroloftheirlives.Thechronicnatureofthediseasemeansthatrelapsingtodrugabuseisnotonlypossiblebutalsolikely,withsymptomrecurrenceratessimilartothoseforotherwell-characterizedchronicmedicalillnesses—suchasdiabetes,hypertension,andasthma(seefigure,"ComparisonofRelapseRatesBetweenDrugAddictionandOtherChronicIllnesses”)—thatalsohavebothphysiologicalandbehavioralcomponents.

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Unfortunately,whenrelapseoccursmanydeemtreatmentafailure.Thisisnotthecase:Successfultreatmentforaddictiontypicallyrequirescontinualevaluationandmodificationasappropriate,similartotheapproachtakenforotherchronicdiseases.Forexample,whenapatientisreceivingactivetreatmentforhypertensionandsymptomsdecrease,treatmentisdeemedsuccessful,eventhoughsymptomsmayrecurwhentreatmentisdiscontinued.Fortheaddictedindividual,lapsestodrugabusedonotindicatefailure—rather,theysignifythattreatmentneedstobereinstatedoradjusted,orthatalternatetreatmentisneeded(seefigure,"WhyisAddictionTreatmentEvaluatedDifferently?").

Isdrugaddictiontreatmentworthitscost?

SubstanceabusecostsourNationover$600billionannuallyandtreatmentcanhelpreducethesecosts.Drugaddictiontreatmenthasbeenshowntoreduceassociatedhealthandsocialcostsbyfarmorethanthecostofthetreatmentitself.Treatmentisalsomuchlessexpensivethanitsalternatives,suchasincarceratingaddictedpersons.Forexample,theaveragecostfor1fullyearofmethadonemaintenancetreatmentisapproximately$4,700perpatient,whereas1fullyearofimprisonmentcostsapproximately$24,000perperson.

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Drugaddictiontreatmentreducesdruguseanditsassociatedhealthandsocialcosts.

Accordingtoseveralconservativeestimates,everydollarinvestedinaddictiontreatmentprogramsyieldsareturnofbetween$4and$7inreduceddrug-relatedcrime,criminaljusticecosts,andtheft.Whensavingsrelatedtohealthcareareincluded,totalsavingscanexceedcostsbyaratioof12to1.Majorsavingstotheindividualandtosocietyalsostemfromfewerinterpersonalconflicts;greaterworkplaceproductivity;andfewerdrug-relatedaccidents,includingoverdosesanddeaths.

Howlongdoesdrugaddictiontreatmentusuallylast?

Individualsprogressthroughdrugaddictiontreatmentatvariousrates,sothereisnopredeterminedlengthoftreatment.However,researchhasshownunequivocallythatgoodoutcomesarecontingentonadequatetreatmentlength.Generally,forresidentialoroutpatienttreatment,participationforlessthan90daysisoflimitedeffectiveness,andtreatmentlastingsignificantlylongerisrecommendedformaintainingpositiveoutcomes.Formethadonemaintenance,12monthsisconsideredtheminimum,andsomeopioid-addictedindividualscontinuetobenefitfrommethadonemaintenanceformanyyears.

Goodoutcomesarecontingentonadequatetreatmentlength.

Treatmentdropoutisoneofthemajorproblemsencounteredbytreatmentprograms;therefore,motivationaltechniquesthatcankeeppatientsengagedwillalsoimproveoutcomes.Byviewingaddictionasachronicdiseaseandofferingcontinuingcareandmonitoring,programscansucceed,butthiswilloftenrequiremultipleepisodesoftreatmentandreadilyreadmittingpatientsthathaverelapsed.

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Whathelpspeoplestayintreatment?

Becausesuccessfuloutcomesoftendependonaperson’sstayingintreatmentlongenoughtoreapitsfullbenefits,strategiesforkeepingpeopleintreatmentarecritical.Whetherapatientstaysintreatmentdependsonfactorsassociatedwithboththeindividualandtheprogram.Individualfactorsrelatedtoengagementandretentiontypicallyincludemotivationtochangedrug-usingbehavior;degreeofsupportfromfamilyandfriends;and,frequently,pressurefromthecriminaljusticesystem,childprotectionservices,employers,orfamily.Withinatreatmentprogram,successfulclinicianscanestablishapositive,therapeuticrelationshipwiththeirpatients.Theclinicianshouldensurethatatreatmentplanisdevelopedcooperativelywiththepersonseekingtreatment,thattheplanisfollowed,andthattreatmentexpectationsareclearlyunderstood.Medical,psychiatric,andsocialservicesshouldalsobeavailable.

Whetherapatientstaysintreatmentdependsonfactorsassociatedwithboththeindividualandtheprogram.

Becausesomeproblems(suchasseriousmedicalormentalillnessorcriminalinvolvement)increasethelikelihoodofpatientsdroppingoutoftreatment,intensiveinterventionsmayberequiredtoretainthem.Afteracourseofintensivetreatment,theprovidershouldensureatransitiontolessintensivecontinuingcaretosupportandmonitorindividualsintheirongoingrecovery.

Howdowegetmoresubstance-abusingpeopleintotreatment?

Ithasbeenknownformanyyearsthatthe"treatmentgap”ismassive—thatis,amongthosewhoneedtreatmentforasubstanceusedisorder,fewreceiveit.In2011,21.6millionpersonsaged12orolderneededtreatmentforanillicitdrugoralcoholuseproblem,butonly2.3millionreceivedtreatmentataspecialtysubstanceabusefacility.

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Reducingthisgaprequiresamultiprongedapproach.Strategiesincludeincreasingaccesstoeffectivetreatment,achievinginsuranceparity(nowinitsearliestphaseofimplementation),reducingstigma,andraisingawarenessamongbothpatientsandhealthcareprofessionalsofthevalueofaddictiontreatment.Toassistphysiciansinidentifyingtreatmentneedintheirpatientsandmakingappropriatereferrals,NIDAisencouragingwidespreaduseofscreening,briefintervention,andreferraltotreatment(SBIRT)toolsforuseinprimarycaresettingsthroughitsNIDAMEDinitiative.SBIRT,whichevidenceshowstobeeffectiveagainsttobaccoandalcoholuse—and,increasingly,againstabuseofillicitandprescriptiondrugs—hasthepotentialnotonlytocatchpeoplebeforeseriousdrugproblemsdevelop,butalsotoidentifypeopleinneedoftreatmentandconnectthemwithappropriatetreatmentproviders.

Howcanfamilyandfriendsmakeadifferenceinthelifeofsomeoneneedingtreatment?

Familyandfriendscanplaycriticalrolesinmotivatingindividualswithdrugproblemstoenterandstayintreatment.Familytherapycanalsobeimportant,especiallyforadolescents.Involvementofafamilymemberorsignificantotherinanindividual'streatmentprogramcanstrengthenandextendtreatmentbenefits.

Wherecanfamilymembersgoforinformationontreatmentoptions?

Tryingtolocateappropriatetreatmentforalovedone,especiallyfindingaprogramtailoredtoanindividual'sparticularneeds,canbeadifficultprocess.However,therearesomeresourcestohelpwiththisprocess.Forexample,NIDA’shandbookSeekingDrugAbuseTreatment:KnowWhattoAskoffersguidanceinfindingtherighttreatmentprogram.Numerousonlineresourcescanhelplocatealocalprogramorprovideotherinformation,including:

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TheSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA)maintainsaWebsite(www.findtreatment.samhsa.gov)thatshowsthelocationofresidential,outpatient,andhospitalinpatienttreatmentprogramsfordrugaddictionandalcoholismthroughoutthecountry.Thisinformationisalsoaccessiblebycalling1-800-662-HELP.

TheNationalSuicidePreventionLifeline(1-800-273-TALK)offersmorethanjustsuicideprevention—itcanalsohelpwithahostofissues,includingdrugandalcoholabuse,andcanconnectindividualswithanearbyprofessional.

TheNationalAllianceonMentalIllness(www.nami.org)andMentalHealthAmerica(www.mentalhealthamerica.net)arealliancesofnonprofit,self-helpsupportorganizationsforpatientsandfamiliesdealingwithavarietyofmentaldisorders.BothhaveStateandlocalaffiliatesthroughoutthecountryandmaybeespeciallyhelpfulforpatientswithcomorbidconditions.

TheAmericanAcademyofAddictionPsychiatryandtheAmericanAcademyofChildandAdolescentPsychiatryeachhavephysicianlocatortoolspostedontheirWebsitesataaap.organdaacap.org,respectively.

Faces&VoicesofRecovery(facesandvoicesofrecovery.org),foundedin2001,isanadvocacyorganizationforindividualsinlong-termrecoverythatstrategizesonwaystoreachouttothemedical,publichealth,criminaljustice,andothercommunitiestopromoteandcelebraterecoveryfromaddictiontoalcoholandotherdrugs.

ThePartnershipatDrugfree.org(drugfree.org)isanorganizationthatprovidesinformationandresourcesonteendruguseandaddictionforparents,tohelpthempreventandinterveneintheirchildren’sdruguseorfindtreatmentforachildwhoneedsit.Theyofferatoll-freehelplineforparents(1-855-378-4373).

TheAmericanSocietyofAddictionMedicine(asam.org)isasocietyofphysiciansaimedatincreasingaccesstoaddictiontreatment.TheirWebsitehasanationwidedirectoryofaddictionmedicineprofessionals.

NIDA’sNationalDrugAbuseTreatmentClinicalTrialsNetwork(drugabuse.gov/about-nida/organization/cctn/ctn)providesinformationforthoseinterestedinparticipatinginaclinicaltrialtestingapromisingsubstanceabuseintervention;orvisitclinicaltrials.gov.

NIDA’sDrugPubsResearchDisseminationCenter

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(drugpubs.drugabuse.gov)providesbooklets,pamphlets,factsheets,andotherinformationalresourcesondrugs,drugabuse,andtreatment.

TheNationalInstituteonAlcoholAbuseandAlcoholism(niaaa.nih.gov)providesinformationonalcohol,alcoholuse,andtreatmentofalcohol-relatedproblems(niaaa.nih.gov/search/node/treatment).

Howcantheworkplaceplayaroleinsubstanceabusetreatment?

ManyworkplacessponsorEmployeeAssistancePrograms(EAPs)thatoffershort-termcounselingand/orassistanceinlinkingemployeeswithdrugoralcoholproblemstolocaltreatmentresources,includingpeersupport/recoverygroups.Inaddition,therapeuticworkenvironmentsthatprovideemploymentfordrug-abusingindividualswhocandemonstrateabstinencehavebeenshownnotonlytopromoteacontinueddrug-freelifestylebutalsotoimprovejobskills,punctuality,andotherbehaviorsnecessaryforactiveemploymentthroughoutlife.Urinetestingfacilities,trainedpersonnel,andworkplacemonitorsareneededtoimplementthistypeoftreatment.

Whatrolecanthecriminaljusticesystemplayinaddressingdrugaddiction?

Itisestimatedthataboutone-halfofStateandFederalprisonersabuseorareaddictedtodrugs,butrelativelyfewreceivetreatmentwhileincarcerated.Initiatingdrugabusetreatmentinprisonandcontinuingituponreleaseisvitaltobothindividualrecoveryandtopublichealthandsafety.Variousstudieshaveshownthatcombiningprison-andcommunity-basedtreatmentforaddictedoffendersreducestheriskofbothrecidivismtodrug-relatedcriminalbehaviorandrelapsetodruguse—which,inturn,netshugesavingsinsocietalcosts.A2009studyinBaltimore,Maryland,forexample,foundthatopioid-addictedprisonerswhostartedmethadonetreatment(alongwithcounseling)inprisonandthencontinueditafterreleasehadbetteroutcomes(reduceddruguseandcriminalactivity)thanthosewhoonlyreceivedcounselingwhileinprisonorthosewhoonlystartedmethadonetreatmentaftertheirrelease.

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Individualswhoentertreatmentunderlegalpressurehaveoutcomesasfavorableasthosewhoentertreatmentvoluntarily.

Themajorityofoffendersinvolvedwiththecriminaljusticesystemarenotinprisonbutareundercommunitysupervision.Forthosewithknowndrugproblems,drugaddictiontreatmentmayberecommendedormandatedasaconditionofprobation.Researchhasdemonstratedthatindividualswhoentertreatmentunderlegalpressurehaveoutcomesasfavorableasthosewhoentertreatmentvoluntarily.

Thecriminaljusticesystemrefersdrugoffendersintotreatmentthroughavarietyofmechanisms,suchasdivertingnonviolentoffenderstotreatment;stipulatingtreatmentasaconditionofincarceration,probation,orpretrialrelease;andconveningspecializedcourts,ordrugcourts,thathandledrugoffensecases.Thesecourtsmandateandarrangefortreatmentasanalternativetoincarceration,activelymonitorprogressintreatment,andarrangeforotherservicesfordrug-involvedoffenders.

Themosteffectivemodelsintegratecriminaljusticeanddrugtreatmentsystemsandservices.Treatmentandcriminaljusticepersonnelworktogetherontreatmentplanning—includingimplementationofscreening,placement,testing,monitoring,andsupervision—aswellasonthesystematicuseofsanctionsandrewards.Treatmentforincarcerateddrugabusersshouldincludecontinuingcare,monitoring,andsupervisionafterincarcerationandduringparole.Methodstoachievebettercoordinationbetweenparole/probationofficersandhealthprovidersarebeingstudiedtoimproveoffenderoutcomes.(Formoreinformation,pleaseseeNIDA’sPrinciplesofDrugAbuseTreatmentforCriminalJusticePopulations:AResearch-BasedGuide[revised2012].)

Whataretheuniqueneedsofwomenwithsubstanceusedisorders?

Gender-relateddrugabusetreatmentshouldattendnotonlytobiological

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differencesbutalsotosocialandenvironmentalfactors,allofwhichcaninfluencethemotivationsfordruguse,thereasonsforseekingtreatment,thetypesofenvironmentswheretreatmentisobtained,thetreatmentsthataremosteffective,andtheconsequencesofnotreceivingtreatment.Manylifecircumstancespredominateinwomenasagroup,whichmayrequireaspecializedtreatmentapproach.Forexample,researchhasshownthatphysicalandsexualtraumafollowedbypost-traumaticstressdisorder(PTSD)ismorecommonindrug-abusingwomenthaninmenseekingtreatment.Otherfactorsuniquetowomenthatcaninfluencethetreatmentprocessincludeissuesaroundhowtheycomeintotreatment(aswomenaremorelikelythanmentoseektheassistanceofageneralormentalhealthpractitioner),financialindependence,andpregnancyandchildcare.

Whataretheuniqueneedsofpregnantwomenwithsubstanceusedisorders?

Usingdrugs,alcohol,ortobaccoduringpregnancyexposesnotjustthewomanbutalsoherdevelopingfetustothesubstanceandcanhavepotentiallydeleteriousandevenlong-termeffectsonexposedchildren.Smokingduringpregnancycanincreaseriskofstillbirth,infantmortality,suddeninfantdeathsyndrome,pretermbirth,respiratoryproblems,slowedfetalgrowth,andlowbirthweight.Drinkingduringpregnancycanleadtothechilddevelopingfetalalcoholspectrumdisorders,characterizedbylowbirthweightandenduringcognitiveandbehavioralproblems.

Prenataluseofsomedrugs,includingopioids,maycauseawithdrawalsyndromeinnewbornscalledneonatalabstinencesyndrome(NAS).BabieswithNASareatgreaterriskofseizures,respiratoryproblems,feedingdifficulties,lowbirthweight,andevendeath.

Researchhasestablishedthevalueofevidence-basedtreatmentsforpregnantwomen(andtheirbabies),includingmedications.Forexample,althoughnomedicationshavebeenFDA-approvedtotreatopioiddependenceinpregnantwomen,methadonemaintenancecombinedwithprenatalcareandacomprehensivedrugtreatmentprogramcanimprovemanyofthedetrimental

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outcomesassociatedwithuntreatedheroinabuse.However,newbornsexposedtomethadoneduringpregnancystillrequiretreatmentforwithdrawalsymptoms.Recently,anothermedicationoptionforopioiddependence,buprenorphine,hasbeenshowntoproducefewerNASsymptomsinbabiesthanmethadone,resultinginshorterinfanthospitalstays.Ingeneral,itisimportanttocloselymonitorwomenwhoaretryingtoquitdruguseduringpregnancyandtoprovidetreatmentasneeded.

Whataretheuniqueneedsofadolescentswithsubstanceusedisorders?

Adolescentdrugabusershaveuniqueneedsstemmingfromtheirimmatureneurocognitiveandpsychosocialstageofdevelopment.Researchhasdemonstratedthatthebrainundergoesaprolongedprocessofdevelopmentandrefinementfrombirththroughearlyadulthood.Overthecourseofthisdevelopmentalperiod,ayoungperson’sactionsgofrombeingmoreimpulsivetobeingmorereasonedandreflective.Infact,thebrainareasmostcloselyassociatedwithaspectsofbehaviorsuchasdecision-making,judgment,planning,andself-controlundergoaperiodofrapiddevelopmentduringadolescenceandyoungadulthood.

Adolescentdrugabuseisalsooftenassociatedwithotherco-occurringmentalhealthproblems.Theseincludeattention-deficithyperactivitydisorder(ADHD),oppositionaldefiantdisorder,andconductproblems,aswellasdepressiveandanxietydisorders.

Adolescentsarealsoespeciallysensitivetosocialcues,withpeergroupsandfamiliesbeinghighlyinfluentialduringthistime.Therefore,treatmentsthatfacilitatepositiveparentalinvolvement,integrateothersystemsinwhichtheadolescentparticipates(suchasschoolandathletics),andrecognizetheimportanceofprosocialpeerrelationshipsareamongthemosteffective.Accesstocomprehensiveassessment,treatment,casemanagement,andfamily-supportservicesthataredevelopmentally,culturally,andgender-appropriateisalsointegralwhenaddressingadolescentaddiction.

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Medicationsforsubstanceabuseamongadolescentsmayincertaincasesbehelpful.Currently,theonlyaddictionmedicationsapprovedbyFDAforpeopleunder18areover-the-countertransdermalnicotineskinpatches,chewinggum,andlozenges(physicianadviceshouldbesoughtfirst).Buprenorphine,amedicationfortreatingopioidaddictionthatmustbeprescribedbyspeciallytrainedphysicians,hasnotbeenapprovedforadolescents,butrecentresearchsuggestsitcouldbeeffectiveforthoseasyoungas16.Studiesareunderwaytodeterminethesafetyandefficacyofthisandothermedicationsforopioid-,nicotine-,andalcohol-dependentadolescentsandforadolescentswithco-occurringdisorders.

Aretherespecificdrugaddictiontreatmentsforolderadults?

Withtheagingofthebabyboomergeneration,thecompositionofthegeneralpopulationischangingdramaticallywithrespecttothenumberofolderadults.Suchachange,coupledwithagreaterhistoryoflifetimedruguse(thanpreviousoldergenerations),differentculturalnormsandgeneralattitudesaboutdruguse,andincreasesintheavailabilityofpsychotherapeuticmedications,isalreadyleadingtogreaterdrugusebyolderadultsandmayincreasesubstanceuseproblemsinthispopulation.Whilesubstanceabuseinolderadultsoftengoesunrecognizedandthereforeuntreated,researchindicatesthatcurrentlyavailableaddictiontreatmentprogramscanbeaseffectiveforthemasforyoungeradults.

Canapersonbecomeaddictedtomedicationsprescribedbyadoctor?

Yes.Peoplewhoabuseprescriptiondrugs—thatis,takingtheminamanneroradoseotherthanprescribed,ortakingmedicationsprescribedforanotherperson—riskaddictionandotherserioushealthconsequences.Suchdrugsincludeopioidpainrelievers,stimulantsusedtotreatADHD,andbenzodiazepinestotreatanxietyorsleepdisorders.Indeed,in2010,anestimated2.4millionpeople12oroldermetcriteriaforabuseofordependence

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onprescriptiondrugs,thesecondmostcommonillicitdruguseaftermarijuana.Tominimizetheserisks,aphysician(orotherprescribinghealthprovider)shouldscreenpatientsforpriororcurrentsubstanceabuseproblemsandassesstheirfamilyhistoryofsubstanceabuseoraddictionbeforeprescribingapsychoactivemedicationandmonitorpatientswhoareprescribedsuchdrugs.Physiciansalsoneedtoeducatepatientsaboutthepotentialriskssothattheywillfollowtheirphysician’sinstructionsfaithfully,safeguardtheirmedications,anddisposeofthemappropriately.

Isthereadifferencebetweenphysicaldependenceandaddiction?

Yes.Addiction—orcompulsivedrugusedespiteharmfulconsequences—ischaracterizedbyaninabilitytostopusingadrug;failuretomeetwork,social,orfamilyobligations;and,sometimes(dependingonthedrug),toleranceandwithdrawal.Thelatterreflectphysicaldependenceinwhichthebodyadaptstothedrug,requiringmoreofittoachieveacertaineffect(tolerance)andelicitingdrug-specificphysicalormentalsymptomsifdruguseisabruptlyceased(withdrawal).Physicaldependencecanhappenwiththechronicuseofmanydrugs—includingmanyprescriptiondrugs,eveniftakenasinstructed.Thus,physicaldependenceinandofitselfdoesnotconstituteaddiction,butitoftenaccompaniesaddiction.Thisdistinctioncanbedifficulttodiscern,particularlywithprescribedpainmedications,forwhichtheneedforincreasingdosagescanrepresenttoleranceoraworseningunderlyingproblem,asopposedtothebeginningofabuseoraddiction.

Howdoothermentaldisorderscoexistingwithdrugaddictionaffectdrugaddictiontreatment?

Drugaddictionisadiseaseofthebrainthatfrequentlyoccurswithothermentaldisorders.Infact,asmanyas6in10peoplewithanillicitsubstanceusedisorderalsosufferfromanothermentalillness;andratesaresimilarforusersoflicitdrugs—i.e.,tobaccoandalcohol.Fortheseindividuals,onecondition

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becomesmoredifficulttotreatsuccessfullyasanadditionalconditionisintertwined.Thus,peopleenteringtreatmenteitherforasubstanceusedisorderorforanothermentaldisordershouldbeassessedfortheco-occurrenceoftheothercondition.Researchindicatesthattreatingboth(ormultiple)illnessessimultaneouslyinanintegratedfashionisgenerallythebesttreatmentapproachforthesepatients.

Istheuseofmedicationslikemethadoneandbuprenorphinesimplyreplacingoneaddictionwithanother?

No.Buprenorphineandmethadoneareprescribedoradministeredundermonitored,controlledconditionsandaresafeandeffectivefortreatingopioidaddictionwhenusedasdirected.Theyareadministeredorallyorsublingually(i.e.,underthetongue)inspecifieddoses,andtheireffectsdifferfromthoseofheroinandotherabusedopioids.

Heroin,forexample,isofteninjected,snorted,orsmoked,causinganalmostimmediate"rush,"orbriefperiodofintenseeuphoria,thatwearsoffquicklyandendsina"crash."Theindividualthenexperiencesanintensecravingtousethedrugagaintostopthecrashandreinstatetheeuphoria.

Thecycleofeuphoria,crash,andcraving—sometimesrepeatedseveraltimesaday—isahallmarkofaddictionandresultsinseverebehavioraldisruption.Thesecharacteristicsresultfromheroin’srapidonsetandshortdurationofactioninthebrain.

Asusedinmaintenancetreatment,methadoneandbuprenorphinearenotheroin/opioidsubstitutes.

Incontrast,methadoneandbuprenorphinehavegradualonsetsofactionandproducestablelevelsofthedruginthebrain.Asaresult,patientsmaintained

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onthesemedicationsdonotexperiencearush,whiletheyalsomarkedlyreducetheirdesiretouseopioids.

Ifanindividualtreatedwiththesemedicationstriestotakeanopioidsuchasheroin,theeuphoriceffectsareusuallydampenedorsuppressed.Patientsundergoingmaintenancetreatmentdonotexperiencethephysiologicalorbehavioralabnormalitiesfromrapidfluctuationsindruglevelsassociatedwithheroinuse.Maintenancetreatmentssavelives—theyhelptostabilizeindividuals,allowingtreatmentoftheirmedical,psychological,andotherproblemssotheycancontributeeffectivelyasmembersoffamiliesandofsociety.

Wheredo12-steporself-helpprogramsfitintodrugaddictiontreatment?

Self-helpgroupscancomplementandextendtheeffectsofprofessionaltreatment.Themostprominentself-helpgroupsarethoseaffiliatedwithAlcoholicsAnonymous(AA),NarcoticsAnonymous(NA),andCocaineAnonymous(CA),allofwhicharebasedonthe12-stepmodel.Mostdrugaddictiontreatmentprogramsencouragepatientstoparticipateinself-helpgrouptherapyduringandafterformaltreatment.Thesegroupscanbeparticularlyhelpfulduringrecovery,offeringanaddedlayerofcommunity-levelsocialsupporttohelppeopleachieveandmaintainabstinenceandotherhealthylifestylebehaviorsoverthecourseofalifetime.

Canexerciseplayaroleinthetreatmentprocess?

Yes.Exerciseisincreasinglybecomingacomponentofmanytreatmentprogramsandhasproveneffective,whencombinedwithcognitive-behavioraltherapy,athelpingpeoplequitsmoking.Exercisemayexertbeneficialeffectsbyaddressingpsychosocialandphysiologicalneedsthatnicotinereplacementalonedoesnot,byreducingnegativefeelingsandstress,andbyhelpingpreventweightgainfollowingcessation.Researchtodetermineifandhow

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exerciseprogramscanplayasimilarroleinthetreatmentofotherformsofdrugabuseisunderway.

HowdoesdrugaddictiontreatmenthelpreducethespreadofHIV/AIDS,HepatitisC(HCV),andotherinfectiousdiseases?

Drug-abusingindividuals,includinginjectingandnon-injectingdrugusers,areatincreasedriskofhumanimmunodeficiencyvirus(HIV),hepatitisCvirus(HCV),andotherinfectiousdiseases.Thesediseasesaretransmittedbysharingcontaminateddruginjectionequipmentandbyengaginginriskysexualbehaviorsometimesassociatedwithdruguse.EffectivedrugabusetreatmentisHIV/HCVpreventionbecauseitreducesactivitiesthatcanspreaddisease,suchassharinginjectionequipmentandengaginginunprotectedsexualactivity.CounselingthattargetsarangeofHIV/HCVriskbehaviorsprovidesanaddedlevelofdiseaseprevention.

DrugabusetreatmentisHIVandHCVprevention.

InjectiondruguserswhodonotentertreatmentareuptosixtimesmorelikelytobecomeinfectedwithHIVthanthosewhoenterandremainintreatment.ParticipationintreatmentalsopresentsopportunitiesforHIVscreeningandreferraltoearlyHIVtreatment.Infact,recentresearchfromNIDA’sNationalDrugAbuseTreatmentClinicalTrialsNetworkshowedthatprovidingrapidonsiteHIVtestinginsubstanceabusetreatmentfacilitiesincreasedpatients’likelihoodofbeingtestedandofreceivingtheirtestresults.HIVcounselingandtestingarekeyaspectsofsuperiordrugabusetreatmentprogramsandshouldbeofferedtoallindividualsenteringtreatment.GreateravailabilityofinexpensiveandunobtrusiverapidHIVtestsshouldincreaseaccesstotheseimportantaspectsofHIVpreventionandtreatment.

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DrugAddictionTreatmentintheUnitedStates

Treatmentfordrugabuseandaddictionisdeliveredinmanydifferentsettings,usingavarietyofbehavioralandpharmacologicalapproaches.

Drugaddictionisacomplexdisorderthatcaninvolvevirtuallyeveryaspectofanindividual'sfunctioning—inthefamily,atworkandschool,andinthecommunity.

Becauseofaddiction'scomplexityandpervasiveconsequences,drugaddictiontreatmenttypicallymustinvolvemanycomponents.Someofthosecomponentsfocusdirectlyontheindividual'sdruguse;others,likeemploymenttraining,focusonrestoringtheaddictedindividualtoproductivemembershipinthefamilyandsociety(Seediagram"ComponentsofComprehensiveDrugAbuseTreatment"),enablinghimorhertoexperiencetherewardsassociatedwithabstinence.

Treatmentfordrugabuseandaddictionisdeliveredinmanydifferentsettingsusingavarietyofbehavioralandpharmacologicalapproaches.IntheUnitedStates,morethan14,500specializeddrugtreatmentfacilitiesprovidecounseling,behavioraltherapy,medication,casemanagement,andothertypesofservicestopersonswithsubstanceusedisorders.

Alongwithspecializeddrugtreatmentfacilities,drugabuseandaddictionaretreatedinphysicians'officesandmentalhealthclinicsbyavarietyofproviders,includingcounselors,physicians,psychiatrists,psychologists,nurses,andsocialworkers.Treatmentisdeliveredinoutpatient,inpatient,andresidentialsettings.Althoughspecifictreatmentapproachesoftenareassociatedwithparticulartreatmentsettings,avarietyoftherapeuticinterventionsorservicescanbeincludedinanygivensetting.

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Becausedrugabuseandaddictionaremajorpublichealthproblems,alargeportionofdrugtreatmentisfundedbylocal,State,andFederalgovernments.Privateandemployer-subsidizedhealthplansalsomayprovidecoveragefortreatmentofaddictionanditsmedicalconsequences.Unfortunately,managedcarehasresultedinshorteraveragestays,whileahistoricallackoforinsufficientcoverageforsubstanceabusetreatmenthascurtailedthenumberofoperationalprograms.Therecentpassageofparityforinsurancecoverageofmentalhealthandsubstanceabuseproblemswillhopefullyimprovethisstateofaffairs.HealthCareReform(i.e.,thePatientProtectionandAffordableCareActof2010,"ACA")alsostandstoincreasethedemandfordrugabusetreatmentservicesandpresentsanopportunitytostudyhowinnovationsinservicedelivery,organization,andfinancingcanimproveaccesstoanduseofthem.

TypesofTreatmentPrograms

Researchstudiesonaddictiontreatmenttypicallyhaveclassifiedprogramsintoseveralgeneraltypesormodalities.Treatmentapproachesandindividualprogramscontinuetoevolveanddiversify,andmanyprogramstodaydonotfitneatlyintotraditionaldrugadictiontreatmentclassifications.

Most,however,startwithdetoxificationandmedicallymanagedwithdrawal,oftenconsideredthefirststageoftreatment.Detoxification,theprocessbywhichthebodyclearsitselfofdrugs,isdesignedtomanagetheacuteandpotentiallydangerousphysiologicaleffectsofstoppingdruguse.Asstatedpreviously,detoxificationalonedoesnotaddressthepsychological,social,andbehavioralproblemsassociatedwithaddictionandthereforedoesnottypicallyproducelastingbehavioralchangesnecessaryforrecovery.Detoxificationshouldthusbefollowedbyaformalassessmentandreferraltodrugaddictiontreatment.

Becauseitisoftenaccompaniedbyunpleasantandpotentiallyfatalsideeffectsstemmingfromwithdrawal,detoxificationisoftenmanagedwithmedicationsadministeredbyaphysicianinaninpatientoroutpatientsetting;therefore,itisreferredtoas"medicallymanagedwithdrawal.”Medicationsareavailabletoassistinthewithdrawalfromopioids,benzodiazepines,alcohol,nicotine,

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barbiturates,andothersedatives.

FurtherReading:

Kleber,H.D.Outpatientdetoxificationfromopiates.PrimaryPsychiatry1:42-52,1996.

Long-TermResidentialTreatment

Long-termresidentialtreatmentprovidescare24hoursaday,generallyinnon-hospitalsettings.Thebest-knownresidentialtreatmentmodelisthetherapeuticcommunity(TC),withplannedlengthsofstayofbetween6and12months.TCsfocusonthe"resocialization"oftheindividualandusetheprogram’sentirecommunity—includingotherresidents,staff,andthesocialcontext—asactivecomponentsoftreatment.Addictionisviewedinthecontextofanindividual’ssocialandpsychologicaldeficits,andtreatmentfocusesondevelopingpersonalaccountabilityandresponsibilityaswellassociallyproductivelives.Treatmentishighlystructuredandcanbeconfrontationalattimes,withactivitiesdesignedtohelpresidentsexaminedamagingbeliefs,self-concepts,anddestructivepatternsofbehaviorandadoptnew,moreharmoniousandconstructivewaystointeractwithothers.ManyTCsoffercomprehensiveservices,whichcanincludeemploymenttrainingandothersupportservices,onsite.ResearchshowsthatTCscanbemodifiedtotreatindividualswithspecialneeds,includingadolescents,women,homelessindividuals,peoplewithseverementaldisorders,andindividualsinthecriminaljusticesystem(see"TreatingCriminalJustice-InvolvedDrugAbusersandAddictedIndividuals").

FurtherReading:

Lewis,B.F.;McCusker,J.;Hindin,R.;Frost,R.;andGarfield,F.Fourresidentialdrugtreatmentprograms: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.Modifiedtherapeuticcommunityforco-occurringdisorders:Asummaryoffourstudies.Journalof

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SubstanceAbuseTreatment34(1):112-122,2008.

Sacks,S.;Sacks,J.;DeLeon,G.;Bernhardt,A.;andStaines,G.Modifiedtherapeuticcommunityformentallyillchemical"abusers":Background;influences;programdescription;preliminaryfindings.SubstanceUseandMisuse32(9):1217-1259,1997.

Stevens,S.J.,andGlider,P.J.Therapeuticcommunities:Substanceabusetreatmentforwomen.In:F.M.Tims,G.DeLeon,andN.Jainchill(eds.),TherapeuticCommunity:AdvancesinResearchandApplication,NationalInstituteonDrugAbuseResearchMonograph144,NIHPub.No.94-3633,U.S.GovernmentPrintingOffice,pp.162-180,1994.

Sullivan,C.J.;McKendrick,K.;Sacks,S.;andBanks,S.M.ModifiedtherapeuticcommunityforoffenderswithMICAdisorders:Substanceuseoutcomes.AmericanJournalofDrugandAlcoholAbuse33(6):823-832,2007.

Short-TermResidentialTreatment

Short-termresidentialprogramsprovideintensivebutrelativelybrieftreatmentbasedonamodified12-stepapproach.Theseprogramswereoriginallydesignedtotreatalcoholproblems,butduringthecocaineepidemicofthemid-1980s,manybegantotreatothertypesofsubstanceusedisorders.Theoriginalresidentialtreatmentmodelconsistedofa3-to6-weekhospital-basedinpatienttreatmentphasefollowedbyextendedoutpatienttherapyandparticipationinaself-helpgroup,suchasAA.Followingstaysinresidentialtreatmentprograms,itisimportantforindividualstoremainengagedinoutpatienttreatmentprogramsand/oraftercareprograms.Theseprogramshelptoreducetheriskofrelapseonceapatientleavestheresidentialsetting.

FurtherReading:

Hubbard,R.L.;Craddock,S.G.;Flynn,P.M.;Anderson,J.;andEtheridge,R.M.Overviewof1-yearfollow-upoutcomesintheDrugAbuseTreatmentOutcomeStudy(DATOS).PsychologyofAddictiveBehaviors11(4):291-298,1998.

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Miller,M.M.Traditionalapproachestothetreatmentofaddiction.In:A.W.GrahamandT.K.Schultz(eds.),PrinciplesofAddictionMedicine(2nded.).Washington,D.C.:AmericanSocietyofAddictionMedicine,1998.

OutpatientTreatmentPrograms

Outpatienttreatmentvariesinthetypesandintensityofservicesoffered.Suchtreatmentcostslessthanresidentialorinpatienttreatmentandoftenismoresuitableforpeoplewithjobsorextensivesocialsupports.Itshouldbenoted,however,thatlow-intensityprogramsmayofferlittlemorethandrugeducation.Otheroutpatientmodels,suchasintensivedaytreatment,canbecomparabletoresidentialprogramsinservicesandeffectiveness,dependingontheindividualpatient’scharacteristicsandneeds.Inmanyoutpatientprograms,groupcounselingcanbeamajorcomponent.Someoutpatientprogramsarealsodesignedtotreatpatientswithmedicalorothermentalhealthproblemsinadditiontotheirdrugdisorders.

FurtherReading:

Hubbard,R.L.;Craddock,S.G.;Flynn,P.M.;Anderson,J.;andEtheridge,R.M.Overviewof1-yearfollow-upoutcomesintheDrugAbuseTreatmentOutcomeStudy(DATOS).PsychologyofAddictiveBehaviors11(4):291-298,1998.

InstituteofMedicine.TreatingDrugProblems.Washington,D.C.:NationalAcademyPress,1990.

McLellan,A.T.;Grisson,G.;Durell,J.;Alterman,A.I.;Brill,P.;andO'Brien,C.P.Substanceabusetreatmentintheprivatesetting:Aresomeprogramsmoreeffectivethanothers?JournalofSubstanceAbuseTreatment10:243-254,1993.

Simpson,D.D.,andBrown,B.S.Treatmentretentionandfollow-upoutcomesintheDrugAbuseTreatmentOutcomeStudy(DATOS).PsychologyofAddictiveBehaviors11(4):294-307,1998.

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IndividualizedDrugCounseling

Individualizeddrugcounselingnotonlyfocusesonreducingorstoppingillicitdrugoralcoholuse;italsoaddressesrelatedareasofimpairedfunctioning—suchasemploymentstatus,illegalactivity,andfamily/socialrelations—aswellasthecontentandstructureofthepatient’srecoveryprogram.Throughitsemphasisonshort-termbehavioralgoals,individualizedcounselinghelpsthepatientdevelopcopingstrategiesandtoolstoabstainfromdruguseandmaintainabstinence.Theaddictioncounselorencourages12-stepparticipation(atleastoneortwotimesperweek)andmakesreferralsforneededsupplementalmedical,psychiatric,employment,andotherservices.

GroupCounseling

Manytherapeuticsettingsusegrouptherapytocapitalizeonthesocialreinforcementofferedbypeerdiscussionandtohelppromotedrug-freelifestyles.Researchhasshownthatwhengrouptherapyeitherisofferedinconjunctionwithindividualizeddrugcounselingorisformattedtoreflecttheprinciplesofcognitive-behavioraltherapyorcontingencymanagement,positiveoutcomesareachieved.Currently,researchersaretestingconditionsinwhichgrouptherapycanbestandardizedandmademorecommunity-friendly.

TreatingCriminalJustice-InvolvedDrugAbusersandAddictedIndividuals

Often,drugabuserscomeintocontactwiththecriminaljusticesystemearlierthanotherhealthorsocialsystems,presentingopportunitiesforinterventionandtreatmentpriorto,during,after,orinlieuofincarceration.Researchhasshownthatcombiningcriminaljusticesanctionswithdrugtreatmentcanbeeffectiveindecreasingdrugabuseandrelatedcrime.Individualsunderlegalcoerciontendtostayintreatmentlongeranddoaswellasorbetterthanthosenotunderlegalpressure.Studiesshowthatforincarceratedindividualswithdrugproblems,startingdrugabusetreatmentinprisonandcontinuingthesametreatmentuponrelease—inotherwords,aseamlesscontinuumofservices—resultsinbetteroutcomes:lessdruguseandlesscriminalbehavior.Moreinformationonhowthecriminaljusticesystemcanaddresstheproblemofdrug

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addictioncanbefoundinPrinciplesofDrugAbuseTreatmentforCriminalJusticePopulations:AResearch-BasedGuide(NationalInstituteonDrugAbuse,revised2012).

TreatingCriminalJustice-InvolvedDrugAbusersandAddictedIndividuals

Often,drugabuserscomeintocontactwiththecriminaljusticesystemearlierthanotherhealthorsocialsystems,presentingopportunitiesforinterventionandtreatmentpriorto,during,after,orinlieuofincarceration.Researchhasshownthatcombiningcriminaljusticesanctionswithdrugtreatmentcanbeeffectiveindecreasingdrugabuseandrelatedcrime.Individualsunderlegalcoerciontendtostayintreatmentlongeranddoaswellasorbetterthanthosenotunderlegalpressure.Studiesshowthatforincarceratedindividualswithdrugproblems,startingdrugabusetreatmentinprisonandcontinuingthesametreatmentuponrelease—inotherwords,aseamlesscontinuumofservices—resultsinbetteroutcomes:lessdruguseandlesscriminalbehavior.MoreinformationonhowthecriminaljusticesystemcanaddresstheproblemofdrugaddictioncanbefoundinPrinciplesofDrugAbuseTreatmentforCriminalJusticePopulations:AResearch-BasedGuide(NationalInstituteonDrugAbuse,revised2012).

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Evidence-BasedApproachestoDrugAddictionTreatment

Eachapproachtodrugtreatmentisdesignedtoaddresscertainaspectsofdrugaddictionanditsconsequencesfortheindividual,family,andsociety.

Thissectionpresentsexamplesoftreatmentapproachesandcomponentsthathaveanevidencebasesupportingtheiruse.Eachapproachisdesignedtoaddresscertainaspectsofdrugaddictionanditsconsequencesfortheindividual,family,andsociety.Someoftheapproachesareintendedtosupplementorenhanceexistingtreatmentprograms,andothersarefairlycomprehensiveinandofthemselves.

ThefollowingsectionisbrokendownintoPharmacotherapies,BehavioralTherapies,andBehavioralTherapiesPrimarilyforAdolescents.Theyarefurthersubdividedaccordingtoparticularsubstanceusedisorders.Thislistisnotexhaustive,andnewtreatmentsarecontinuallyunderdevelopment.

Pharmacotherapies

OpioidAddiction

Methadone

Methadoneisalong-actingsyntheticopioidagonistmedicationthatcanpreventwithdrawalsymptomsandreducecravinginopioid-addictedindividuals.Itcanalsoblocktheeffectsofillicitopioids.Ithasalonghistoryofuseintreatmentofopioiddependenceinadultsandistakenorally.MethadonemaintenancetreatmentisavailableinallbutthreeStatesthroughspeciallylicensedopioidtreatmentprogramsormethadonemaintenanceprograms.

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Combinedwithbehavioraltreatment:Researchhasshownthatmethadonemaintenanceismoreeffectivewhenitincludesindividualand/orgroupcounseling,withevenbetteroutcomeswhenpatientsareprovidedwith,orreferredto,otherneededmedical/psychiatric,psychological,andsocialservices(e.g.,employmentorfamilyservices).

FurtherReading:

Dole,V.P.;Nyswander,M.;andKreek,M.J.Narcoticblockade.ArchivesofInternalMedicine118:304–309,1966.

McLellan,A.T.;Arndt,I.O.;Metzger,D.;Woody,G.E.;andO’Brien,C.P.Theeffectsofpsychosocialservicesinsubstanceabusetreatment.TheJournaloftheAmericanMedicalAssociation269(15):1953–1959,1993.

TheRockerfellerUniversity.Thefirstpharmacologicaltreatmentfornarcoticaddiction:Methadonemaintenance.TheRockefellerUniversityHospitalCentennial,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

Buprenorphineisasyntheticopioidmedicationthatactsasapartialagonistatopioidreceptors—itdoesnotproducetheeuphoriaandsedationcausedbyheroinorotheropioidsbutisabletoreduceoreliminatewithdrawalsymptomsassociatedwithopioiddependenceandcarriesalowriskofoverdose.

Buprenorphineiscurrentlyavailableintwoformulationsthataretakensublingually:(1)apureformofthedrugand(2)amorecommonlyprescribedformulationcalledSuboxone,whichcombinesbuprenorphinewiththedrugnaloxone,anantagonist(orblocker)atopioidreceptors.Naloxonehasnoeffect

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whenSuboxoneistakenasprescribed,butifanaddictedindividualattemptstoinjectSuboxone,thenaloxonewillproduceseverewithdrawalsymptoms.Thus,thisformulationlessensthelikelihoodthatthedrugwillbeabusedordivertedtoothers.

Buprenorphinetreatmentfordetoxificationand/ormaintenancecanbeprovidedinoffice-basedsettingsbyqualifiedphysicianswhohavereceivedawaiverfromtheDrugEnforcementAdministration(DEA),allowingthemtoprescribeit.Theavailabilityofoffice-basedtreatmentforopioidaddictionisacost-effectiveapproachthatincreasesthereachoftreatmentandtheoptionsavailabletopatients.

Buprenorphineisalsoavailableasinanimplantandinjection.TheU.S.FoodandDrugAdministration(FDA)approveda6-monthsubdermalbuprenorphineimplantinMay2016andaonce-monthlybuprenorphineinjectioninNovember2017.

FurtherReading:

Fiellin,D.A.;Pantalon,M.V.;Chawarski,M.C.;Moore,B.A.;Sullivan,L.E.;O’Connor,P.G.;andSchottenfeld,R.S.Counselingplusbuprenorphine/naloxonemaintenancetherapyforopioiddependence.TheNewEnglandJournalofMedicine355(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.fortheBuprenorphine/NaloxoneCollaborativeStudyGroup.Office-basedtreatmentofopiateaddictionwithasublingual-tabletformulationofbuprenorphineandnaloxone.TheNewEnglandJournalofMedicine349(10):949–958,2003.

Kosten,T.R.;andFiellin,D.A.U.S.NationalBuprenorphineImplementationProgram:Buprenorphineforoffice-basedpractice.Consensusconferenceoverview.TheAmericanJournalonAddictions13(Suppl.1):S1–S7,2004.

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McCance-Katz,E.F.Office-basedbuprenorphinetreatmentforopioid-dependentpatients.HarvardReviewofPsychiatry12(6):321–338,2004.

Treatment,notSubstitution

Becausemethadoneandbuprenorphinearethemselvesopioids,somepeopleviewthesetreatmentsforopioiddependenceasjustsubstitutionsofoneaddictivedrugforanother(seeQuestion19).Buttakingthesemedicationsasprescribedallowspatientstoholdjobs,avoidstreetcrimeandviolence,andreducetheirexposuretoHIVbystoppingordecreasinginjectiondruguseanddrug-relatedhigh-risksexualbehavior.Patientsstabilizedonthesemedicationscanalsoengagemorereadilyincounselingandotherbehavioralinterventionsessentialtorecovery.

Naltrexone

Naltrexoneisasyntheticopioidantagonist—itblocksopioidsfrombindingtotheirreceptorsandtherebypreventstheireuphoricandothereffects.Ithasbeenusedformanyyearstoreverseopioidoverdoseandisalsoapprovedfortreatingopioidaddiction.Thetheorybehindthistreatmentisthattherepeatedabsenceofthedesiredeffectsandtheperceivedfutilityofabusingopioidswillgraduallydiminishcravingandaddiction.Naltrexoneitselfhasnosubjectiveeffectsfollowingdetoxification(thatis,apersondoesnotperceiveanyparticulardrugeffect),ithasnopotentialforabuse,anditisnotaddictive.

Naltrexoneasatreatmentforopioidaddictionisusuallyprescribedinoutpatientmedicalsettings,althoughthetreatmentshouldbeginaftermedicaldetoxificationinaresidentialsettinginordertopreventwithdrawalsymptoms.

Naltrexonemustbetakenorally—eitherdailyorthreetimesaweek—butnoncompliancewithtreatmentisacommonproblem.Manyexperiencedclinicianshavefoundnaltrexonebestsuitedforhighlymotivated,recentlydetoxifiedpatientswhodesiretotalabstinencebecauseofexternalcircumstances—forinstance,professionalsorparolees.Recently,along-acting

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injectableversionofnaltrexone,calledVivitrol,wasapprovedtotreatopioidaddiction.Becauseitonlyneedstobedeliveredonceamonth,thisversionofthedrugcanfacilitatecomplianceandoffersanalternativeforthosewhodonotwishtobeplacedonagonist/partialagonistmedications.

FurtherReading:

Cornish,J.W.;Metzger,D.;Woody,G.E.;Wilson,D.;McClellan,A.T.;andVandergrift,B.Naltrexonepharmacotherapyforopioiddependentfederalprobationers.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.Efficacyandsafetyofextended-releaseinjectablenaltrexone(XR-NTX)forthetreatmentofopioiddependence.Paperpresentedatthe2010annualmeetingoftheAmericanPsychiatricAssociation,NewOrleans,LA.

ComparingBuprenorphineandNaltrexone

ANIDAstudycomparingtheeffectivenessofabuprenorphine/naloxonecombinationandanextendedreleasenaltrexoneformulationontreatingopioidusedisorderhasfoundthatbothmedicationsaresimilarlyeffectiveintreatingopioidusedisorderoncetreatmentisinitiated.Becausenaltrexonerequiresfulldetoxification,initiatingtreatmentamongactiveopioiduserswasmoredifficultwiththismedication.However,oncedetoxificationwascomplete,thenaltrexoneformulationhadasimilareffectivenessasthebuprenorphine/naloxonecombination.

TobaccoAddiction

NicotineReplacementTherapy(NRT)

Avarietyofformulationsofnicotinereplacementtherapies(NRTs)nowexist,

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includingthetransdermalnicotinepatch,nicotinespray,nicotinegum,andnicotinelozenges.Becausenicotineisthemainaddictiveingredientintobacco,therationaleforNRTisthatstablelowlevelsofnicotinewillpreventwithdrawalsymptoms—whichoftendrivecontinuedtobaccouse—andhelpkeeppeoplemotivatedtoquit.Researchshowsthatcombiningthepatchwithanotherreplacementtherapyismoreeffectivethanasingletherapyalone.

Bupropion(Zyban )

Bupropionwasoriginallymarketedasanantidepressant(Wellbutrin).Itproducesmildstimulanteffectsbyblockingthereuptakeofcertainneurotransmitters,especiallynorepinephrineanddopamine.Aserendipitousobservationamongdepressedpatientswasthatthemedicationwasalsoeffectiveinsuppressingtobaccocraving,helpingthemquitsmokingwithoutalsogainingweight.Althoughbupropion’sexactmechanismsofactioninfacilitatingsmokingcessationareunclear,ithasFDAapprovalasasmokingcessationtreatment.

Varenicline(Chantix )

VareniclineisthemostrecentlyFDA-approvedmedicationforsmokingcessation.Itactsonasubsetofnicotinicreceptorsinthebrainthoughttobeinvolvedintherewardingeffectsofnicotine.Vareniclineactsasapartialagonist/antagonistatthesereceptors—thismeansthatitmidlystimulatesthenicotinereceptorbutnotsufficientlytotriggerthereleaseofdopamine,whichisimportantfortherewardingeffectsofnicotine.Asanantagonist,vareniclinealsoblockstheabilityofnicotinetoactivatedopamine,interferingwiththereinforcingeffectsofsmoking,therebyreducingcravingsandsupportingabstinencefromsmoking.

CombinedWithBehavioralTreatment

Eachoftheabovepharmacotherapiesisrecommendedforuseincombinationwithbehavioralinterventions,includinggroupandindividualtherapies,aswellastelephonequitlines.Behavioralapproachescomplementmosttobaccoaddictiontreatmentprograms.Theycanamplifytheeffectsofmedicationsby

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teachingpeoplehowtomanagestress,recognizeandavoidhigh-risksituationsforsmokingrelapse,anddevelopalternativecopingstrategies(e.g.,cigaretterefusalskills,assertiveness,andtimemanagementskills)thattheycanpracticeintreatment,social,andworksettings.Combinedtreatmentisurgedbecausebehavioralandpharmacologicaltreatmentsarethoughttooperatebydifferentyetcomplementarymechanismsthatcanhaveadditiveeffects.

FurtherReading:

Alterman,A.I.;Gariti,P.;andMulvaney,F.Short-andlong-termsmokingcessationforthreelevelsofintensityofbehavioraltreatment.PsychologyofAddictiveBehaviors15:261-264,2001.

Hall,S.M.;Humfleet,G.L.;Muñoz,R.F.;V.I;Prochaska,J.J.;andRobbins,J.A.Usingextendedcognitivebehavioraltreatmentandmedicationtotreatdependentsmokers.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:Arandomizedcontrolledtrial.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.Systematicreviewandmeta-analysisofcombinationtherapyforsmokingcessation.JournaloftheAmericanPharmaceuticalAssociation48(5):659–665,2008.

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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.Comparativeeffectivenessof5smokingcessationpharmacotherapiesinprimarycareclinics.ArchivesofInternalMedicine169:2148–2155,2009.

Stitzer,M.Combinedbehavioralandpharmacologicaltreatmentsforsmokingcessation.Nicotine&TobaccoResearch1:S181–S187,1999.

AlcoholAddiction

Naltrexone

Naltrexoneblocksopioidreceptorsthatareinvolvedintherewardingeffectsofdrinkingandthecravingforalcohol.Ithasbeenshowntoreducerelapsetoproblemdrinkinginsomepatients.Anextendedreleaseversion,Vivitrol—administeredonceamonthbyinjection—isalsoFDA-approvedfortreatingalcoholism,andmayofferbenefitsregardingcompliance.

Acamprosate

Acamprosate(Campral )actsonthegamma-aminobutyricacid(GABA)andglutamateneurotransmittersystemsandisthoughttoreducesymptomsofprotractedwithdrawal,suchasinsomnia,anxiety,restlessness,anddysphoria.Acamprosatehasbeenshowntohelpdependentdrinkersmaintainabstinenceforseveralweekstomonths,anditmaybemoreeffectiveinpatientswithseveredependence.

Disulfiram

Disulfiram(Antabuse )interfereswithdegradationofalcohol,resultingintheaccumulationofacetaldehyde,which,inturn,producesaveryunpleasantreactionthatincludesflushing,nausea,andplapitationsifapersondrinksalcohol.Theutilityandeffectivenessofdisulfiramareconsideredlimitedbecausecomplianceisgenerallypoor.However,amongpatientswhoarehighlymotivated,disulfiramcanbeeffective,andsomepatientsuseit

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episodicallyforhigh-risksituations,suchassocialoccasionswherealcoholispresent.Itcanalsobeadministeredinamonitoredfashion,suchasinaclinicorbyaspouse,improvingitsefficacy.

Topiramate

Topiramateisthoughttoworkbyincreasinginhibitory(GABA)neurotransmissionandreducingstimulatory(glutamate)neurotransmission,althoughitsprecisemechanismofactionisnotknown.AlthoughtopiramatehasnotyetreceivedFDAapprovalfortreatingalcoholaddiction,itissometimesusedoff-labelforthispurpose.Topiramatehasbeenshowninstudiestosignificantlyimprovemultipledrinkingoutcomes,comparedwithaplacebo.

CombinedWithBehavioralTreatment

Whileanumberofbehavioraltreatmentshavebeenshowntobeeffectiveinthetreatmentofalcoholaddiction,itdoesnotappearthatanadditiveeffectexistsbetweenbehavioraltreatmentsandpharmacotherapy.Studieshaveshownthatjustgettinghelpisoneofthemostimportantfactorsintreatingalcoholaddiction;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.,fortheCOMBINEStudyResearchGroup.Combinedpharmacotherapiesandbehavioralinterventionsforalcoholdependence:TheCOMBINEstudy:Arandomizedcontrolledtrial.TheJournaloftheAmericanMedicalAssociation295(17):2003–2017,2006.

NationalInstituteonAlcoholAbuseandAlcoholism.HelpingPatientsWhoDrinkTooMuch:AClinician’sGuide,Updated2005Edition.Bethesda,MD:NIAAA,updated2005.Availableatpubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm

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BehavioralTherapies

Behavioralapproacheshelpengagepeopleindrugabusetreatment,provideincentivesforthemtoremainabstinent,modifytheirattitudesandbehaviorsrelatedtodrugabuse,andincreasetheirlifeskillstohandlestressfulcircumstancesandenvironmentalcuesthatmaytriggerintensecravingfordrugsandpromptanothercycleofcompulsiveabuse.Belowareanumberofbehavioraltherapiesshowntobeeffectiveinaddressingsubstanceabuse(effectivenesswithparticulardrugsofabuseisdenotedinparentheses).

Cognitive-BehavioralTherapy(Alcohol,Marijuana,Cocaine,Methamphetamine,Nicotine)

Cognitive-BehavioralTherapy(CBT)wasdevelopedasamethodtopreventrelapsewhentreatingproblemdrinking,andlateritwasadaptedforcocaine-addictedindividuals.Cognitive-behavioralstrategiesarebasedonthetheorythatinthedevelopmentofmaladaptivebehavioralpatternslikesubstanceabuse,learningprocessesplayacriticalrole.IndividualsinCBTlearntoidentifyandcorrectproblematicbehaviorsbyapplyingarangeofdifferentskillsthatcanbeusedtostopdrugabuseandtoaddressarangeofotherproblemsthatoftenco-occurwithit.

AcentralelementofCBTisanticipatinglikelyproblemsandenhancingpatients’self-controlbyhelpingthemdevelopeffectivecopingstrategies.Specifictechniquesincludeexploringthepositiveandnegativeconsequencesofcontinueddruguse,self-monitoringtorecognizecravingsearlyandidentifysituationsthatmightputoneatriskforuse,anddevelopingstrategiesforcopingwithcravingsandavoidingthosehigh-risksituations.

Researchindicatesthattheskillsindividualslearnthroughcognitive-behavioralapproachesremainafterthecompletionoftreatment.CurrentresearchfocusesonhowtoproduceevenmorepowerfuleffectsbycombiningCBTwithmedicationsfordrugabuseandwithothertypesofbehavioraltherapies.Acomputer-basedCBTsystemhasalsobeendevelopedandhasbeenshowntobeeffectiveinhelpingreducedrugusefollowingstandarddrugabuse

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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.Theuseofcontingencymanagementandmotivational/skills-buildingtherapytotreatyoungadultswithmarijuanadependence.JournalofConsultingandClinicalPsychology74(5):955–966,2006.

Carroll,K.M.;andOnken,L.S.Behavioraltherapiesfordrugabuse.TheAmericanJournalofPsychiatry168(8):1452–1460,2005.

Carroll,K.M.;Sholomskas,D.;Syracuse,G.;Ball,S.A.;Nuro,K.;andFenton,L.R.Wedon’ttraininvain:Adisseminationtrialofthreestrategiesoftrainingcliniciansincognitive-behavioraltherapy.JournalofConsultingandClinicalPsychology73(1):106–115,2005.

Carroll,K.;Fenton,L.R.;Ball,S.A.;Nich,C.;Frankforter,T.L.;Shi,J.;andRounsaville,B.J.Efficacyofdisulfiramandcognitivebehaviortherapyincocaine-dependentoutpatients:Arandomizedplacebo-controlledtrial.ArchivesofGeneralPsychiatry61(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-assisteddeliveryofcognitive-behavioraltherapyforaddiction:arandomizedtrialofCBT4CBT.TheAmericanJournalofPsychiatry165(7):881–888,2008.

ContingencyManagementInterventions/MotivationalIncentives(Alcohol,Stimulants,Opioids,Marijuana,Nicotine)

Researchhasdemonstratedtheeffectivenessoftreatmentapproachesusingcontingencymanagement(CM)principles,whichinvolvegivingpatients

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tangiblerewardstoreinforcepositivebehaviorssuchasabstinence.Studiesconductedinbothmethadoneprogramsandpsychosocialcounselingtreatmentprogramsdemonstratethatincentive-basedinterventionsarehighlyeffectiveinincreasingtreatmentretentionandpromotingabstinencefromdrugs.

Voucher-BasedReinforcement(VBR)augmentsothercommunity-basedtreatmentsforadultswhoprimarilyabuseopioids(especiallyheroin)orstimulants(especiallycocaine)orboth.InVBR,thepatientreceivesavoucherforeverydrug-freeurinesampleprovided.Thevoucherhasmonetaryvaluethatcanbeexchangedforfooditems,moviepasses,orothergoodsorservicesthatareconsistentwithadrug-freelifestyle.Thevouchervaluesarelowatfirst,butincreaseasthenumberofconsecutivedrug-freeurinesamplesincreases;positiveurinesamplesresetthevalueofthevoucherstotheinitiallowvalue.VBRhasbeenshowntobeeffectiveinpromotingabstinencefromopioidsandcocaineinpatientsundergoingmethadonedetoxification.

PrizeIncentivesCMappliessimilarprinciplesasVBRbutuseschancestowincashprizesinsteadofvouchers.Overthecourseoftheprogram(atleast3months,oneormoretimesweekly),participantssupplyingdrug-negativeurineorbreathtestsdrawfromabowlforthechancetowinaprizeworthbetween$1and$100.Participantsmayalsoreceivedrawsforattendingcounselingsessionsandcompletingweeklygoal-relatedactivities.Thenumberofdrawsstartsatoneandincreaseswithconsecutivenegativedrugtestsand/orcounselingsessionsattendedbutresetstoonewithanydrug-positivesampleorunexcusedabsence.Thepractitionercommunityhasraisedconcernsthatthisinterventioncouldpromotegambling—asitcontainsanelementofchance—andthatpathologicalgamblingandsubstanceusedisorderscanbecomorbid.However,studiesexaminingthisconcernfoundthatPrizeIncentivesCMdidnotpromotegamblingbehavior.

FurtherReading:

Budney,A.J.;Moore,B.A.;Rocha,H.L.;andHiggins,S.T.Clinicaltrialofabstinence-basedvouchersandcognitivebehavioraltherapyforcannabisdependence.JournalofConsultingandClinicalPsychology74(2):307–316,2006.

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Budney,A.J.;Roffman,R.;Stephens,R.S.;andWalker,D.Marijuanadependenceanditstreatment.AddictionScience&ClinicalPractice4(1):4–16,2007.

Elkashef,A.;Vocci,F.;Huestis,M.;Haney,M.;Budney,A.;Gruber,A.;andel-Guebaly,N.Marijuananeurobiologyandtreatment.SubstanceAbuse29(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.Effectsoflower-costincentivesonstimulantabstinenceinmethadonemaintenancetreatment: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.Effectofprizebasedincentivesonoutcomesinstimulantabusersinoutpatientpsychosocialtreatmentprograms:ANationalDrugAbuseTreatmentClinicalTrialsNetworkstudy.ArchivesofGeneralPsychiatry62(10):1148–1156,2005.

Petry,N.M.;Kolodner,K.B.;Li,R.;Peirce,J.M.;Roll,J.M.;Stitzer,M.L.;andHamilton,J.A.Prize-basedcontingencymanagementdoesnotincreasegambling.DrugandAlcoholDependence83(3):269–273,2006.

Prendergast,M.;Podus,D.;Finney,J.;Greenwell,L.;andRoll,J.Contingencymanagementfortreatmentofsubstanceusedisorders: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.Contingencymanagementforthetreatmentofmethamphetamineusedisorders.TheAmericanJournalofPsychiatry163(11):1993–1999,2006.

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CommunityReinforcementApproachPlusVouchers(Alcohol,Cocaine,Opioids)

CommunityReinforcementApproach(CRA)PlusVouchersisanintensive24-weekoutpatienttherapyfortreatingpeopleaddictedtococaineandalcohol.Itusesarangeofrecreational,familial,social,andvocationalreinforcers,alongwithmaterialincentives,tomakeanon-drug-usinglifestylemorerewardingthansubstanceuse.Thetreatmentgoalsaretwofold:

Tomaintainabstinencelongenoughforpatientstolearnnewlifeskillstohelpsustainit;and

Toreducealcoholconsumptionforpatientswhosedrinkingisassociatedwithcocaineuse

Patientsattendoneortwoindividualcounselingsessionseachweek,wheretheyfocusonimprovingfamilyrelations,learnavarietyofskillstominimizedruguse,receivevocationalcounseling,anddevelopnewrecreationalactivitiesandsocialnetworks.Thosewhoalsoabusealcoholreceiveclinic-monitoreddisulfiram(Antabuse)therapy.Patientssubmiturinesamplestwoorthreetimeseachweekandreceivevouchersforcocaine-negativesamples.AsinVBR,thevalueofthevouchersincreaseswithconsecutivecleansamples,andthevouchersmaybeexchangedforretailgoodsthatareconsistentwithadrug-freelifestyle.Studiesinbothurbanandruralareashavefoundthatthisapproachfacilitatespatients’engagementintreatmentandsuccessfullyaidsthemingainingsubstantialperiodsofcocaineabstinence.

Acomputer-basedversionofCRAPlusVoucherscalledtheTherapeuticEducationSystem(TES)wasfoundtobenearlyaseffectiveastreatmentadministeredbyatherapistinpromotingabstinencefromopioidsandcocaineamongopioid-dependentindividualsinoutpatienttreatment.AversionofCRAforadolescentsaddressesproblem-solving,coping,andcommunicationskillsandencouragesactiveparticipationinpositivesocialandrecreationalactivities.

FurtherReading:

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Brooks,A.C.;Ryder,D.;Carise,D.;andKirby,K.C.Feasibilityandeffectivenessofcomputer-basedtherapyincommunitytreatment.JournalofSubstanceAbuseTreatment39(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.Asystemicreviewoftheeffectivenessofthecommunityreinforcementapproachinalcohol,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.Sustainedcocaineabstinenceinmethadonemaintenancepatientsthroughvoucher-basedreinforcementtherapy.ArchivesofGeneralPsychiatry53(5):409–415,1996.

Smith,J.E.;Meyers,R.J.;andDelaney,H.D.Thecommunityreinforcementapproachwithhomelessalcohol-dependentindividuals.JournalofConsultingandClinicalPsychology66(3):541–548,1998.

Stahler,G.J.;Shipley,T.E.;Kirby,K.C.;Godboldte,C.;Kerwin,M.E;Shandler,I.;andSimons,L.Developmentandinitialdemonstrationofacommunity-basedinterventionforhomeless,cocaine-using,African-Americanwomen.JournalofSubstanceAbuseTreatment28(2):171–179,2005.

MotivationalEnhancementTherapy(Alcohol,Marijuana,Nicotine)

MotivationalEnhancementTherapy(MET)isacounselingapproachthathelpsindividualsresolvetheirambivalenceaboutengagingintreatmentandstoppingtheirdruguse.Thisapproachaimstoevokerapidandinternallymotivatedchange,ratherthanguidethepatientstepwisethroughtherecoveryprocess.

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Thistherapyconsistsofaninitialassessmentbatterysession,followedbytwotofourindividualtreatmentsessionswithatherapist.Inthefirsttreatmentsession,thetherapistprovidesfeedbacktotheinitialassessment,stimulatingdiscussionaboutpersonalsubstanceuseandelicitingself-motivationalstatements.Motivationalinterviewingprinciplesareusedtostrengthenmotivationandbuildaplanforchange.Copingstrategiesforhigh-risksituationsaresuggestedanddiscussedwiththepatient.Insubsequentsessions,thetherapistmonitorschange,reviewscessationstrategiesbeingused,andcontinuestoencouragecommitmenttochangeorsustainedabstinence.Patientssometimesareencouragedtobringasignificantothertosessions.

ResearchonMETsuggeststhatitseffectsdependonthetypeofdrugusedbyparticipantsandonthegoaloftheintervention.Thisapproachhasbeenusedsuccessfullywithpeopleaddictedtoalcoholtobothimprovetheirengagementintreatmentandreducetheirproblemdrinking.METhasalsobeenusedsuccessfullywithmarijuana-dependentadultswhencombinedwithcognitive-behavioraltherapy,constitutingamorecomprehensivetreatmentapproach.TheresultsofMETaremixedforpeopleabusingotherdrugs(e.g.,heroin,cocaine,nicotine)andforadolescentswhotendtousemultipledrugs.Ingeneral,METseemstobemoreeffectiveforengagingdrugabusersintreatmentthanforproducingchangesindruguse.

FurtherReading:

Baker,A.;Lewin,T.;Reichler,H.;Clancy,R.;Carr,V.;Garrett,R.;Sly,K.;Devir,H.;andTerry,M.Evaluationofamotivationalinterviewforsubstanceusewithpsychiatricin-patientservices.Addiction97(10):1329-1337,2002.

Haug,N.A.;Svikis,D.S.;andDiclemente,C.Motivationalenhancementtherapyfornicotinedependenceinmethadone-maintainedpregnantwomen.PsychologyofAddictiveBehaviors18(3):289-292,2004.

MarijuanaTreatmentProjectResearchGroup.Brieftreatmentsforcannabisdependence:Findingsfromarandomizedmultisitetrial.JournalofConsultingandClinicalPsychology72(3):455-466,2004.

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Miller,W.R.;Yahne,C.E.;andTonigan,J.S.Motivationalinterviewingindrugabuseservices:Arandomizedtrial.JournalofConsultingandClinicalPsychology71(4):754-763,2003.

Stotts,A.L.;Diclemente,C.C.;andDolan-Mullen,P.One-to-one:Amotivationalinterventionforresistantpregnantsmokers.AddictiveBehaviors27(2):275-292,2002.

TheMatrixModel(Stimulants)

TheMatrixModelprovidesaframeworkforengagingstimulant(e.g.,methamphetamineandcocaine)abusersintreatmentandhelpingthemachieveabstinence.Patientslearnaboutissuescriticaltoaddictionandrelapse,receivedirectionandsupportfromatrainedtherapist,andbecomefamiliarwithself-helpprograms.Patientsaremonitoredfordrugusethroughurinetesting.

Thetherapistfunctionssimultaneouslyasteacherandcoach,fosteringapositive,encouragingrelationshipwiththepatientandusingthatrelationshiptoreinforcepositivebehaviorchange.Theinteractionbetweenthetherapistandthepatientisauthenticanddirectbutnotconfrontationalorparental.Therapistsaretrainedtoconducttreatmentsessionsinawaythatpromotesthepatient’sself-esteem,dignity,andself-worth.Apositiverelationshipbetweenpatientandtherapistiscriticaltopatientretention.

Treatmentmaterialsdrawheavilyonothertestedtreatmentapproachesand,thus,includeelementsofrelapseprevention,familyandgrouptherapies,drugeducation,andself-helpparticipation.Detailedtreatmentmanualscontainworksheetsforindividualsessions;othercomponentsincludefamilyeducationgroups,earlyrecoveryskillsgroups,relapsepreventiongroups,combinedsessions,urinetests,12-stepprograms,relapseanalysis,andsocialsupportgroups.

AnumberofstudieshavedemonstratedthatparticipantstreatedusingtheMatrixModelshowstatisticallysignificantreductionsindrugandalcoholuse,improvementsinpsychologicalindicators,andreducedriskysexualbehaviors

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associatedwithHIVtransmission.

FurtherReading:

Huber,A.;Ling,W.;Shoptaw,S.;Gulati,V.;Brethen,P.;andRawson,R.Integratingtreatmentsformethamphetamineabuse:Apsychosocialperspective.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.Anintensiveoutpatientapproachforcocaineabuse:TheMatrixmodel.JournalofSubstanceAbuseTreatment12(2):117-127,1995.

Rawson,R.A.;Huber,A.;McCann,M.;Shoptaw,S.;Farabee,D.;Reiber,C.;andLing,W.Acomparisonofcontingencymanagementandcognitive-behavioralapproachesduringmethadonemaintenancetreatmentforcocainedependence.ArchivesofGeneralPsychiatry59(9):817-824,2002.

12-StepFacilitationTherapy(Alcohol,Stimulants,Opiates)

Twelve-stepfacilitationtherapyisanactiveengagementstrategydesignedtoincreasethelikelihoodofasubstanceabuserbecomingaffiliatedwithandactivelyinvolvedin12-stepself-helpgroups,therebypromotingabstinence.Threekeyideaspredominate:(1)acceptance,whichincludestherealizationthatdrugaddictionisachronic,progressivediseaseoverwhichonehasnocontrol,thatlifehasbecomeunmanageablebecauseofdrugs,thatwillpoweraloneisinsufficienttoovercometheproblem,andthatabstinenceistheonlyalternative;(2)surrender,whichinvolvesgivingoneselfovertoahigherpower,acceptingthefellowshipandsupportstructureofotherrecoveringaddictedindividuals,andfollowingtherecoveryactivitieslaidoutbythe12-stepprogram;and(3)activeinvolvementin12-stepmeetingsandrelatedactivities.Whiletheefficacyof12-stepprograms(and12-stepfacilitation)intreatingalcoholdependencehasbeenestablished,theresearchonitsusefulnessforotherformsofsubstanceabuseismorepreliminary,butthetreatmentappears

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promisingforhelpingdrugabuserssustainrecovery.

FurtherReading:

Carroll,K.M.;Nich,C.;Ball,S.A.;McCance,E.;Frankforter,T.L.;andRounsaville,B.J.One-yearfollow-upofdisulfiramandpsychotherapyforcocaine-alcoholusers:Sustainedeffectsoftreatment.Addiction95(9):1335-1349,2000.

DonovanD.M.,andWellsE.A."Tweaking12-step":Thepotentialroleof12-Stepself-helpgroupinvolvementinmethamphetaminerecovery.Addiction102(Suppl.1):121-129,2007.

ProjectMATCHResearchGroup.Matchingalcoholismtreatmentstoclientheterogeneity:ProjectMATCHposttreatmentdrinkingoutcomes.JournalofStudiesonAlcohol58(1)7-29,1997.

FamilyBehaviorTherapy

FamilyBehaviorTherapy(FBT),whichhasdemonstratedpositiveresultsinbothadultsandadolescents,isaimedataddressingnotonlysubstanceuseproblemsbutotherco-occurringproblemsaswell,suchasconductdisorders,childmistreatment,depression,familyconflict,andunemployment.FBTcombinesbehavioralcontractingwithcontingencymanagement.

FBTinvolvesthepatientalongwithatleastonesignificantothersuchasacohabitingpartneroraparent(inthecaseofadolescents).Therapistsseektoengagefamiliesinapplyingthebehavioralstrategiestaughtinsessionsandinacquiringnewskillstoimprovethehomeenvironment.PatientsareencouragedtodevelopbehavioralgoalsforpreventingsubstanceuseandHIVinfection,whichareanchoredtoacontingencymanagementsystem.Substance-abusingparentsarepromptedtosetgoalsrelatedtoeffectiveparentingbehaviors.Duringeachsession,thebehavioralgoalsarereviewed,withrewardsprovidedbysignificantotherswhengoalsareaccomplished.Patientsparticipateintreatmentplanning,choosingspecificinterventionsfromamenuofevidence-

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basedtreatmentoptions.Inaseriesofcomparisonsinvolvingadolescentswithandwithoutconductdisorder,FBTwasfoundtobemoreeffectivethansupportivecounseling.

FurtherReading:

Azrin,N.H.;Donohue,B.;Besalel,V.A.;Kogan,E.S.;andAcierno,R.Youthdrugabusetreatment:acontrolledoutcomestudy.JournalofChildandAdolescentSubstanceAbuse3:1–16,1994.

Carroll,K.M.;andOnken,L.S.Behavioraltherapiesfordrugabuse.AmericanJournalofPsychiatry168(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.;andVanHasselt,V.B.FamilyBehaviorTherapyforsubstanceabuse:Areviewofitsinterventioncomponentsandapplicability.BehaviorModification33:495–519,2009.

LaPota,H.B.;Donohue,B.;Warren,C.S.;andAllen,D.N.IntegrationofaHealthyLivingcurriculumwithinFamilyBehaviorTherapy:Aclinicalcaseexampleinawomanwithahistoryofdomesticviolence,childneglect,drugabuse,andobesity.JournalofFamilyViolence26:227–234,2011.

BehavioralTherapiesPrimarilyforAdolescents

Drug-abusingandaddictedadolescentshaveuniquetreatmentneeds.Researchhasshownthattreatmentsdesignedforandtestedinadultpopulationsoftenneedtobemodifiedtobeeffectiveinadolescents.Familyinvolvementisaparticularlyimportantcomponentforinterventionstargetingyouth.Belowareexamplesofbehavioralinterventionsthatemploytheseprinciplesandhaveshownefficacyfortreatingaddictioninyouth.

MultisystemicTherapy

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MultisystemicTherapy(MST)addressesthefactorsassociatedwithseriousantisocialbehaviorinchildrenandadolescentswhoabusealcoholandotherdrugs.Thesefactorsincludecharacteristicsofthechildoradolescent(e.g.,favorableattitudestowarddruguse),thefamily(poordiscipline,familyconflict,parentaldrugabuse),peers(positiveattitudestowarddruguse),school(dropout,poorperformance),andneighborhood(criminalsubculture).Byparticipatinginintensivetreatmentinnaturalenvironments(homes,schools,andneighborhoodsettings),mostyouthsandfamiliescompleteafullcourseoftreatment.MSTsignificantlyreducesadolescentdruguseduringtreatmentandforatleast6monthsaftertreatment.Fewerincarcerationsandout-of-homejuvenileplacementsoffsetthecostofprovidingthisintensiveserviceandmaintainingtheclinicians’lowcaseloads.

FurtherReading:

Henggeler,S.W.;Clingempeel,W.G.;Brondino,M.J.;andPickrel,S.G.Four-yearfollow-upofmultisystemictherapywithsubstance-abusingandsubstance-dependentjuvenileoffenders.JournaloftheAmericanAcademyofChildandAdolescentPsychiatry41(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.;andSantos,A.B.Home-basedmultisystemictherapyasanalternativetothehospitalizationofyouthsinpsychiatriccrisis:Clinicaloutcomes.JournaloftheAmericanAcademyofChildandAdolescentPsychiatry38(11):1331-1339,1999.

Henggeler,S.W.;Halliday-Boykins,C.A.;Cunningham,P.B.;Randall,J.;Shapiro,S.B.;andChapman,J.E.Juveniledrugcourt:Enhancingoutcomesbyintegratingevidence-basedtreatments.JournalofConsultingandClinicalPsychology74(1):42–54,2006.

Henggeler,S.W.;Pickrel,S.G.;Brondino,M.J.;andCrouch,J.L.Eliminating(almost)treatmentdropoutofsubstance-abusingordependentdelinquentsthroughhome-basedmultisystemictherapy.TheAmericanJournalofPsychiatry153(3):427–428,1996.

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Huey,S.J.;Henggeler,S.W.;Brondino,M.J.;andPickrel,S.G.Mechanismsofchangeinmultisystemictherapy:Reducingdelinquentbehaviorthroughtherapistadherenceandimprovedfamilyfunctioning.JournalofConsultingandClinicalPsychology68(3):451–467,2000.

MultidimensionalFamilyTherapy

MultidimensionalFamilyTherapy(MDFT)foradolescentsisanoutpatient,family-basedtreatmentforteenagerswhoabusealcoholorotherdrugs.MDFTviewsadolescentdruguseintermsofanetworkofinfluences(individual,family,peer,community)andsuggeststhatreducingunwantedbehaviorandincreasingdesirablebehavioroccurinmultiplewaysindifferentsettings.Treatmentincludesindividualandfamilysessionsheldintheclinic,inthehome,orwithfamilymembersatthefamilycourt,school,orothercommunitylocations.

Duringindividualsessions,thetherapistandadolescentworkonimportantdevelopmentaltasks,suchasdevelopingdecision-making,negotiation,andproblem-solvingskills.Teenagersacquirevocationalskillsandskillsincommunicatingtheirthoughtsandfeelingstodealbetterwithlifestressors.Parallelsessionsareheldwithfamilymembers.Parentsexaminetheirparticularparentingstyles,learningtodistinguishinfluencefromcontrolandtohaveapositiveanddevelopmentallyappropriateinfluenceontheirchildren.

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.TheCannabisYouthTreatment(CYT)Study:Mainfindingsfromtworandomizedclinicaltrials.JournalofSubstanceAbuseTreatment27(3):197-213,2004.

Liddle,H.A.;Dakof,G.A.;Parker,K.;Diamond,G.S.;Barrett,K;,andTejeda,M.Multidimensionalfamilytherapyforadolescentdrugabuse:Resultsofarandomizedclinicaltrial.TheAmericanJournalofDrugandAlcoholAbuse27(4):651-688,2001.

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Liddle,H.A.,andHogue,A.Multidimensionalfamilytherapyforadolescentsubstanceabuse.InE.F.WagnerandH.B.Waldron(eds.),InnovationsinAdolescentSubstanceAbuseInterventions.London:Pergamon/ElsevierScience,pp.227-261,2001.

Liddle,H.A.;Rowe,C.L.;Dakof,G.A.;Ungaro,R.A.;andHenderson,C.E.Earlyinterventionforadolescentsubstanceabuse:Pretreatmenttoposttreatmentoutcomesofarandomizedclinicaltrialcomparingmultidimensionalfamilytherapyandpeergrouptreatment.JournalofPsychoactiveDrugs36(1):49-63,2004.

Schmidt,S.E.;Liddle,H.A.;andDakof,G.A.Effectsofmultidimensionalfamilytherapy:Relationshipofchangesinparentingpracticestosymptomreductioninadolescentsubstanceabuse.JournalofFamilyPsychology10(1):1-16,1996.

BriefStrategicFamilyTherapy

BriefStrategicFamilyTherapy(BSFT)targetsfamilyinteractionsthatarethoughttomaintainorexacerbateadolescentdrugabuseandotherco-occurringproblembehaviors.Suchproblembehaviorsincludeconductproblemsathomeandatschool,oppositionalbehavior,delinquency,associatingwithantisocialpeers,aggressiveandviolentbehavior,andriskysexualbehavior.BSFTisbasedonafamilysystemsapproachtotreatment,inwhichfamilymembers’behaviorsareassumedtobeinterdependentsuchthatthesymptomsofonemember(thedrug-abusingadolescent,forexample)areindicative,atleastinpart,ofwhatelseisoccurringinthefamilysystem.TheroleoftheBSFTcounseloristoidentifythepatternsoffamilyinteractionthatareassociatedwiththeadolescent’sbehaviorproblemsandtoassistinchangingthoseproblem-maintainingfamilypatterns.BSFTismeanttobeaflexibleapproachthatcanbeadaptedtoabroadrangeoffamilysituationsinvarioussettings(mentalhealthclinics,drugabusetreatmentprograms,othersocialservicesettings,andfamilies’homes)andinvarioustreatmentmodalities(asaprimaryoutpatientintervention,incombinationwithresidentialordaytreatment,andasanaftercare/continuing-careservicefollowingresidentialtreatment).

FurtherReading:

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Coatsworth,J.D.;Santisteban,D.A.;McBride,C.K.;andSzapocznik,J.BriefStrategicFamilyTherapyversuscommunitycontrol:Engagement,retention,andanexplorationofthemoderatingroleofadolescentseverity.FamilyProcess40(3):313-332,2001.

Kurtines,W.M.;Murray,E.J.;andLaperriere,A.Efficacyofinterventionforengagingyouthandfamiliesintotreatmentandsomevariablesthatmaycontributetodifferentialeffectiveness.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.JournalofCommunityPsychology25(5):453-471,1997.

Santisteban,D.A.;Suarez-Morales,L.;Robbins,M.S.;andSzapocznik,J.Briefstrategicfamilytherapy:Lessonslearnedinefficacyresearchandchallengestoblendingresearchandpractice.FamilyProcess45(2):259-271,2006.

Santisteban,D.A.;Szapocznik,J.;Perez-Vidal,A.;Mitrani,V.;Jean-Gilles,M.;andSzapocznik,J.BriefStructural/StrategicFamilyTherapywithAfrican-AmericanandHispanichigh-riskyouth.JournalofCommunityPsychology25(5):453–471,1997.

Szapocznik,J.,etal.Engagingadolescentdrugabusersandtheirfamiliesintreatment:Astrategicstructuralsystemsapproach.JournalofConsultingandClinicalPsychology56(4):552-557,1988.

FunctionalFamilyTherapy

FunctionalFamilyTherapy(FFT)isanothertreatmentbasedonafamilysystemsapproach,inwhichanadolescent’sbehaviorproblemsareseenasbeingcreatedormaintainedbyafamily’sdysfunctionalinteractionpatterns.FFTaimstoreduceproblembehaviorsbyimprovingcommunication,problem-solving,conflictresolution,andparentingskills.Theinterventionalways

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includestheadolescentandatleastonefamilymemberineachsession.Principaltreatmenttacticsinclude(1)engagingfamiliesinthetreatmentprocessandenhancingtheirmotivationforchangeand(2)bringingaboutchangesinfamilymembers’behaviorusingcontingencymanagementtechniques,communicationandproblem-solving,behavioralcontracts,andotherbehavioralinterventions.

FurtherReading:

Waldron,H.B.;Slesnick,N.;Brody,J.L.;Turner,C.W.;andPeterson,T.R.Treatmentoutcomesforadolescentsubstanceabuseat4-and7-monthassessments.JournalofConsultingandClinicalPsychology69:802–813,2001.

Waldron,H.B.;Turner,C.W.;andOzechowski,T.J.Profilesofdrugusebehaviorchangeforadolescentsintreatment.AddictiveBehaviors30:1775–1796,2005.

AdolescentCommunityReinforcementApproachandAssertiveContinuingCare

TheAdolescentCommunityReinforcementApproach(A-CRA)isanothercomprehensivesubstanceabusetreatmentinterventionthatinvolvestheadolescentandhisorherfamily.Itseekstosupporttheindividual’srecoverybyincreasingfamily,social,andeducational/vocationalreinforcers.Afterassessingtheadolescent’sneedsandlevelsoffunctioning,thetherapistchoosesfromamong17A-CRAprocedurestoaddressproblem-solving,coping,andcommunicationskillsandtoencourageactiveparticipationinpositivesocialandrecreationalactivities.A-CRAskillstraininginvolvesrole-playingandbehavioralrehearsal.

AssertiveContinuingCare(ACC)isahome-basedcontinuing-careapproachtopreventingrelapse.Weeklyhomevisitstakeplaceovera12-to14-weekperiodafteranadolescentisdischargedfromresidential,intensiveoutpatient,orregularoutpatienttreatment.Usingpositiveandnegativereinforcementtoshapebehaviors,alongwithtraininginproblem-solvingandcommunication

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skills,ACCcombinesA-CRAandassertivecasemanagementservices(e.g.,useofamultidisciplinaryteamofprofessionals,round-the-clockcoverage,assertiveoutreach)tohelpadolescentsandtheircaregiversacquiretheskillstoengageinpositivesocialactivities.

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.TheCannabisYouthTreatment(CYT)Study:Mainfindingsfromtworandomizedtrials.JournalofSubstanceAbuseTreatment27:197–213,2004.

Godley,S.H.;Garner,B.R.;Passetti,L.L.;Funk,R.R.;Dennis,M.L.;andGodley,M.D.Adolescentoutpatienttreatmentandcontinuingcare:Mainfindingsfromarandomizedclinicaltrial.DrugandAlcoholDependenceJul1;110(1-2):44–54,2010.

Godley,M.D.;Godley,S.H.;Dennis,M.L.;Funk,R.;andPassetti,L.L.Preliminaryoutcomesfromtheassertivecontinuingcareexperimentforadolescentsdischargedfromresidentialtreatment.JournalofSubstanceAbuseTreatment23:21–32,2002.

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Resources

NationalAgencies

TheNationalInstituteonDrugAbuse(NIDA)leadstheNationinscientificresearchonthehealthaspectsofdrugabuseandaddiction.Itsupportsandconductsresearchacrossabroadrangeofdisciplines,includinggenetics,functionalneuroimaging,socialneuroscience,prevention,medicationandbehavioraltherapies,andhealthservices.Itthendisseminatestheresultsofthatresearchtosignificantlyimprovepreventionandtreatmentandtoinformpolicyasitrelatestodrugabuseandaddiction.Additionalinformationisavailableatdrugabuse.govorbycalling301-443-1124.

NationalInstituteonAlcoholAbuseandAlcoholism(NIAAA)

TheNationalInstituteonAlcoholAbuseandAlcoholism(NIAAA)providesleadershipinthenationalefforttoreducealcohol-relatedproblemsbyconductingandsupportingresearchinawiderangeofscientificareas,includinggenetics,neuroscience,epidemiology,healthrisksandbenefitsofalcoholconsumption,prevention,andtreatment;coordinatingandcollaboratingwithotherresearchinstitutesandFederalprogramsonalcohol-relatedissues;collaboratingwithinternational,national,State,andlocalinstitutions,organizations,agencies,andprogramsengagedinalcohol-relatedwork;andtranslatinganddisseminatingresearchfindingstohealthcareproviders,researchers,policymakers,andthepublic.Additionalinformationisavailableatwww.niaaa.nih.govorbycalling301-443-3860.

NationalInstituteofMentalHealth(NIMH)

ThemissionofNationalInstituteofMentalHealth(NIMH)istotransformtheunderstandingandtreatmentofmentalillnessesthroughbasicandclinicalresearch,pavingthewayforprevention,recovery,andcure.Insupportofthismission,NIMHgeneratesresearchandpromotesresearchtrainingtofulfillthefollowingfourobjectives:(1)promotediscoveryinthebrainandbehavioralsciencestofuelresearchonthecausesofmentaldisorders;(2)chartmental

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illnesstrajectoriestodeterminewhen,where,andhowtointervene;(3)developnewandbetterinterventionsthatincorporatethediverseneedsandcircumstancesofpeoplewithmentalillnesses;and(4)strengthenthepublichealthimpactofNIMH-supportedresearch.Additionalinformationisavailableatnimh.nih.govorbycalling301-443-4513.

CenterforSubstanceAbuseTreatment(CSAT)

TheCenterforSubstanceAbuseTreatment(CSAT),apartoftheSubstanceAbuseandMentalHealthServicesAdministration(SAMHSA),isresponsibleforsupportingtreatmentservicesthroughablockgrantprogram,aswellasdisseminatingfindingstothefieldandpromotingtheiradoption.CSATalsooperatesthe24-hourNationalTreatmentReferralHotline(1-800-662-HELP),whichoffersinformationandreferralservicestopeopleseekingtreatmentprogramsandotherassistance.CSATpublicationsareavailablethroughSAMHSA'sStore(store.samhsa.gov).AdditionalinformationaboutCSATcanbefoundonSAMHSA'sWebsiteatwww.samhsa.gov/about-us/who-we-are/offices-centers/csat.

SelectedNIDAEducationalResourcesonDrugAddictionTreatment

ThefollowingareavailablefromtheNIDADrugPubsResearchDisseminationCenter,theNationalTechnicalInformationService(NTIS),ortheGovernmentPrintingOffice(GPO).Toorder,refertotheDrugPubs(877-NIDANIH[643-2644]),NTIS(1-800-553-6847),orGPO(202-512-1800)numberprovidedwiththeresourcedescription.

Blendingproducts.NIDA'sBlendingInitiative—ajointventurewithSAMHSAanditsnationwidenetworkofAddictionTechnologyTransferCenters(ATTCs)—uses"BlendingTeams"ofcommunitypractitioners,SAMHSAtrainers,andNIDAresearcherstocreateproductsanddevisestrategicdisseminationplansforthem.CompletedproductsincludethosethataddressthevalueofbuprenorphinetherapyandonsiterapidHIVtestingincommunitytreatmentprograms;strategiesfortreatingprescriptionopioiddependence;andtheneedtoenhancehealthcareworkers'proficiencyinusingtoolssuchastheAddiction

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SeverityIndex(ASI),motivationalinterviewing,andmotivationalincentives.FormoreinformationonBlendingproducts,pleasevisitNIDA'sWebsiteatdrugabuse.gov/blending-initiative.

AddictionSeverityIndex.Providesastructuredclinicalinterviewdesignedtocollectinformationaboutsubstanceuseandfunctioninginlifeareasfromadultclientsseekingdrugabusetreatment.FormoreinformationonusingtheASIandtoobtaincopiesofthemostrecentedition,pleasevisittriweb.tresearch.org/index.php/tools/download-asiinstruments-manuals/.

Drugs,Brains,andBehavior:TheScienceofAddiction(Reprinted2010).Thispublicationprovidesanoverviewofthesciencebehindthediseaseofaddiction.Publication#NIH10-5605.Availableonlineatdrugabuse.gov/publications/science-addiction.

SeekingDrugAbuseTreatment:KnowWhatToAsk(2011).Thislay-friendlypublicationoffersguidanceinseekingdrugabusetreatmentandlistsfivequestionstoaskwhensearchingforatreatmentprogram.NIDAPublication#12-7764.Availableonlineatdrugabuse.gov/publications/seeking-drug-abuse-treatment.

PrinciplesofDrugAbuseTreatmentforCriminalJusticePopulations:AResearch-BasedGuide(Revised2012).Provides13essentialtreatmentprinciplesandincludesresourceinformationandanswerstofrequentlyaskedquestions.NIHPublicationNo.:11-5316.Availableonlineatdrugabuse.gov/publications/principles-drug-abuse-treatment-criminal-justice-populations-research-based-guide.

NIDADrugFacts:TreatmentApproachesforDrugAddiction(Revised2009).Thisisafactsheetcoveringresearchfindingsoneffectivetreatmentapproachesfordrugabuseandaddiction.Availableonlineatdrugabuse.gov/publications/drugfacts/treatment-approaches-drugaddiction.

AlcoholAlert(publishedbyNIAAA).Thisisaquarterlybulletinthatdisseminatesimportantresearchfindingsonalcoholabuseandalcoholism.Availableonlineatwww.niaaa.nih.gov/publications/journals-and-

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reports/alcohol-alert.

HelpingPatientsWhoDrinkTooMuch:AClinicians'sguide(publishedbyNIAAA).Thisbookletiswrittenforprimarycareandmentalhealthcliniciansandprovidesguidanceinscreeningandmanagingalcohol-dependentpatients.Availableonlineatpubs.niaaa.nih.gov/publications/Practitioner/CliniciansGuide2005/clinicians_guide.htm.

ResearchReportSeries:TherapeuticCommunity(2002).Thisreportprovidesinformationontheroleofresidentialdrug-freesettingsandtheirroleinthetreatmentprocess.NIHPublication#02-4877.Availableonlineatdrugabuse.gov/publications/research-reports/therapeutic-community.

InitiativesDesignedtoMoveTreatmentResearchintoPractice

ClinicalTrialsNetwork

Assessingthereal-worldeffectivenessofevidence-basedtreatmentsisacrucialstepinbringingresearchtopractice.Establishedin1999,NIDA’sNationalDrugAbuseTreatmentClinicalTrialsNetwork(CTN)usescommunitysettingswithdiversepatientpopulationsandconditionstoadjustandtestprotocolstomeetthepracticalneedsofaddictiontreatment.Sinceitsinception,theCTNhastestedpharmacologicalandbehavioralinterventionsfordrugabuseandaddiction,alongwithcommonco-occurringconditions(e.g.,HIVandPTSD)amongvarioustargetpopulations,includingadolescentdrugabusers,pregnantdrug-abusingwomen,andSpanish-speakingpatients.TheCTNhasalsotestedpreventionstrategiesindrug-abusinggroupsathighriskforHCVandHIVandhasbecomeakeyelementofNIDA’smultiprongedapproachtomovepromisingscience-baseddrugaddictiontreatmentsrapidlyintocommunitysettings.FormoreinformationontheCTN,pleasevisitdrugabuse.gov/CTN.

CriminalJustice-DrugAbuseTreatmentStudies

NIDAistakinganapproachsimilartotheCTNtoenhancetreatmentfordrug-

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addictedindividualsinvolvedwiththecriminaljusticesystemthroughCriminalJustice–DrugAbuseTreatmentStudies(CJ-DATS).WhereasNIDA’sCTNhasasitsoverridingmissiontheimprovementofthequalityofdrugabusetreatmentbymovinginnovativeapproachesintothelargercommunity,researchsupportedthroughCJ-DATSisdesignedtoeffectchangebybringingnewtreatmentmodelsintothecriminaljusticesystemandtherebyimproveoutcomesforoffenderswithsubstanceusedisorders.ItseekstoachievebetterintegrationofdrugabusetreatmentwithotherpublichealthandpublicsafetyforumsandrepresentsacollaborationamongNIDA;SAMHSA;theCentersforDiseaseControlandPrevention(CDC);DepartmentofJusticeagencies;andahostofdrugtreatment,criminaljustice,andhealthandsocialserviceprofessionals.

BlendingTeams

AnotherwayinwhichNIDAisseekingtoactivelymovescienceintopracticeisthroughajointventurewithSAMHSAanditsnationwidenetworkofAddictionTechnologyTransferCenters(ATTCs).Thisprocessinvolvesthecollaborativeeffortsofcommunitytreatmentpractitioners,SAMHSAtrainers,andNIDAresearchers,someofwhomform"BlendingTeams"tocreateproductsanddevisestrategicdisseminationplansforthem.Throughthecreationofproductsdesignedtofosteradoptionofnewtreatmentstrategies,BlendingTeamsareinstrumentalingettingthelatestevidence-basedtoolsandpracticesintothehandsoftreatmentprofessionals.Todate,anumberofproductshavebeencompleted.Topicshaveincludedincreasingawarenessofthevalueofbuprenorphinetherapyandenhancinghealthcareworkers'proficiencyinusingtoolssuchastheASI,motivationalinterviewing,andmotivationalincentives.FormoreinformationonBlendingproducts,pleasevisitNIDA’sWebsiteatdrugabuse.gov/nidasamhsa-blending-initiative.

OtherFederalResources

NIDADrugPubsResearchDisseminationCenter.NIDApublicationsandtreatmentmaterialsareavailablefromthisinformationsource.StaffprovideassistanceinEnglishandSpanish,andhaveTTY/TDDcapability.Phone:877-NIDA-NIH(877-643-2644);TTY/TDD:240-645-0228;fax:240-645-0227;e-mail:drugpubs@nida.nih.gov;Website:drugpubs.drugabuse.gov.

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TheNationalRegistryofEvidence-BasedProgramsandPractices.ThisdatabaseofinterventionsforthepreventionandtreatmentofmentalandsubstanceusedisordersismaintainedbySAMHSAandcanbeaccessedatnrepp.samhsa.gov.

SAMHSA'sStorehasawiderangeofproducts,includingmanuals,brochures,videos,andotherpublications.Phone:800-487-4889;Website:store.samhsa.gov.

TheNationalInstituteofJustice.AstheresearchagencyoftheDepartmentofJustice,theNationalInstituteofJustice(NIJ)supportsresearch,evaluation,anddemonstrationprogramsrelatingtodrugabuseinthecontextofcrimeandthecriminaljusticesystem.Forinformation,includingawealthofpublications,contacttheNationalCriminalJusticeReferenceServiceat800-851-3420or301-519-5500;orvisitnij.gov.

ClinicalTrials.Formoreinformationonfederallyandprivatelysupportedclinicaltrials,pleasevisitclinicaltrials.gov.

ThispublicationisavailableforyouruseandmaybereproducedinitsentiretywithoutpermissionfromtheNIDA.Citationofthesourceisappreciated,usingthefollowinglanguage:Source:NationalInstituteonDrugAbuse;NationalInstitutesofHealth;U.S.DepartmentofHealthandHumanServices.

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Acknowledgments

TheNationalInstituteonDrugAbusewishestothankthefollowingindividualsforreviewingthispublication.

MartinW.Adler,Ph.D.TempleUniversitySchoolofMedicine

KathleenBrady,M.D.,Ph.D.MedicalUniversityofSouthCarolina

GregBrigham,Ph.D.Maryhaven,Inc.

KathleenM.Carroll,Ph.D.YaleUniversitySchoolofMedicine

RichardR.Clayton,Ph.D.UniversityofKentucky

LindaB.Cottler,Ph.D.WashingtonUniversitySchoolofMedicine

DavidP.Friedman,Ph.D.WakeForestUniversityBowmanGraySchoolofMedicine

ReeseT.Jones,M.D.UniversityofCaliforniaatSanFrancisco

NancyK.Mello,Ph.D.HarvardMedicalSchool

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WilliamR.Miller,Ph.D.UniversityofNewMexico

CharlesP.O’Brien,M.D.,Ph.D.UniversityofPennsylvania

JeffreySelzer,M.D.ZuckerHillsideHospital

EricJ.Simon,Ph.D.NewYorkUniversityLangoneMedicalCenter

JoseSzapocznik,Ph.D.UniversityofMiamiMillerSchoolofMedicine

GeorgeWoody,M.D.UniversityofPennsylvania