hart13 ppt ch18
DESCRIPTION
(c) McGraw-Hill 2011TRANSCRIPT
© 2011 McGraw-Hill Higher Education. All rights reserved.
Chapter 18Chapter 18
Treating Substance Abuse and Dependence
© 2011 McGraw-Hill Higher Education. All rights reserved.
TreatmentTreatment
Hundreds of thousands of Americans undergo treatment for substance abuse and dependence each year
A variety of treatment approaches are used, often in combination Behavioral/psychosocial treatments Pharmacotherapies
Different approaches reflect Different substance abuse problems Different theories about substance abuse
© 2011 McGraw-Hill Higher Education. All rights reserved.
Defining Treatment GoalsDefining Treatment Goals
Treatment goals are influenced by the underlying theoretical view of substance abuse
Alcohol View that substance dependence is a biological
disease that someone either has or does not have Only acceptable treatment goal is complete
abstinence
View that substance dependence represents one end of a continuum of drinking A possible treatment goal is controlled social use
© 2011 McGraw-Hill Higher Education. All rights reserved.
Defining Treatment GoalsDefining Treatment Goals
Opioids View that substance dependence undermines the
physical and mental health of its victims Only acceptable treatment goal is abstinence (traditional
view)
View that dependence on legal methadone is preferable to dependence on illegal heroin Goal of treatment has changed from eliminating opioid use to
eliminating heroin use
Tobacco Complete abstinence (most common goal) vs. cutting
down on smoking or switching to cigarettes lower in tar and nicotine
© 2011 McGraw-Hill Higher Education. All rights reserved.
Defining Treatment GoalsDefining Treatment Goals
How to evaluate treatment outcomes of reduced use as opposed to abstinence?
Researchers are beginning to develop cost/benefit analyses Cost of treatment
vs.
Cost savings from increased employment and decreased crime after treatment
© 2011 McGraw-Hill Higher Education. All rights reserved.
Alcoholics Anonymous and Alcoholics Anonymous and OthersOthers
Founded in 1935: A loose affiliation of local groups that adhere to common methods
Based on the disease model of dependence An alcoholic is biologically different from others, so
abstinence is the only appropriate goal The disease takes away a person’s control over his
or her own drinking behavior It removes the blame for the problem from the alcoholic
but not the responsibility for dealing with it
Major approaches are group support and a buddy system
© 2011 McGraw-Hill Higher Education. All rights reserved.
Alcoholics Anonymous and Alcoholics Anonymous and OthersOthers
Formal evaluations of AA have not been very positive However, studying people who have court-ordered
referrals to AA might not be an appropriate evaluation method
A more appropriate evaluation might be to determine which types of drinkers are most likely to benefit from AA’s programs
Evaluation is important because many treatment programs follow the 12-step model of AA Betty Ford Center, Hazelden, Phoenix House
© 2011 McGraw-Hill Higher Education. All rights reserved.
Motivational Enhancement Motivational Enhancement TherapyTherapy
Conventional wisdom about people with substance abuse problems: Most substance abusers use the
defense mechanism of denial and are unwilling to admit they have a problem
Only when a user suffers serious consequences (“hits bottom”) will he or she be ready to seek help
Problem with this perspective is that very serious consequences may occur before the abuser is ready for treatment
© 2011 McGraw-Hill Higher Education. All rights reserved.
Motivational Enhancement Motivational Enhancement TherapyTherapy
Motivational enhancement therapy attempts to shift the focus away from denial and toward motivation to change
Motivational interviewing Used to boost the motivation to change of an
ambivalent or less ready substance abuser A nonconfrontational process of determining
the abuser’s current stage of change and then helping the individual move forward
© 2011 McGraw-Hill Higher Education. All rights reserved.
Motivational Enhancement Motivational Enhancement TherapyTherapy
Stages of change Precontemplation: Individual doesn’t recognize that
a problem exists Contemplation: Individual recognizes there is a
problem and begins to consider the possibility of changing her or his behavior
Preparation: Individual decides to change and makes plans to change
Action: Individual takes active steps toward change Maintenance: Individual engages in activities
intended to maintain the change
© 2011 McGraw-Hill Higher Education. All rights reserved.
Motivational Enhancement Motivational Enhancement TherapyTherapy
Goals of motivational interviews Help the client focus on
problem behaviors Help the client move forward
to the next stage of change
Motivational enhancement therapy is probably best conceptualized as preparation for other therapies rather than as a stand-alone treatment
© 2011 McGraw-Hill Higher Education. All rights reserved.
Contingency ManagementContingency Management
An approach in which individuals receive immediate rewards for providing drug-free urine samples Value of the rewards increases with consecutive
drug-free samples
Clients also participate in weekly skill-building counseling sessions
Has produced consistent reduction in use Downside of approach is the cost of rewards
© 2011 McGraw-Hill Higher Education. All rights reserved.
Cognitive Behavioral Therapy Cognitive Behavioral Therapy (CBT)(CBT)
An approach that combines cognitive therapy techniques with behavioral skills training
Individuals learn to identify and change behaviors that could lead to relapse, such as associating with drug users
Evaluation Shown to be more effective than most therapies Considered challenging because it places significant demands
on patients Despite this, it remains one of the most widely used substance
abuse treatment strategy
© 2011 McGraw-Hill Higher Education. All rights reserved.
PharmacotherapiesPharmacotherapies
Study of dependence as a brain disease has focused research efforts on developing medications for treatment
Many experts believe that pharmacotherapies alone will not cure a chronic, relapsing, behavioral disorder like substance abuse
Pharmacotherapies can provide a window of opportunity for behavioral/psychosocial treatments by relieving withdrawal symptoms
© 2011 McGraw-Hill Higher Education. All rights reserved.
DetoxificationDetoxification
Detoxification is an initial and immediate phase of treatment
Medications are administered to alleviate unpleasant and/or dangerous withdrawal symptoms that may appear following abrupt cessation of drug use
Some of these medications may also be used during maintenance stage
© 2011 McGraw-Hill Higher Education. All rights reserved.
MaintenanceMaintenance
Maintenance is a longer-term strategy used to help a dependent individual avoid relapse
Three general categories of pharmacotherapy for maintenance Agonist or substitution therapy Antagonist therapy Punishment therapy
© 2011 McGraw-Hill Higher Education. All rights reserved.
MaintenanceMaintenance
Agonist or substitution therapy is used to induce cross-tolerance to the abused drug Examples: methadone for heroin dependence,
nicotine replacement for tobacco dependence Agonists typically have safer routes of administration
and/or diminished psychoactive effects compared to the original drug
Substituting a longer-acting, pharmacologically equivalent drug allows the user to be stabilized on the agonist and then slowly tapered off it, avoiding withdrawal symptoms
© 2011 McGraw-Hill Higher Education. All rights reserved.
MaintenanceMaintenance
Antagonist therapy is used to prevent the user from experiencing the reinforcing effects of the abused drug Example: naltrexone, which blocks opioid effects
Punishment therapy is used to produce an aversive reaction following ingestion of the abused drug Example: disulfiram for alcohol dependence
© 2011 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for AlcoholPharmacotherapies for Alcohol
Detoxification phase Pharmacological therapies are important
because acute alcohol withdrawal syndrome has serious effects
Medical risks often require an inpatient medical setting for alcohol detoxification
Benzodiazepines are typically used Reduce autonomic hyperactivity and
prevent seizures Best choices are those with a slow onset
of action
© 2011 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for AlcoholPharmacotherapies for Alcohol
Maintenance therapy Usually given for weeks or months rather
than indefinitely Three approved medications
Disulfiram (Antabuse) NaltrexoneAcamprosate
© 2011 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for AlcoholPharmacotherapies for Alcohol
Disulfiram (Antabuse) causes unpleasant symptoms (headache, vomiting, and breathing difficulties) if alcohol is consumed Inhibits aldehyde dehydrogenase, thereby increasing acetaldehyde
Not very effective because most people don’t take the medication
Naltrexone Reduces alcohol craving, days per week of drinking, and rate of
relapse—but hasn’t had a large impact on overall treatment success
Unclear how it works; it may block opioid receptors and the reinforcing effects of alcohol
Acamprosate, a compound structurally similar to GABA Normalizes basal GABA concentrations
Blocks the glutamate increases observed during alcohol withdrawal
Recently approved, so effectiveness hasn’t been determined
© 2011 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for NicotinePharmacotherapies for Nicotine
Nicotine withdrawal symptoms (anxiety, depression, insomnia, cigarette cravings) occur in most smokers who stop smoking
Five nicotine replacement products are approved by the FDA Transdermal nicotine patch
Nicotine gum
Nicotine nasal spray
Nicotine vapor inhaler
Nicotine lozenge
Smokers should stop smoking before using any of them to avoid nicotine toxicity
Use of nicotine replacement products has been shown to increase quit rates in controlled clinical studies Success rates are probably lower in a real world setting
© 2011 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for NicotinePharmacotherapies for Nicotine
Bupropion (Zyban), a non-nicotine pharmacotherapy for smoking cessation Approved by the FDA in 1997 Also used in the treatment of depression Mechanisms of action haven’t been definitively
determined May inhibit reuptake of dopamine and norepinephrine and,
to a lesser extent, block acetylcholine receptors
Has been shown to gradually decrease cigarette craving and use
© 2011 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for OpioidsPharmacotherapies for Opioids
Traditionally, anticholinergic drugs like belladonna were used to treat opioid dependence Goal: To produce a state of delirium for several days so that
the dependent person would avoid experiencing withdrawal
More recent version is “rapid opioid detoxification,” in which a dependent person is anesthetized and given an opioid antagonist that causes immediate withdrawal Person is released after 24 hours and enters a period of
counseling while continuing to take an opioid antagonist Criticisms of approach
Medical risks of rapid withdrawal process Behavioral/psychosocial aftercare is often deemphasized
© 2011 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for OpioidsPharmacotherapies for Opioids
Detoxification Medications given to reduce withdrawal symptoms
(nausea, vomiting, diarrhea, aches, pain) Methadone, a long-acting opioid Buprenorphine, a partial opioid agonist with a long duration
of action
Maintenance Methadone maintenance is the most common form
of treatment for opioid dependence May continue for months or years
Less data available on more recently approved buprenorphine maintenance
© 2011 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for OpioidsPharmacotherapies for Opioids
Naloxone, a short-acting opioid antagonist, is used to treat opioid overdose
Naltrexone, a long-acting opioid antagonist, is approved for treating opioid dependence Has been shown to be effective, but it is appropriate
only for highly motivated individuals A once-per-month form is being studied; initial
findings are promising
© 2011 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for CocainePharmacotherapies for Cocaine
Withdrawal symptoms Can include depression, nervousness, anhedonia (lack of
emotional response), fatigue, irritability, sleep and activity disturbances, craving for cocaine
Risk of relapse may be greatest during withdrawal period
Reduced monoamine neurotransmitter activity may underlie withdrawal symptoms
Medications that increase monoamine neurotransmitter activity have been tested but have not been found useful in treating withdrawal symptoms or dependence
Currently no approved pharmacotherapy for cocaine dependence
© 2011 McGraw-Hill Higher Education. All rights reserved.
Pharmacotherapies for Pharmacotherapies for CannabisCannabis
Withdrawal from cannabis People seeking treatment for cannabis dependence
often report withdrawal symptoms that make it more difficult to maintain abstinence
Symptoms may include irritability, anxiety, sleep disruption, aches
Many medications have been tested for relief of cannabis withdrawal symptoms One drug has been found effective: oral ∆9-THC
Currently no approved pharmacotherapy for cannabis dependence
© 2011 McGraw-Hill Higher Education. All rights reserved.
Treatment: The Big Picture in the Treatment: The Big Picture in the United States United States
Most frequently reported drugs for substance abuse treatment admissions Alcohol (40 percent) Opioids (19 percent) Marijuana/hashish (16 percent) Cocaine (13 percent) Stimulants (8 percent, primarily methamphetamine)
Abusers admitted for treatment Average age of those admitted with marijuana as the primary drug
of abuse is 24
Sites of treatment 47 percent treated as outpatients 13 percent treated as hospital inpatients (detoxification) 18 percent treated in a residential setting
© 2011 McGraw-Hill Higher Education. All rights reserved.
Treatment: The Big Picture in the Treatment: The Big Picture in the United States United States
Substance abuse treatment development should focus on More effective interventions for commonly abused
drugs Alcohol Opioids Marijuana Cocaine
Treatment delivery on an outpatient basis
Effective outpatient behavioral/psychosocial interventions are needed to improve the overall success of treatment
© 2011 McGraw-Hill Higher Education. All rights reserved.
Is Treatment Effective?Is Treatment Effective?
Substance dependence is a chronic illness Treatment doesn’t work for every
individual every time Condition may require continuing
care throughout life
Studies show that treatment is cost-effective by reducing crime and increasing employment
Treatment also saves lives in the long term
© 2011 McGraw-Hill Higher Education. All rights reserved.
Chapter 18Chapter 18
Treating Substance Abuse and Dependence