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© 2011 McGraw-Hill Higher Education. All rights reserved. Chapter 18 Chapter 18 Treating Substance Abuse and Dependence

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Page 1: Hart13 ppt ch18

© 2011 McGraw-Hill Higher Education. All rights reserved.

Chapter 18Chapter 18

Treating Substance Abuse and Dependence

Page 2: Hart13 ppt ch18

© 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

Page 3: Hart13 ppt ch18

© 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

Page 4: Hart13 ppt ch18

© 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

Page 5: Hart13 ppt ch18

© 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

Page 6: Hart13 ppt ch18

© 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

Page 7: Hart13 ppt ch18

© 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

Page 8: Hart13 ppt ch18

© 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

Page 9: Hart13 ppt ch18

© 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

Page 10: Hart13 ppt ch18

© 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

Page 11: Hart13 ppt ch18

© 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

Page 12: Hart13 ppt ch18

© 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

Page 13: Hart13 ppt ch18

© 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

Page 14: Hart13 ppt ch18

© 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

Page 15: Hart13 ppt ch18

© 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

Page 16: Hart13 ppt ch18

© 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

Page 17: Hart13 ppt ch18

© 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

Page 18: Hart13 ppt ch18

© 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

Page 19: Hart13 ppt ch18

© 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

Page 20: Hart13 ppt ch18

© 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

Page 21: Hart13 ppt ch18

© 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

Page 22: Hart13 ppt ch18

© 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

Page 23: Hart13 ppt ch18

© 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

Page 24: Hart13 ppt ch18

© 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

Page 25: Hart13 ppt ch18

© 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

Page 26: Hart13 ppt ch18

© 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

Page 27: Hart13 ppt ch18

© 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

Page 28: Hart13 ppt ch18

© 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

Page 29: Hart13 ppt ch18

© 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

Page 30: Hart13 ppt ch18

© 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

Page 31: Hart13 ppt ch18

© 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

Page 32: Hart13 ppt ch18

© 2011 McGraw-Hill Higher Education. All rights reserved.

Chapter 18Chapter 18

Treating Substance Abuse and Dependence