Addiction treatment

Treatment

• 2 approaches
  • Abstinence
  • Harm reduction
• Treatment settings
  • Outpatient
  • Residential treatment programs
• Psychotherapy

Types of Psychotherapies and Behavioral Interventions

(WHO 2006)

• Cognitive behavioral therapies
  • Focus on: a. altering the cognitive processes that lead to maladaptive behaviors of substance users; b. intervening in the behavioral chain of events that lead to substance use; c. helping patients deal successfully with acute or chronic substance craving; d. promoting and reinforcing the development of social skills and behaviors compatible with remaining substance-free.
  • The foundation of cognitive therapy is the belief that by identifying and subsequently modifying maladaptive thinking patterns, patients can reduce or eliminate negative feelings and behavior (e.g. substance use).
• Relapse prevention
  • An approach to treatment in which cognitive behavioral techniques are used in an attempt to help patients develop greater self-control in order to avoid relapse. Specific relapse prevention strategies include discussing ambivalence, identifying emotional and environmental triggers of craving and substance use, and developing and reviewing specific coping strategies to deal with internal or external stressors.
• Contingency management
  • A behavioral treatment based on the use of predetermined positive or negative consequences to reward abstinence or to punish (and thus deter) substance-related behaviors. Rewards have included vouchers awarded for producing substance-free urine samples that can be exchanged for mutually agreed-upon items (e.g. cinema tickets) and community reinforcement in which family members or peers reinforce behaviors that demonstrate or facilitate abstinence (e.g. participation in positive activities). Negative consequences for returning to substance use may include notification of courts, employers, or family members.
• Motivational enhancement therapy
  • This brief treatment modality is characterized by an empathetic approach in which the therapist helps to motivate the patient by asking about the pros and cons of specific behaviors; by exploring the patient’s goals and associated ambivalence about reaching these goals; and by listening reflectively. Motivational enhancement therapy has demonstrated substantial efficacy in the treatment of substance dependence.
• Other Treatments
  • Motivational Interviewing
  • Cognitive Behavioral Therapy
  • Social Skills Training
  • Contingency Management
  • Pharmacological Therapy

Change Theory

(Prochaska & DiClemente)

• STAGES OF CHANGE
  1. Precontemplation
  2. Contemplation
  3. Preparation
  4. Action
  5. Maintenance

RECOMMENDING ABSTINENCE if: Pregnant or trying to get pregnant, taking meds that interact with alcohol, contraindicated by medical conditions, alcohol dependent, want to find out if dependent

Psychotherapy

• Focuses on the present interests, concerns, and perspectives of the individual.
• Focuses on the resolution of ambivalence.
• Elicits and selectively reinforces change talk.
• Is a method of communicating rather than a set of techniques.
• It is fundamentally a way of being with and for people- “facilitative approach to communication that evokes natural change”.
• Ellicits the person’s intrinsic motivation for change.

Motivational interviewing

• Four General Principles
  1. Express Empathy
     • Acceptance facilitates change
  2. Develop Discrepancy
     • Between behavior and personal goals
  3. Roll with resistance
     • Patient primary resource for solutions
     • Signal to respond differently
  4. Support self-efficacy
     • Patient responsible for choosing and carrying out change

CBT for Substance Abuse

• Cognitive Behavior Therapy for substance has two main components: functional analysis and skills training.
• Functional Analysis: Working together, the therapist and the patient try to identify the thoughts, feelings, and circumstances of the patient before and after they drank or used drugs. This helps the patient determine the risks that are likely to lead to a relapse.
• Functional analysis can also give the person insight into why they drink or use drugs in the first place and identify situations in which the person has coping difficulties.
• Skills Training: If someone is at the point where they need professional treatment for their alcohol or drug dependence, chances are they are using alcohol or drugs as their main means of coping with their problems. The goal of cognitive behavior therapy is to get the person to learn or relearn better coping skills.

Pharmacological Treatments for Substance Dependence

(WHO 2006)

• Refer to Table 5, Pages 75 and 76.
• Summary Table includes:
  • Substance
  • Treatment
  • Efficacy
• Substances and Treatments covered:
  • Alcohol:
    • Acamprosate
    • Naltrexone
    • Disulfiram
  • Nicotine:
    • Nicotine substitution
    • Bupropion
    • Immunotherapy
  • Heroin:
    • Methadone
    • Buprenorphine
    • Levo-alpha-acetyl-methadol (LAAM)
    • Naltrexone
  • Cocaine:
    • GBR 12909
    • Immunotherapies
  • Sedatives/Hypnotics
    • Slow tapering of substance dose combined with behavioral therapy.
• A number of medications have been approved for the treatment of substance abuse. These include replacement therapies such as buprenorphine and methadone as well as antagonist medications like disulfiram and naltrexone in either short-acting, or the newer long-acting form (under the brand name Vivitrol).
• Several other medications, often ones originally used in other contexts, have also been shown to be effective including bupropion (Zyban or Wellbutrin), Modafinil (Provigil) and more.