All of the Following Are Drug-resistant Strategies Except:

Handling Models and Approaches

Historically, handling programs were developed to reflect the philosophical orientations of founders and their beliefs regarding the etiology of alcoholism and drug dependence. Although most programs now integrate the following three approaches, a brief review of before distinctions will assistance principal intendance clinicians sympathise what precursors may survive or boss among programs. The three historical orientations that still underlie different handling models are

1. A medical model,
   emphasizing biological and genetic or physiological causes of addiction that require handling past a physician and utilize pharmacotherapy to salve symptoms or change behavior (due east.g., disulfiram, methadone, and medical management of withdrawal).

2. A psychological model,
   focusing on an individual’s maladaptive motivational learning or emotional dysfunction equally the primary cause of substance abuse. This approach includes psychotherapy or behavioral therapy directed by a mental health professional person.

3. A sociocultural model,
   stressing deficiencies in the social and cultural milieu or socialization process that tin can be ameliorated past changing the concrete and social environment, peculiarly through involvement in self-help fellowships or spiritual activities and supportive social networks. Treatment authorization is often vested in persons who are in recovery themselves and whose experiential knowledge is valued.

These 3 models have been woven into a biopsychosocial approach in nigh gimmicky programs. The four major handling approaches now prevalent in public and private programs are

1. The Minnesota model of residential chemic dependency treatment
   incorporates a biopsychosocial disease model of addiction that focuses on forbearance every bit the chief handling goal and uses the AA 12-Footstep program equally a major tool for recovery and relapse prevention. Although this arroyo, which has evolved from earlier precursors (i.e., Willmar State Hospital, Hazelden Foundation, and Johnson Institute efforts), initially required 28 to 30 days of inpatient treatment followed past extensive community-based aftercare, more recent models have shortened inpatient stays considerably and substituted intensive outpatient treatment followed past less intensive continuing care. The new hybrid, used extensively by public and individual sector programs, blends 12-Step concepts with professional medical practices. Skilled chemical dependency counselors, oft people in recovery as well every bit mental wellness and social work professionals, apply a variety of behavioral and reality-oriented approaches. Psychosocial evaluations and psychological testing are conducted; medical and psychiatric support is provided for identified conditions; and the inpatient program utilizes therapeutic community concepts. Although a disease model of etiology is stressed, the individual patient has ultimate responsibleness for making behavioral changes. Pharmacological interventions may be used, particularly for detoxification; extensive education nearly chemical dependency is provided through lectures, reading, and writing; and individual and grouping therapy are stressed, as is the involvement of the family unit in treatment planning and aftercare (Institute of Medicine, 1990; Gerstein and Harwood, 1990; Landry, 1996).

2. Drug-costless outpatient treatment
   uses a variety of counseling and therapeutic techniques, skills training, and educational supports and little or no pharmacotherapy to address the specific needs of individuals moving from active substance abuse to forbearance. This is the least standardized treatment approach and varies considerably in both intensity, duration of care, and staffing patterns. Most of these programs see patients only once or twice weekly and utilize some combination of counseling strategies, social work, and 12-Step or self-help meetings. Some programs at present offer prescribed medications to ameliorate prolonged withdrawal symptoms; others stress case management and referral of patients to available customs resources for medical, mental health, or family unit treatment; educational, vocational, or financial counseling; and legal or social services. Optimally, a comprehensive continuum of straight and supportive services is offered through a combination of onsite and referral services. High rates of attrition are often a trouble for drug-free outpatient programs; legal, family, or employer pressure may be used to encourage patients to remain in handling (Landry, 1996; American Psychiatric Association, 1995; Gerstein and Harwood, 1990).

3. Methadone maintenance — or opioid substitution — handling
   specifically targets chronic heroin or opioid addicts who have not benefited from other handling approaches. Such handling includes replacement of licit or illicit morphine derivatives with longer-interim, medically safe, stabilizing substitutes of known potency and purity that are ingested orally on a regular ground. The methadone or other long-acting opioid, when administered in acceptable doses, reduces drug craving, blocks euphoric effects from continued utilize of heroin or other illegal opioids, and eliminates the rapid mood swings associated with short-acting and usually injected heroin. The approach, which allows patients to part normally, does non focus on abstinence as a goal, but rather on rehabilitation and the development of a productive lifestyle. A major accent in contempo years has been on reducing HIV infection transmission rates among patients who remain in treatment and end injection drug use. Private and group counseling in addition to pharmacotherapy and urine testing are the mainstay of most programs, simply more comprehensive and successful programs too offering psychological and medical services, social work assistance, family therapy, and vocational grooming. Methadone maintenance treatment, which is more controversial and extensively evaluated than any other treatment approach, has consistently been found to be constructive in reducing the use of illicit opioids and criminal activity likewise every bit in improving health, social operation, and employment (Gerstein and Harwood, 1990; Landry, 1996; National Establish on Drug Corruption, 1996).

4. Therapeutic community residential treatment
   is best suited to patients with a substance dependence diagnosis who as well have serious psychosocial adjustment problems and require resocialization in a highly structured setting. Treatment mostly focuses on negative patterns of thinking and behavior that can be changed through reality-oriented individual and grouping therapy, intensive run across sessions with peers, and participation in a therapeutic milieu with hierarchical roles, privileges, and responsibilities. Strict and explicit behavioral norms are emphasized and reinforced with specified rewards and punishments directed toward developing self-control and social responsibleness. Tutorials, remedial and formal education, and daily work assignments in the communal setting or conventional jobs (for residents in the concluding stages earlier graduation) are commonly required. Enrollment is relatively long-term and intensive, entailing a minimum of 3 to ix months of residential living and gradual reentry into the community setting. While patients who stay in therapeutic communities for at least a tertiary to half the planned course of treatment commonly have markedly improved operation in terms of reduced criminal activeness and drug consumption and improved rates of employment or schooling (and graduates exercise even better), the biggest drawback to therapeutic communities is the large per centum of enrollees (75 percent or more) who never consummate treatment (Gerstein and Harwood, 1990; Landry, 1996).

Treatment Settings

Substance corruption treatment is delivered in two basic settings or environments: inpatient and outpatient. Although the ii types of settings vary widely by cost, contempo evaluation studies have not establish that handling setting correlates strongly with a successful outcome. In fact, inquiry has non found a articulate human relationship between treatment setting and the amounts or types of services offered, although there is a correlation between the services provided and posttreatment outcomes. Essentially, most patients tin can do good from treatment delivered in either in- or outpatient settings, although specific subgroups seem to respond optimally to particular environments (Landry, 1996).

Initially, notwithstanding, it is of import to match the patient’south needs to a treatment setting. The goal is to place patients in the least restrictive environs that is even so safe and effective and then movement them forth a continuum of care as they demonstrate the chapters and motivation to cooperate with handling and no longer demand a more structured setting or the types of services offered only in that surroundings (i.east., medical or nursing supervision and room and lath). Motion, however, is not e’er in the direction of less intensive care as relapse or failure to respond to one setting may require moving a patient to a more restrictive environment (American Psychiatric Clan, 1995; Landry, 1996).

The continuum of treatment settings, from most intensive to least, includes inpatient hospitalization, residential treatment, intensive outpatient handling, and outpatient treatment.

Inpatient hospitalization
includes effectually-the-clock treatment and supervision by a multidisciplinary staff that emphasizes medical management of detoxification or other medical and psychiatric crises, normally for a short period of time. Currently, infirmary care is usually restricted to patients with (1) severe overdoses and serious respiratory depression or blackout; (two) severe withdrawal syndromes complicated by multiple drugs or a history of delirium tremens; (3) acute or chronic general medical conditions that could complicate withdrawal; (4) marked psychiatric comorbidity who are a danger to themselves or others; and (v) astute substance dependence and a history of nonresponse to other less intensive forms of treatment (American Psychiatric Association, 1995).

Residential treatment
in a live-in facility with 24-hour supervision is best for patients with overwhelming substance use problems who lack sufficient motivation or social supports to stay abstinent on their ain but practise not meet clinical criteria for hospitalization. Many residential facilities offer medical monitoring of detoxification and are appropriate for individuals who demand that level of care but exercise not need management of other medical or psychiatric problems. These facilities range in intensity and duration of care from long-term and self-contained therapeutic communities to less supervised halfway and quarterway houses from which the residents are transitioning back into the community. Specialized residential programs are specifically tailored to the needs of adolescents, pregnant or postpartum women and their dependent children, those under supervision by the criminal justice organisation, or public inebriates for whom extensive treatment has not worked (American Psychiatric Association, 1995; Landry, 1996).

Intensive outpatient treatment
requires a minimum of 9 hours of weekly omnipresence, usually in increments of 3 to 8 hours a day for 5 to vii days a calendar week. This setting is too known every bit partial hospitalization in some States and is often recommended for patients in the early stages of treatment or those transitioning from residential or infirmary settings. This environment is suitable for patients who do not need full-time supervision and accept some bachelor supports simply need more structure than is unremarkably available in less intensive outpatient settings. This treatment encompasses mean solar day intendance programs and evening or weekend programs that may offer a total range of services. The frequency and length of sessions is ordinarily tapered every bit patients demonstrate progress, less risk of relapse, and a stronger reliance on drug-free community supports (American Psychiatric Association, 1995).

Least intensive is
outpatient treatment
with scheduled attendance of less than 9 hours per week, usually including in one case- or twice-weekly individual, group, or family counseling as well as other services. As already noted, these programs can vary from convalescent methadone maintenance treatment to drug-free approaches. Patients attending outpatient programs should have some appropriate back up systems in place, adequate living arrangements, transportation to the services, and considerable motivation to nourish consistently and benefit from these least intensive efforts. Ambulatory care is used by both public programs and private practitioners for primary intervention efforts likewise as extended aftercare and followup (Institute of Medicine, 1990).

Pharmacotherapy

Medications to manage withdrawal
accept reward of cantankerous-tolerance to replace the abused drug with some other and safer drug in the aforementioned class. The latter can then be gradually tapered until physiologic homeostasis is restored. Benzodiazepines are oft used to alleviate alcohol withdrawal symptoms, and methadone to manage opioid withdrawal, although buprenorphine and clonidine are also used. Numerous drugs such every bit buprenorphine and amantadine and desipramine hydrochloride take been tried with cocaine abusers experiencing withdrawal, but their efficacy is not established. Acute opioid intoxication with marked respiratory low or blackout tin can be fatal and requires prompt reversal, using naloxone. Yet, if a patient is physically dependent on opioids, naloxone will precipitate withdrawal symptoms (American Psychiatric Association, 1995; Constitute of Medicine, 1990; Gerstein and Harwood, 1990). (Encounter Appendix A.)

Medications to discourage substance utilize
precipitate an unpleasant reaction or diminish the euphoric effects of alcohol and other drugs. Disulfiram (Antabuse), the best known of these agents, inhibits the activity of the enzyme that metabolizes a major metabolite of alcohol, resulting in the accumulation of toxic levels of acetaldehyde and numerous highly unpleasant side effects such as flushing, nausea, airsickness, hypotension, and anxiety. More recently, the narcotic antagonist, naltrexone, has too been found to be effective in reducing relapse to booze use, patently by blocking the subjective effects of the first beverage. Naltrexone too is used with well-motivated, drug-gratis opioid addicts to block the effects of usual street doses of heroin or morphine derivatives. Naltrexone keeps opioids from occupying receptor sites, thereby inhibiting their euphoric effects. These antidipsotropic agents, such as disulfiram, and blocking agents, such as naltrexone, are simply useful as an adjunct to other treatment, especially every bit motivators for relapse prevention (American Psychiatric Association, 1995; Landry, 1996). (Run into Appendix A.)

Agonist substitution therapy
replaces an illicit drug with a prescribed medication. Opioid maintenance treatment, currently the just blazon of this therapy available, both prevents withdrawal symptoms from emerging and reduces craving among opioid-dependent patients. The leading substitution therapies are methadone and the fifty-fifty longer interim levo-blastoff-acetyl-methadol (LAAM). Patients using LAAM but need to ingest the drug 3 times a calendar week, while methadone is taken daily. Buprenorphine, a mixed opioid agonist-antagonist, is too being used to suppress withdrawal, reduce drug peckish, and cake euphoric and reinforcing effects (American Psychiatric Association, 1995; Landry, 1996).

Medications to treat comorbid psychiatric conditions
are an essential offshoot to substance abuse treatment for patients diagnosed with both a substance use disorder and a psychiatric disorder. Prescribing medication for these patients requires farthermost caution, partly due to difficulties in making an accurate differential diagnosis and partly due to the dangers of intentional or unintentional overdose if the patient combines medications with driveling substances or takes higher than prescribed doses of psychotropic medications. Since there is a high prevalence of comorbid psychiatric disorders amidst people with substance dependence, pharmacotherapy directed at these atmospheric condition is oft indicated (e.g., lithium or other mood stabilizers for patients with confirmed bipolar disorder, neuroleptics for patients with schizophrenia, and antidepressants for patients with major or singular depressive disorder). Many psychiatrists agree that diagnoses for comorbid psychiatric conditions cannot exist fabricated until patients accept been detoxified from driveling substances and observed in a drug-free status for 3 to 4 weeks since many withdrawal symptoms mimic those of psychiatric disorders. Absent a confirmed psychiatric diagnosis, information technology is unwise for principal intendance clinicians and other physicians in substance abuse treatment programs to prescribe medications for insomnia, feet, or depression (especially benzodiazepines with a high abuse potential) to patients who have alcohol or other drug disorders. Even with a confirmed psychiatric diagnosis, patients with substance use disorders should be prescribed drugs with a low potential for (one) lethality in overdose situations, (two) exacerbation of the effects of the abused substance, and (iii) corruption itself. Selective serotonin reuptake inhibitors (SSRIs) for patients with depressive disorders and buspirone for patients with feet disorders are examples of psychoactive drugs with low abuse potential. These medications should also be dispensed in limited amounts and be closely monitored (Institute of Medicine, 1990; Schuckit, 1994; American Psychiatric Association, 1995; Landry, 1996).

Because prescribing psychotropic medications for patients with dual diagnoses is clinically complex, a conservative and sequential 3-stage approach is recommended. For a person with both an feet disorder and alcohol dependence, for example, nonpsychoactive alternatives such every bit exercise, biofeedback, or stress reduction techniques should be tried first. If these are not effective, nonpsychoactive drugs such every bit buspirone (or SSRIs for depression) should exist administered. But if these do not convalesce symptoms and complaints should psychoactive medications exist provided. Proper prescribing practices for these dually diagnosed patients encompass the post-obit six “Ds” (Landry et al., 1991a):

1. Diagnosis is essential and should exist confirmed past a conscientious history, thorough examination, and appropriate tests before prescribing psychotropic medications. Patients with substance use disorders should be evaluated for feet disorders and, conversely, those with anxiety disorders evaluated for substance corruption or dependence rather than just treating presenting symptoms.

2. Dosage must exist appropriate for the diagnosis and the severity of the trouble, without over- or undermedicating. If high doses are needed, these should be administered daily in the office to ensure compliance with the prescribed amount.

3. Duration should non be longer than recommended in the package insert or the
   Dr.’southward Desk Reference
   so that additional dependence can be avoided.

4. Discontinuation must be considered if there are complications (e.m., toxicity or dependence), at the expiration of the planned trial, if the original crisis abates, or when the patient learns and accepts alternative coping strategies.

5. Dependence development must be continuously monitored. The clinician also should warn the patient of this possibility and the need to brand decisions regarding whether the status warrants toleration of dependence.

6. Documentation is disquisitional to ensure a record of the presenting complaints, the diagnosis, the course of treatment, and all prescriptions that are filled or refused as well as whatever consultations and their recommendations.

Psychosocial Interventions

Individual therapy uses psychodynamic principles with such modifications as limit-setting and explicit advice or suggestions to help patients address difficulties in interpersonal functioning. I approach that has been tested with cocaine- and booze-dependent persons is supportive-expressive therapy, which attempts to create a safe and supportive therapeutic alliance that encourages the patient to address negative patterns in other relationships (American Psychiatric Association, 1995; National Institute on Drug Corruption, unpublished). This technique is usually used in conjunction with more comprehensive handling efforts and focuses on current life problems, not developmental issues. Some research studies point that individual psychotherapy is near benign for opiate-dependent patients with moderate levels of psychopathology who tin grade a therapeutic alliance (National Institute on Drug Abuse, unpublished). Drug counseling provided past paraprofessionals focuses on specific strategies for reducing drug apply or businesslike issues related to treatment retention or participation (due east.g., urine testing results, omnipresence, and referral for special services). This differs from psychotherapy by trained mental wellness professionals (American Psychiatric Association, 1995).

Group therapy
is 1 of the most often used techniques during principal and extended care phases of substance corruption treatment programs. Many different approaches are used, and there is niggling understanding on session length, meeting frequency, optimal size, open or closed enrollment, duration of grouping participation, number or training of the involved therapists, or manner of group interaction. Nearly controversial is whether confrontation or support should be emphasized.

Grouping therapy offers the experience of closeness, sharing of painful experiences, communication of feelings, and helping others who are struggling with control over substance corruption. The principles of group dynamics often extend across therapy in substance corruption treatment, in educational presentations and discussions about driveling substances, their furnishings on the body and psychosocial functioning, prevention of HIV infection and infection through sexual contact and injection drug use, and numerous other substance abuse-related topics (Institute of Medicine, 1990; American Psychiatric Association, 1995).

Marital therapy and family therapy
focus on the substance abuse behaviors of the identified patient and also on maladaptive patterns of family unit interaction and advice. Many different schools of family therapy have been used in treatment programs, including structural, strategic, behavioral, and psychodynamic orientations. The goals of family therapy besides vary, as does the phase of treatment when this technique is used and the type of family unit participating (e.grand., nuclear family, married couple, multigenerational family, remarried family, cohabitating aforementioned or different sex couples, and adults notwithstanding suffering the consequences of their parents’ substance corruption or dependence). Family intervention, a structured and guided endeavour to move a resistant and active substance abuser into treatment, can be a helpful motivator for program entry. Involved family unit members tin can help ensure medication compliance and attendance, program treatment strategies, and monitor forbearance, while therapy focused on ameliorating dysfunctional family dynamics and restructuring poor communication patterns can help establish a more appropriate environs and support system for the person in recovery. Several well-designed research studies support the effectiveness of behavioral human relationship therapy in improving the healthy performance of families and couples and improving treatment outcomes for individuals (Landry, 1996; Plant of Medicine, 1990; American Psychiatric Association, 1995). Preliminary studies of Multidimensional Family Therapy (MFT), a multicomponent family intervention for parents and substance-abusing adolescents, have found comeback in parenting skills and associated abstinence in adolescents for as long equally a year after the intervention (National Constitute on Drug Abuse, 1996).

Behavioral Therapies

Cognitive behavioral therapy
attempts to change the cognitive processes that lead to maladaptive behavior, intervene in the chain of events that pb to substance abuse, and then promote and reinforce necessary skills and behaviors for achieving and maintaining abstinence. Research studies consistently demonstrate that such techniques improve cocky-control and social skills and thus help reduce drinking (American Psychiatric Association, 1995). Some of the strategies used are self-monitoring, goal setting, rewards for goal attainment, and learning new coping skills. Stress management grooming — using biofeedback, progressive relaxation techniques, meditation, or practice — has become very popular in substance abuse treatment efforts. Social skills training to meliorate the general functioning of persons who are scarce in ordinary communications and interpersonal interactions has besides been demonstrated to exist an effective treatment technique in promoting sobriety and reducing relapse. Grooming sessions focus on how to express and react to specific feelings, how to handle criticism, or how to initiate social encounters (Establish of Medicine, 1990; American Psychiatric Association, 1995; Landry, 1996).

Behavioral contracting or contingency management
uses a fix of predetermined rewards and punishments established by the therapist and patient (and significant others) to reinforce desired behaviors. Constructive use of this technique requires that the rewards and punishments, or contingencies, exist meaningful, that the contract be mutually developed, and that the contingencies be applied every bit specified. Some studies suggest that positive contingencies are more effective than negative ones (National Institute on Drug Abuse, unpublished). Care must be taken that negative contingencies are not unethical or counterproductive (e.k., reducing methadone doses if urine results indicate standing illicit drug apply). Contingency management is only constructive inside the context of a comprehensive handling program (National Institute on Drug Abuse, unpublished; Establish of Medicine, 1990; Landry, 1996).

Relapse prevention
helps patients starting time recognize potentially high-risk situations or emotional “triggers” that have led to substance abuse, and so learn a repertoire of substitute responses to cravings. Patients also develop new coping strategies for handling external stressors and learn both to accept lapses into substance abuse as part of the recovery process and to interrupt them earlier agin consequences ensue. Controlled studies have constitute relapse prevention to be equally effective as other psychosocial treatments, especially for patients with comorbid sociopathy or psychiatric symptoms (American Psychiatric Clan, 1995). Cognitive-behavioral strategies, the improvement of self-efficacy, cocky-control training, and cue exposure and extinction have all been used as components of relapse prevention. In recent years, relapse prevention has become a vital part of most handling efforts, learned during the intensive stage of treatment and skillful during aftercare (Constitute of Medicine, 1990; American Psychiatric Association, 1995; Landry, 1996).

Self-Assist Groups

Mutual back up, 12-Step groups such as Alcoholics Bearding, Narcotics Anonymous, Cocaine Anonymous or more recent alternatives (e.g., Rational Recovery and Women for Sobriety) are the courage of many handling efforts likewise equally a major class of standing intendance. While AA and related groups are widely used, the success of this technique has non been rigorously evaluated. Nonetheless, these fellowships apparently help persons at any point in the recovery process to change old behavior patterns, react responsibly to drug cravings, maintain hope and conclusion to get and remain abstemious. Self-assist groups tin can also help people build a new social network in a customs of understanding peers, observe satisfactory drug-free activities and recreational skills, establish healthy intimate relationships, and avoid stressful social situations and environments.

The procedure of working through the 12 steps under the tutelage of a sponsor encourages group members to reassess past life experiences and take more than responsibility for their substance use disorders. Attendance may vary from daily to much less frequent, with more than intensive involvement bachelor whenever the recovering person feels this need.

Patients who exercise not accept the spiritual focus and abstinence orientation of AA may do good from Rational Recovery groups or the Recovery Training and Self-Help (RTSH) programs in some communities. Patients who are prescribed psychotropic medications for comorbid psychiatric disorders (eastward.g., antidepressants or neuroleptics) or are maintained on methadone or LAAM must attend fellowships or groups where pharmacotherapy is accepted equally appropriate treatment. Young persons, persons of colour, and gays and lesbians often detect more acceptance in groups where at least some members have similar characteristics. Friends and relatives of persons in recovery and of those who refuse treatment can benefit from Al-Anon, Alateen, Nar-Betimes, and similar groups that offer support and education about the affliction of alcoholism or other forms of substance abuse and teach participants to curb their own “enabling” behaviors. Improvements in substance-abusing behavior among meeting participants are associated with frequent omnipresence, obtaining a sponsor, “working” the 12 steps, and leading meetings (National Institute on Drug Abuse, 1993; American Psychiatric Association, 1995; Landry, 1996).

Other Primary and Ancillary Services

Patients in treatment may need other primary and adjunctive services also: social services, vocational training, teaching, legal assistance, financial counseling, wellness and dental care, and mental wellness treatment. These may be provided onsite or through referral to community resource. Adjunctive services to encourage patients to enter and remain in treatment may include kid care, transportation arrangements, fiscal assist or welfare support, supported housing, and other supplemental help. The types of additional services supplied or arranged through a treatment program will obviously depend heavily on the characteristics of the population served. For instance, persons with heroin, cocaine, or methamphetamine dependence disorders who inject these drugs will require many specialized education, identification, counseling, and wellness care services for HIV infection and AIDS that are not likely to be needed by programs for people with booze dependence.