All of the Following Are Drug-resistant Strategies Except:

All of the Following Are Drug-resistant Strategies Except:

Primary care clinicians demand to be familiar with available treatment resource for their patients who accept diagnosed substance corruption or dependence disorders. The clinician’s responsibility to the patient does not terminate with the patient’s entry into formal handling; rather, the physician may get a collaborative part of the treatment team, or, minimally, go on to treat the patient’s medical conditions during the specialized treatment, encourage continuing participation in the program, and schedule followup visits later treatment termination to monitor progress and assist prevent relapse.

Agreement the specialized substance corruption treatment system, however, tin can exist a challenging task. No single definition of treatment exists, and no standard terminology describes different dimensions and elements of treatment. Describing a facility as providing inpatient intendance or ambulatory services characterizes only one attribute (albeit an important 1): the setting. Moreover, the specialized substance abuse treatment organization differs around the country, with each State or metropolis having its own peculiarities and specialties. Minnesota, for example, is well known for its array of public and private alcoholism facilities, more often than not modeled on the fixed-length inpatient rehabilitation programs initially established by the Hazelden Foundation and the Johnson Institute, which subscribe to a strong Alcoholics Bearding (AA) orientation and have varying intensities of aftercare services. California too offers a number of community-based social model public sector programs that emphasize a 12-Step, cocky-help approach as a foundation for life-long recovery. In this chapter, the term
will be limited to describing the formal programs that serve patients with more serious alcohol and other drug problems who do non respond to brief interventions or other office-based direction strategies. It is besides assumed that an in-depth cess has been conducted to institute a diagnosis and to determine the most suitable resource for the private’s particular needs (see Affiliate four).

Directories of Local Substance Abuse Handling Systems

The outset step in agreement local resources is to collect information about the specialized drug and alcohol treatment currently bachelor in the customs. In most communities, a public or private agency regularly compiles a directory of substance abuse treatment facilities that provides useful information most plan services (e.1000., blazon, location, hours, and accessibility to public transportation), eligibility criteria, cost, and staff complement and qualifications, including language proficiency. This directory may exist produced by the local health section, a council on alcoholism and drug corruption, a social services organization, or volunteers in recovery. Additionally, every State has a single State-level booze and other drug authorisation that usually has the licensing and program review authority for all treatment programs in the Country and often publishes a statewide directory of all alcohol and drug handling programs licensed in the State. Another resource is the National Council on Booze and Drug Dependence, which provides both assessment or referral for a sliding scale fee and distributes free information on treatment facilities nationally. Too, the Substance Corruption and Mental Wellness Services Administration distributes a
National Directory of Drug Abuse and Alcoholism Treatment and Prevention Programs

Knowing the resources and a contact person within each volition facilitate admission to the system. I useful referral tool is a list of agencies organized across dissimilar characteristics, such as services tailored to meet the needs of special populations (e.k., women, adolescents, people who are HIV-positive, and minorities). Resources also should include cocky-help groups in the area.

Goals and Effectiveness of Handling

While each individual in treatment will have specific long- and brusk-term goals, all specialized substance abuse handling programs take three similar generalized goals (Schuckit, 1994; American Psychiatric Association, 1995):

  • Reducing substance abuse or achieving a substance-free life

  • Maximizing multiple aspects of life functioning

  • Preventing or reducing the frequency and severity of relapse

For well-nigh patients, the primary goal of treatment is attainment and maintenance of forbearance (with the exception of methadone-maintained patients), but this may take numerous attempts and failures at “controlled” use before sufficient motivation is mobilized. Until the patient accepts that abstinence is necessary, the treatment program commonly tries to minimize the effects of continuing use and abuse through education, counseling, and self-help groups that stress reducing risky beliefs, edifice new relationships with drug-gratis friends, changing recreational activities and lifestyle patterns, substituting substances used with less risky ones, and reducing the corporeality and frequency of consumption, with a goal of disarming the patient of her individual responsibility for becoming abstinent (American Psychiatric Association, 1995). Total abstinence is strongly associated with a positive long-term prognosis.

Becoming alcohol- or drug-free, however, is but a showtime. Most patients in substance abuse treatment take multiple and complex problems in many aspects of living, including medical and mental illnesses, disrupted relationships, underdeveloped or deteriorated social and vocational skills, impaired performance at work or in schoolhouse, and legal or financial troubles. These conditions may have contributed to the initial development of a substance use problem or resulted from the disorder. Substantial efforts must exist made past treatment programs to help patients in ameliorating these problems so that they can assume appropriate and responsible roles in gild. This entails maximizing concrete health, treating independent psychiatric disorders, improving psychological functioning, addressing marital or other family and relationship problems, resolving financial and legal bug, and improving or developing necessary educational and vocational skills. Many programs besides help participants explore spiritual issues and find advisable recreational activities.

Increasingly, treatment programs are also preparing patients for the possibility of relapse and helping them sympathize and avert dangerous “triggers” of resumed drinking or drug utilise. Patients are taught how to recognize cues, how to handle craving, how to develop contingency plans for handling stressful situations, and what to do if there is a “skid.” Relapse prevention is particularly of import as a treatment goal in an era of shortened formal, intensive intervention and more emphasis on aftercare following discharge.

While the effectiveness of treatment for specific individuals is not always predictable, and unlike programs and approaches have variable rates of success, evaluations of substance corruption handling efforts are encouraging. All the long-term studies find that “treatment works” — the majority of substance-dependent patients eventually stop compulsive use and take less frequent and severe relapse episodes (American Psychiatric Association, 1995; Landry, 1996). The about positive furnishings more often than not happen while the patient is actively participating in treatment, but prolonged abstinence post-obit treatment is a good predictor of continuing success. Almost 90 pct of those who remain abstemious for 2 years are also drug- and alcohol-free at 10 years (American Psychiatric Association, 1995). Patients who remain in handling for longer periods of time are also probable to achieve maximum benefits — duration of the handling episode for three months or longer is often a predictor of a successful outcome (Gerstein and Harwood, 1990). Furthermore, individuals who have lower levels of premorbid psychopathology and other serious social, vocational, and legal problems are near likely to benefit from treatment. Continuing participation in aftercare or self-assistance groups following treatment also appears to exist associated with success (American Psychiatric Association, 1995).

An increasing number of randomized clinical trials and other outcome studies have been undertaken in recent years to examine the effectiveness of alcohol and various forms of drug corruption treatment. It is beyond the scope of this chapter to written report the conclusions in any depth. However, a few summary statements from an Institute of Medicine report on alcohol studies are relevant:

  • No single treatment arroyo is effective for all persons with booze issues, and there is no overall advantage for residential or inpatient treatment over outpatient intendance.

  • Treatment of other life problems associated with drinking improves outcomes.

  • Therapist and patient (and problem) characteristics, treatment procedure, posttreatment adjustment factors, and the interactions among these variables likewise determine outcomes.

  • Patients who significantly reduce alcohol consumption or become totally abstinent usually improve their functioning in other areas (Constitute of Medicine, 1990).

A contempo comparison of treatment compliance and relapse rates for patients in handling for opiate, cocaine, and nicotine dependence with outcomes for iii common and chronic medical conditions (i.e., hypertension, asthma, and diabetes) found similar response rates across the addictive and chronic medical disorders (National Establish on Drug Corruption, 1996). All of these conditions require behavioral change and medication compliance for successful treatment. The conclusion is that treatment of drug addiction has a like success rate equally handling of other chronic medical conditions (National Institute on Drug Corruption, 1996).

Treatment Dimensions

The terminology describing the different elements of treatment treat people with substance employ disorders has evolved as specialized systems accept developed and every bit treatment has adapted to changes in the health care system and financing arrangements. Of import differences in language persist between public and individual sector programs and, to a bottom extent, in treatment efforts originally developed and targeted to persons with alcohol- equally opposed to illicit drug-related problems. Programs are increasingly trying to meet individual needs and to tailor the program to the patients rather than having a single standard format with a fixed length of stay or sequence of specified services.

A recent publication of the Substance Corruption and Mental Health Services Administration,
Overview of Addiction Treatment Effectiveness
(Landry, 1996), divides substance abuse handling along 3 dimensions: (1)
treatment approach
— the underlying philosophical principles that guide the blazon of care offered and that influence access and discharge policies as well equally expected outcomes, attitudes toward patient behavior, and the types of personnel who deliver services; (ii)
treatment setting
— the physical environment in which care is delivered; and (iii)
handling components
— the specific clinical interventions and services offered to meet individual needs. These services tin can exist offered for varying lengths of fourth dimension and delivered at differing intensities. Some other important dimension is treatment stage, because different resource may be targeted at different phases along a continuum of recovery. Programs also have been developed to serve special populations — by historic period, gender, racial and ethnic orientation, drug of choice, and functional level or medical condition. Some of these offer the about appropriate surround and services for special populations.

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).

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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).

Treatment Techniques

Within each handling approach, a multifariousness of specialized treatment techniques (also known as elements, modalities, components, or services) are offered to accomplish specified goals. Each patient is probable to receive more than than one service in various combinations as handling proceeds. The emphasis may change, for case, from pharmacological interventions to save withdrawal discomforts in the initial stage of treatment to behavioral therapy, cocky-help support, and relapse prevention efforts during the primary care and stabilization phase and standing AA participation afterward discharge from formal treatment. A patient in methadone maintenance treatment volition receive pharmacotherapy throughout all phases of care, in addition to other psychological, social, or legal services that are selected as advisable for achieving specified individual treatment goals. Again, the categorization of these techniques is not standardized and the terminology differs amongst programs. Nonetheless, the primary elements are

  • Pharmacotherapies,
    which discourage continuing alcohol or other drug apply, suppress withdrawal symptoms, cake or diminish euphoric furnishings or cravings, supervene upon an illicit drug with a prescribed medication, or treat coexisting psychiatric problems (run into Appendix A for more information on specific pharmacotherapies)

  • Psychosocial or psychological interventions,
    which modify destructive interpersonal feelings, attitudes, and behaviors through private, group, marital, or family unit therapy

  • Behavioral therapies,
    which meliorate or extinguish undesirable behaviors and encourage desired ones

  • Cocky-help groups
    for common support and encouragement to get or remain abstinent earlier, during, and later formal handling


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.)

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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).

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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.

The Handling Procedure

All the components, approaches, techniques, and settings discussed above must be monitored and adjusted as treatment progresses. Primary care clinicians should understand the following aspects of advisable care.

  • Repeating assessments
    to evaluate a patient’s changing medical, psychological, social, vocational, educational, and recreational needs, especially as more than basic and astute deficits or crises are resolved and new problems emerge or go acquiescent to handling. For example, homelessness or astute withdrawal symptoms will need to exist treated before family interactions can be identified or resolved. Suicidal thoughts or actions volition need prompt attention whenever they emerge.

  • Developing a comprehensive treatment plan
    that clearly reflects all identified problems, has explicit goals and strategies for their attainment, and specifies techniques and services to be provided by designated specialists at item frequencies or intensities.

  • Monitoring progress and clinical status
    through written notes or reports that describe responses to treatment approaches and outcomes of services provided, including counseling sessions, grouping meetings, urine or other biological testing, physical examinations, administered medications, and referrals for other care. Each patient should take an individual treatment record that includes all appropriate materials yet maintains the patient’due south privacy.

  • Establishing a therapeutic alliance
    with an empathic chief therapist or counselor who can gain the conviction and trust of the patient and significant others or family unit members and have responsibility for continuity of intendance. This is particularly of import in the early on stages of treatment to forestall dropout and encourage participation.

  • Providing education
    to help the patient and designated others understand the diagnosis, the etiology and prognosis for the disorder, and the benefits and risks of predictable treatment(south). Patients with special problems volition need more than all-encompassing data. As with other medical treatments, informed consent to potentially risky procedures should ever exist obtained (American Psychiatric Association, 1995).

Treatment Programs for Special Populations

A variety of substance abuse treatment programs have been developed to meet the particular needs of special populations, including women, meaning and postpartum mothers, adolescents, elderly persons, members of various minority groups, public inebriates or homeless persons, drinking drivers, and children of alcoholics. These special programs are establish in the public and private sectors and include both residential and ambulatory intendance settings using therapeutic customs, Minnesota model, outpatient drug-gratuitous, and methadone maintenance approaches. Researchers have not confirmed that these divide programs for special populations are superior to mainstream efforts with respect to outcomes, and experts question their cost-effectiveness and applicability to heterogeneous groups with overlapping characteristics that complicate placement of a detail patient in one grouping over another. Clinicians must exist wary of defining any patient in relation only to historic period, gender, racial group membership, or functional characteristics, especially since other patient-related variables accept been found to have greater implications for successful outcomes (east.g., addiction severity, employment stability, criminal involvement, educational level, and socioeconomic status). Nonetheless, clinical observations practise point that treatment of special populations may exist enhanced if their particular needs are considered and met. Notable components of these divide programs for special populations are as follows (Found of Medicine, 1990; American Psychiatric Association, 1995; Landry, 1996).

are more likely than men to have comorbid depressive and feet disorders, including posttraumatic stress disorders equally a event of past or electric current physical or sexual abuse. Although women tended in the past to become involved with unlike substances than men (e.g., prescription drugs), their drug use patterns have become more than similar to males’ in recent years. Handling components can accost women’s special issues and needs for kid care, parenting skills, building healthy relationships, avoiding sexual exploitation or domestic violence, preventing HIV infection and other sexually transmitted diseases, and enhanced self-esteem. A high ratio of female staff and same-sex groups are also thought to improve treatment retention.

Pregnant and postpartum women and their dependent children
have numerous special needs, including prenatal and obstetrical intendance, pediatric care, knowledge of child development, parenting skills, economic security, and safe, affordable housing. Significant women — and those in their childbearing years — need to know most nascence control too as the risks to pregnancy and fetal evolution of continuing substance use (east.g., spontaneous ballgame, abruptio placentae, preeclampsia, early and prolonged labor, birth defects, impaired fetal growth, low birth weight, stillbirth, and neonatal withdrawal syndrome). Methadone maintenance throughout pregnancy and the postpartum flow is ofttimes the handling of choice for opioid-dependent women with seriously compromised lifestyles who are non likely to remain abstinent. Nonetheless, many other medications used in the treatment of habit, including disulfiram and naltrexone, should not be prescribed for meaning substance abusers. See Appendix A and *TIP ii,
Pregnant, Substance-Using Women
(CSAT, 1993a).

Adolescents need treatment that is developmentally appropriate and peer-oriented. Educational needs are especially important likewise every bit interest of family members in treatment planning and therapy for dysfunctional aspects. Substance corruption among adolescents is frequently correlated with depression, eating disorders, and a history of sexual corruption (American Psychiatric Clan, 1995). A history of familial substance abuse and dependence is predictive of serious boyish involvement. More than information on specialized treatment of adolescents tin can exist found in TIP 4,
Guidelines for the Handling of Alcohol- and Other Drug-Abusing Adolescents
*(CSAT, 1993c).

Elderly persons
may have unrecognized and undertreated substance dependence on alcohol or prescribed benzodiazepines and sedative hypnotics that can contribute to unexplained falls and injuries, confusion, and inadvertent overdose considering historic period decreases the body’s ability to metabolize many medications. Other coexisting medical and psychiatric atmospheric condition can besides complicate treatment and compromise elderly patients’ ability to comply with recommended regimens.

Minority group members
may identify with particular cultural norms and institutions that increase feelings of social acceptance. While early phases of treatment that focus on achieving forbearance are not likely to be afflicted past minority grouping differences, the development of appropriate, drug-free social supports and new lifestyles during more extended handling and aftercare stages may be enhanced by support groups with similar ethnic identification and cultural patterns. For some African-American patients, involving the church and treatment that incorporates a spiritual element may improve outcomes. Treatment programs for Native American tribes often incorporate their traditions, and a family focus as well as bilingual staff and translated written materials are important ingredients of many treatment programs for Hispanics. Withal, the Consensus Panel believes that culturally sensitive handling may not exist as of import to individuals who do non strongly identify with an ethnic or cultural group and of less concern than socioeconomic differences, for example, in treatment retention.


One important aspect of working with or making a referral for substance abuse treatment is the legal requirement to comply with Federal regulations governing the confidentiality of information about a patient’southward substance use or abuse. Laws protecting the confidentiality of booze and drug abuse patient records were instituted to encourage patients to enter treatment without fright of stigmatization or bigotry as a result of information disclosure without the patient’southward express permission (42 C.F.R. Function 2). Clarifying amendments passed in 1987 get in articulate that patient records generated in general medical settings and hospitals are not covered unless the treating clinician or unit has a master interest in substance corruption handling *(CSAT, 1995b, p. 64). Nonetheless, records containing data about substance utilise disorders should always exist handled with discretion.

If referral is made by the primary care clinician for a substance abuse assessment or to a specialized handling program, written permission of the patient is required earlier whatever information or records can exist disclosed or redisclosed in which the patient’southward identity is revealed,
except in cases of medical emergency or reporting suspected kid abuse to the proper authorities.
Often, treatment programs will want to coordinate a patient’due south treatment with the primary care provider — such collaboration is essential for certain patients, such every bit chemically involved meaning women. See Appendix B for a detailed discussion of confidentiality. Confidentiality problems are too discussed in TIPs 4
(Guidelines for the Treatment of Booze- and Other Drug-Abusing Adolescents)
(CSAT, 1993c), 8
(Intensive Outpatient Treatment for Booze and Other Drug Abuse)
(CSAT, 1994a), eleven
(Elementary Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases)
(CSAT, 1994c), 13
(The Role and Current Condition of Patient Placement Criteria in the Treatment of Substance Utilize Disorders)
(CSAT, 1995a), 16
(Booze and Other Drug Screening of Hospitalized Trauma Patients)
(CSAT, 1995b), and 19
(Detoxification from Booze and Other Drugs)
(CSAT, 1995c).

The Function of the Primary Intendance Clinician Throughout Handling

As already noted, all primary care clinicians have important roles to play in identifying, screening, and referring patients with substance use disorders for in-depth assessment or treatment and in delivering cursory interventions to patients with milder substance-related issues. In addition, the clinician has an array of options, depending on time and resources bachelor, for offering ongoing support and encouragement to patients who do enter the formal treatment arrangement. These options include

  • Learning about treatment resources in the community that offer advisable services

  • Keeping in touch with the specific treatment plan where the patient is enrolled to ascertain its quality and sympathize the arroyo and services offered

  • Requesting formal reports regarding the handling program and progress indicators from the programme on a periodic basis (with the patient’s explicit permission)

  • Clarifying the clinician’s role in the continued care of the patient (due east.m., treating specified medical weather condition, writing prescriptions, and monitoring compliance through urine or other biological testing)

  • Reinforcing the importance of continuing handling to the patient and relatives

Completing specialized treatment is only the beginning of the patient’s recovery process. Main care clinicians should keep to ask their patients about the trouble they were treated for at every part or clinic visit. During these visits, the clinician can monitor the potential for relapse and have any necessary steps to prevent slips from occurring (Brown, 1992).

The master care clinician too has a responsibility to patients who reject to accept referral to treatment or drop out before completion. In such cases, the master care clinician should

  • Continue treating any medical problems, including those related to standing substance abuse.

  • Reiterate the master diagnosis and be ready to refer the patient for specialized treatment. If the patient objects to the initial referral, the physician should look for acceptable and appropriate alternatives.

  • Encourage family members and friends to participate in advisable Al-Anon, Alateen, Adult Children of Alcoholics, or similar groups in order to larn more about the substance use disorder, how to minimize distress, and how to avoid enabling behaviors.

  • Exercise extreme caution in prescribing psychotropic medications for feet, insomnia, and other complaints considering these drugs may exacerbate continued abuse.

All of the Following Are Drug-resistant Strategies Except: