Andrea G. Barthwell, MD, FASAM, and Lawrence S. Brown, Jr, MD, MPH, FASAM
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GOALS OF SUBSTANCE USE TREATMENT
In the United States, over 11,000 specialized substance use treatment facilities provide rehabilitation, counseling, behavioral therapy, medication, case management, and other types of services to persons with substance use disorders. Care of individuals with substance use disorders includes assessing needs, providing treatment for intoxication and withdrawal, and developing, with appropriate support, a treatment plan that may consist of referrals to psychosocial care.
TREATMENT SETTINGS
Decisions regarding the site of care should be based on the patient’s ability to cooperate with and benefit from treatment offered and to refrain from illicit use of substances as well as the need to avoid high-risk behaviors and the need for structure and support. Patients move from one level of care to another based on these factors and an assessment of their ability to benefit from a different level of care. While some hospitals have inpatient Addiction Medicine Consultation Services with specialty-trained clinicians, other hospitals limit their management of substance use disorders to basic detoxification and referral.
Detoxification refers not only to the attenuation of the physiologic and psychological features of withdrawal syndromes but also to the process of interrupting the momentum of compulsive use in persons diagnosed with substance use disorders. It can be delivered in ambulatory settings with and without extended on-site monitoring. In residential or inpatient settings, it is delivered under clinically managed, medically monitored, or medically managed conditions.
Hospitalization is appropriate for patients whose assessed need cannot be treated safely in an outpatient or emergency department setting due to
- Acute intoxication
- Severe or medically complicated withdrawal potential
- Co-occurring medical or psychiatric conditions that complicate detoxification or impair treatment
- Failure of engagement in treatment at a lower level of care
- Life- or limb-threatening medical conditions that would require hospitalization
- Psychiatric disorders that make the patient an imminent threat to self or others
- Failure to respond to care at any level such that the patient endangers others or poses a self-threat
Partial hospitalization is considered for patients who require intensive care but have a reasonable chance of making progress on treatment goals in the intertreatment interval, including maintenance of abstinence. It is often provided to individuals who still require frequent and concentrated contact with treatment professionals to monitor their behavior and manage their risk of relapse and need to develop support for their recovery-focused efforts beyond the treatment system. The difference between partial hospital programs and intensive outpatient is seen in intensity, number of hours per day, setting of the program, and structure of the program.
Outpatient programs vary in structure and intensity. They are less expensive than residential or inpatient treatment and may be more suitable for individuals with less severe symptoms and a high degree of predicted compliance and those with supportive structure in his or her home environment. High rates of attrition can be problematic, particularly in the early phase.
Outcomes are highly correlated with time in treatment, and as a result, retention should be one focus of treatment, along with self-efficacy regarding adherence to the abstinence plan. In many outpatient programs, as in much of treatment in general, group counseling is emphasized.
RESIDENTIAL PROGRAMS, INCLUDING THERAPEUTIC COMMUNITY
Residential programs have the following characteristics:
- Provide care 24 hours a day
- Are generally conducted in nonhospital settings
- Are generally provided to patients who do not meet the clinical criteria for hospitalization
- May include short-term programs that provide intensive but relatively brief residential treatment based on Twelve-Step Facilitation
- Duration of treatment is determined by the clinical response to therapy
- Duration of treatment also varies on the length of time necessary for the patient to meet specific criteria predictive of success
One residential treatment model is the therapeutic community (TC). TCs are residential programs with planned lengths of stay from 6 to 12 months. TCs focus on the “resocialization” of the individual and use the program’s entire “community”—including other residents, staff, and the social context—as active components of treatment. Treatment is highly structured and can at times be confrontational, with activities designed to help residents examine damaging beliefs, self-concepts, and patterns of behavior and to adopt new, more harmonious, and constructive ways to interact with others.
Retention lengths predict outcomes on abstinence with abstinence success rates of 90% for graduates of 2-year programs and 25% for dropouts of the same programs completing <1 year.
Community residential rehabilitation facilities include “halfway houses” or “sober living facilities,” with the former providing more structure and supervision. Individuals referred to these settings are generally deemed to be at risk for relapse without such support. This setting is offered to the individual whose environmental risk is great or those needing a number of services after primary treatment to address deficits in vocation, employment, and social supports.
Case management is a collaborative process that assesses, plans, implements, coordinates, monitors, and evaluates the options and services to meet an individual’s health needs.
Case management is provided to individuals whose social situation and complex needs would impair their ability to adhere to a prescribed treatment plan and follow-up care.
Aftercare generally follows an episode of care and is focused on maintenance of gains made in treatment over a prescribed period. The patient’s affiliation with a Twelve-Step program is encouraged, and the transition to self-efficacy is monitored.
CRIMINAL JUSTICE SETTINGS FOR MANDATED TREATMENT, INCLUDING DRUG COURTS
Research has shown that combining criminal justice sanctions with substance use treatment can be effective in decreasing substance use and related crime. Individuals under legal coercion tend to stay in treatment for a longer period and do as well as or better than others not under legal pressure.
Often, persons with substance use disorders encounter the criminal justice system earlier than other health or social systems. Substance use treatment may be delivered before, during, after, or in lieu of incarceration.
A number of treatment options exist for those that are incarcerated, including didactic drug education classes, self-help programs, and treatment based on TC or residential milieu therapy models. TC models have been studied extensively and found to be quite effective in reducing substance use and recidivism to criminal behavior. Those in treatment are generally segregated from the general prison population, so that the “prison culture” does not overwhelm progress toward recovery. Research shows that relapse to substance use and recidivism to crime are significantly lower if the offender continues treatment after returning to the community.
Several criminal justice alternatives to incarceration have been tried with offenders who have substance use disorders, including limited diversion programs, pretrial release conditional on entry into treatment, and conditional probation with sanctions. Drug courts mandate and arrange for substance use treatment, actively monitor progress in treatment, and arrange other services for substance-involved offenders.
TREATMENT SERVICES
Because of the limitations of self-report in the initial assessment and during clinical monitoring, substance use testing represents an important tool for addiction medicine specialists.
When used in concert with a good history, physical examination, and biologic markers, substance use testing facilitates screening, assessment, diagnosis, and clinical monitoring of a substance use disorder in the hands of an experienced practitioner.
Intoxication and withdrawal can be life threatening without appropriate, if not emergent, intervention. Pharmacotherapy is the cornerstone for patients suffering from either intoxication or withdrawal. Detoxification is a commonly used approach in responding to patients with clinical signs of intoxication or withdrawal. It is intended to reduce or eliminate the medical consequences of withdrawal/pain of withdrawal/acute increase in craving and prepare individuals for the next stage of treatment.
Behavioral Therapies
Behavioral therapies are particularly important for the treatment of substance use disorders for which pharmacologic treatments are inefficacious. These therapies attempt to arrest compulsive substance use through modification of behaviors, feelings, social functioning, and thoughts. Because no form of psychotherapy has proven superior to another for all patients, successful referral to services is more important than physician determination of the most appropriate approach.
Cognitive–behavioral therapy is based on the theory that learning processes play a critical role in the development of maladaptive patterns of behavior. Cognitive–behavioral therapy targets two processes, dysfunctional thoughts and maladaptive behaviors. Relapse prevention is a hallmark cognitive–behavioral intervention used in addiction treatment. Relapse prevention encompasses several cognitive–behavioral strategies that facilitate abstinence as well as provide help for persons who experience relapse. The goal of relapse prevention is to help individuals with substance use disorders learn to identify and correct problematic behaviors.
Motivational enhancement therapy is a patient-centered counseling approach that attempts to initiate behavior change by helping patients resolve their ambivalence about engaging in treatment and stopping substance use. This approach employs strategies to evoke rapid and internally motivated change in the client, rather than guiding the client stepwise through the recovery process. Motivational interviewing principles are used to strengthen motivation and build a plan for change. Coping strategies for high-risk situations are suggested and discussed with the client.
Community reinforcement approach is an intensive outpatient therapy employed for cocaine dependence with dual goals: to achieve cocaine abstinence long enough for patients to learn new life skills that will help sustain abstinence and to reduce alcohol consumption for patients whose drinking is associated with cocaine use.
Voucher-based reinforcement therapy helps patients achieve and maintain abstinence from illicit substances by providing them with a voucher each time they provide a substance-free urine sample. The voucher has monetary value and can be exchanged for goods and services consistent with the goals of treatment. Initially, the voucher values are low, but their value increases with the number of consecutive substance-free urine specimens the individual provides. Cocaine- or heroin-positive urine specimens reset the value of the vouchers to the initial low value. Studies show that patients receiving vouchers for substance-free urine samples achieved significantly more weeks of abstinence and significantly more weeks of sustained abstinence than patients who were given vouchers independent of urine toxicology results.
Individualized counseling focuses directly on reducing or stopping the patient’s illicit substance use. It also addresses related areas of impaired functioning—such as employment status, illegal activity, and family/social relations—as well as the content and structure of the patient’s recovery program.
Multidimensional family therapy is an outpatient, family-based, substance use treatment approach for adolescents. It approaches adolescent substance use in terms of a network of influences (individual, family, peer, and community) and suggests that reducing unwanted behavior and increasing desirable behavior occur in multiple ways in different settings. Treatment includes individual and family sessions held in the clinic, in the home, or with family members at the family court, school, or other community locations.
Multisystemic therapy addresses the factors associated with serious antisocial behavior in children and adolescents who use illicit substances. These factors include characteristics of
- The adolescent (e.g., favorable attitudes toward substance use)
- The family (poor discipline, family conflict, or parental substance use)
- Peers (positive attitudes toward drug use)
- School (dropout, poor performance)
- Neighborhood (criminal subculture)
Computer-assisted therapy (CAT) programs involve the use of technology in the treatment of substance use disorders. Formal CAT programs are usually clinician facilitated, although some are developed to be used independently by the addicted individual. Randomized controlled trials have demonstrated that, in some cases, this intervention approach may significantly reduce substance use behavior and biochemical measures of substance use. Programs incorporating CATs, like online counseling, Web-based self-help resources, and text messaging, have proven to be more effective than standard treatment when used in smoking cessation, cognitive–behavioral therapy, counseling and information programs for cannabis use, alcohol self-help programs, and screening and brief intervention.
Pharmacologic Therapies
Opioid agonist treatment usually is conducted in outpatient treatment settings, such as methadone maintenance treatment programs or the physician’s office. Agonist treatment employs long-acting synthetic opiate medications, such as methadone or buprenorphine, taken orally for a sustained period at a dose sufficient to prevent opiate withdrawal, block the effects of illicit opiate use, and decrease opiate craving. Patients stabilized on agonist therapy can hold jobs, avoid the crime and violence of the substance use culture, reduce their exposure to HIV by stopping or decreasing injection drug use and substance use-related high-risk sexual behaviors, and engage more readily in counseling and other behavioral interventions that are essential to recovery and rehabilitation.
Naltrexone is a long-acting synthetic opiate antagonist with few side effects that is taken orally, either daily or three times per week, for a sustained period. Candidates for therapy with naltrexone must be medically detoxified and opiate-free before the drug can be given to avoid precipitating the opiate abstinence syndrome. The theory behind this treatment is that the repeated lack of the desired opiate effects, as well as the perceived futility of using the opiate, will gradually extinguish the habit of opiate use. Naltrexone itself has no subjective effects or potential for abuse and is not addicting. Patient noncompliance is a common problem; therefore, a favorable treatment outcome requires that there also be a positive therapeutic relationship, effective counseling or therapy, and careful monitoring of medication compliance.
KEY POINTS
1. Care of individuals with substance use disorders includes assessing needs, providing treatment, and developing an individualized treatment plan.
2. The site of care for a patient is dependent not only upon a patient’s ability to refrain from the use of illicit substances but also upon their needs for structure and support along with their ability to cooperate with and benefit from the treatment offered.
3. Residential programs are among the most popular, effective treatment settings and provide around-the-clock care and include a range of services such as therapeutic communities and sober living facilities.
4. Treatment relies on initial substance use testing as well as ongoing behavioral therapies including cognitive–behavioral, motivational enhancement, and community reinforcement.
5. Opioid agonist treatments, such as methadone or buprenorphine, and opiate antagonist treatments, such as naltrexone, use different mechanisms of action but can offer patients a similar result: a sustained, stabilized recovery from opioid use disorders.
REVIEW QUESTIONS
1. Decisions regarding the substance use disorder treatment site of care should be based on all of the following except:
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