Treatment Types: An Overview

Perhaps there is no other illness to which the saying "an ounce of prevention is worth a pound of cure" is more applicable than it is to substance abuse and dependence. The reason for this is that once a person becomes dependent on, or addicted to, alcohol or some other drug, certain physiological changes occur inside the body, which make it extremely difficult to give up using that particular substance. For example, alcohol affects a variety of neurotransmitters (chemicals that help transmit messages between brain cells), and the overall effect is the inhibition or reduction of brain cell activity. When alcohol is removed, the affected nerve cells are overstimulated, and this results in craving . Similar changes also take place when a person abuses other drugs, such as heroin or cocaine, and some of the brain cells may become permanently damaged in the process.

It is therefore very difficult to cure dependence on substances; however, there are a number of ways in which it can be successfully treated. These include psychological approaches as well as treatments that involve the use of medications.

Psychological Approaches

Alcoholics Anonymous (AA) is the oldest and most popular self- help organization that has been established for (and by) alcoholics. Its aim is to help alcoholics recover from their addiction by using a psychological/spiritual approach. The organization has grown tremendously over the past few decades, and it is now estimated to have approximately 100,000 groups worldwide.

See Organizations of Interest at the back of Volume 3 for address, telephone, and URL.

The concepts of AA have also been applied to other substance use disorders. For example, there is an organization called Narcotics Anonymous for those addicted to narcotics .

See Organizations of Interest at the back of Volume 3 for address, telephone, and URL.

The program of Alcoholics Anonymous is based on a twelve-step process:

1. Admitting powerlessness over alcohol.
2. Believing that a power greater than yourself could restore sanity and normalcy in your life.
3. Making a decision to turn your life over to the care of God.
4. Making a moral inventory of yourself.
5. Admitting to God, yourself, and to others the exact nature of your weaknesses.
6. Being ready to have God remove these weaknesses.
7. Asking God to remove the weaknesses or shortcomings.
8. Making a list of all persons you have harmed, and being ready to make amends to them all.
9. Making direct amends to such people wherever possible, except when to do so would injure them or others.
10. Continuing to take personal inventory, and promptly admitting it when you are wrong.
11. Seeking to improve your conscious contact with God through prayer and meditation.
12. Having had a spiritual awakening as the result of these steps, you try to carry this message to others, and to practice these principles in all parts of life.

The twelve-step model of treatment is usually applied on an out- patient basis, but there are inpatient rehabilitation clinics that are based on the AA twelve-step process. Therapy at such rehabilitation units usually consists of education as well as individual and group therapy sessions.

Behavior Modification. Behavior modification techniques involve rewarding desirable behavior and providing negative consequences for inappropriate behavior. For example, one counselor developed a voucher system in which negative urine tests (which indicate no drug use) were rewarded with gift certificates that could be used to purchase a variety of items. This behavioral group remained in treatment longer and had longer periods of abstinence, compared to a control group that had received standard drug counseling.

"Contingency contracting" is another effective behavior modification technique that is occasionally used for treating substance abuse. With contingency contracting, negative consequences follow undesirable behavior. For example, patients who are concealing their drug use from their bosses, family members, or anyone else may be asked to sign a "contract" that allows their therapist to inform one or more specific individuals if their drug use resumes.

Cognitive Therapy. The aim of cognitive therapy is to change the negative, inappropriate thoughts that lead to substance abuse and dependence. Cognitive psychotherapy for addiction recovery is usually a long process consisting of several phases or stages. Each of the stages has a primary goal, and different types of psychological interventions become appropriate, depending on the goal. During the first two phases, called pretreatment and stabilization, the focus is placed on challenging the denial of patients regarding the consequences of their disease and addressing the symptoms of withdrawal .

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During the third and fourth stages of early and middle recovery, the patients' major goals are to learn to function without drugs and alcohol, and to develop a healthy lifestyle. During these stages, the focus of cognitive therapy is on relapse prevention. Relapse is often due to ineffective coping skills in so-called high-risk situations (for instance, a high-risk situation might develop if the addict attends a party where he or she is strongly tempted to use drugs). Therefore, the therapeutic work of this approach is to develop effective coping responses, as well as to learn to handle a lapse (taking a single drink or drug) so that it does not turn into relapse. The final stages, late recovery and maintenance, emphasize personal growth in areas such as self-esteem, spirituality, intimacy, and work, while individuals are maintaining a drug-free lifestyle.

Treatments Using Medications

Although medications should not be relied upon as the only means of treating substance use disorders, they can be useful and effective components or parts of a comprehensive treatment program that addresses the psychological, social, and spiritual needs of the patient.

The drug disulfiram (Antabuse) has been used to treat alcoholics for over fifty years. Disulfiram acts on the liver to inhibit the metabolism of alcohol, and it results in the production of large amounts of a toxic substance called acetaldehyde. Therefore, if a person who had taken disulfiram drinks some alcohol—even in very small amounts—he or she will experience very unpleasant symptoms, such as nausea and vomiting, as a result. The symptoms vary with each individual, but they are generally proportional to the amounts of disulfiram and alcohol ingested. Severe reactions from unsupervised ingestion of alcohol may cause respiratory depression, unconsciousness, and even death. Because of the possibility of severe reactions, the use of disulfiram has been declining in the United States. Instead, newer drugs are being used to combat alcohol dependence, most of which can be described either as an agonist or as an antagonist .

Agonists. Agonists usually activate the same brain cells that are activated by the original drug that an individual is addicted to. However, the effects of agonist medications are less intense and tend to last longer than those of the addictive drugs they replace. For example, methadone is often given to heroin addicts, because it is metabolized (or broken down) by the body more slowly than heroin, and it does not have such an intense physical effect on a person's body. Because methadone reduces the craving and the withdrawal symptoms that occur when a heroin addict stops using the drug, methadone treatment makes it easier for the addict to quit. Eventually, some patients are able to stop using methadone itself as well. Even when addicts are kept on methadone maintenance treatment for a long time, they may be able to turn their lives around, they can work, and they can be acceptable members of their families and of society in general, which was not the case while they were addicted to heroin.

Antagonists. Antagonists work by preventing the abused drug from producing its usual (intense, pleasurable) effect. Antagonists have no potential for abuse and they produce no withdrawal syndrome. Naltrexone is an antagonist medication that has been used with some success for the treatment of alcohol dependence. It is usually used after detoxification to maintain abstinence. Unfortunately, however, relatively few patients take an antagonist as prescribed because of its lack of pleasant effects, its lack of effect on withdrawal (if the patient stops taking the medication), and its inability to stop the craving. Nevertheless, a review of a large number of studies found that naltrexone, when taken as prescribed, is moderately effective in reducing the number of drinks consumed by alcoholics.

Treatment of Adolescents

Adolescent drug and alcohol use often stems from different causes than it does for adults. For example, several studies have found that the influence of peers (friends, classmates) is very important, and having friends who are substance abusers is one of the biggest risk factors for the development of teen drug abuse and dependence.

In treatment, adolescents must be approached differently from adults. This is true for several reasons: adolescents are still developing or growing; they have different values and belief systems; they are influenced by environmental considerations, such as strong peer influences, that most adults are not influenced by; and they are still in school. Treatment approaches should also account for age, gender, ethnic group, cultural background, family structure, intellectual and social development, and readiness for change. Furthermore, younger adolescents have different developmental needs than older adolescents, and treatment approaches should be developed appropriately for different age groups.

Treatment should involve family members, because family history may play a role in the origins of the problem, and successful treatment cannot take place in isolation. Treatment providers should have specific training in the principles of adolescent development, and treatment programs should avoid mixing adult clients with adolescent clients. Treatment options can vary. Brief interventions, which involve screening, guidance, and educational interventions, are primarily appropriate for adolescents who have mild or moderate substance use disorders. Brief interventions may also occur in primary care settings as part of a routine medical exam.

Treatment may also include various intensities of outpatient treatment, as well as twenty-four-hour intensive inpatient care for adolescents requiring a high level of supervision. Inpatient care generally includes detoxification—a three- to five-day program with intensive medical monitoring and management of withdrawal symptoms. Residential treatment is a long-term model that includes psychosocial rehabilitation among its goals. The duration of residential treatment can range from thirty days to one year, and it is especially beneficial for adolescents with coexisting personality and substance abuse disorders.

Therapeutic communities are intensive and comprehensive (addressing many areas of the patients life) treatment centers. Although originally developed for adults, they have been modified successfully to treat adolescents with the most severe alcohol or substance use disorders for whom long-term care is considered the best choice. The

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community itself is both therapist and teacher in the treatment process. The core goal is to promote a safe, healthy lifestyle and identify behaviors that can lead to alcohol and substance abuse that need to be changed. The community provides a safe and nurturing environment within which adolescents can begin to experience healthy living. Adolescents typically spend twelve to eighteen months living in a therapeutic community.

Self-help groups, such as AA, can be helpful when used in addition to other outpatient services and residential programs for teenagers. Self-help groups offer positive role models, new friends who are learning to enjoy life free from substance use, people celebrating sober living, and a place to learn how to cope with stress. Many adolescents involved with these twelve-step programs have a fellow member serve as a sponsor to provide guidance and help in times of crisis or when the urge to return to drinking or using drugs becomes overwhelming.

Treatment programs can also include family therapy to bring about positive changes in the way family members relate to—and communicate with—each other. This type of therapy may help decrease family conflict and improve effectiveness of communication. Family members, both parents and youth, can learn how to listen to one another and solve problems through negotiation and compromise.

It is extremely important that adolescents are assessed for coexisting mental disorders. Such disorders (if any) should be addressed and treated before substance abuse treatment takes place. Since sub- stance use problems often occur along with other behavior disorders, many providers offer skills training in impulse control, anger management, problem solving, assertiveness, time management, and stress management.

During the final phase of treatment, providers work with adolescents to develop an aftercare plan to make sure they do not start using alcohol or other drugs again. Continuing (long-term) care programs are often needed to help adolescents reduce their risk for relapse. Self-help groups and group homes that offer transitional living arrangements can also be helpful for adolescents trying to recover from substance use disorders.

see also specific drugs for treatment entries; Addiction: Concepts and Definitions; Al-anon; Alateen; Alcoholics Anonymous (AA); Brain Chemistry; Brain Structures; Narcotics Anonymous (NA); Treatment Programs, Centers, and Organizations: A Historical Perspective.