1. SUBSTANCE USE DISORDERS GENERAL METHODS OF TREATMENT Inpatient Detoxification and Rehabilitation Outpatient Individual, Couple, or Family Counseling Self-help Groups (Alcoholics Anonymous; NA, CA, OA, GA, Al-Anon etc.) Residential Facilities & Therapeutic Communities Medications

2. Early identification Education about diagnosis Acceptance of disease and overcoming “denial” Abstinence 12-steps essential for real recovery Disease Model - Treatment

3. TREATMENT OF SUBSTANCE USE DISORDERS Addictive Behavior Meds ETOH: antabuse, naltrexone, acomprosate; benzodiazepines Opiates: Methadone; LAAM narcan/naltrexone; depot naltrexone buprenorphine Cocaine: Modafinil (mechanism unknown, but does inc. glutamate, DA, NE; decrease of GABA) Nicotine: Nicotine Replacement Therapies Zyban, Wellbutrin (bupropion) Effexor (venlafaxine)

4. Strength of Evidence of Pharmacotherapies for Alcohol Dependence Naltrexone – Acomprosate – Disulfiram – Serotonergic drugs – Lithium –

5. Strength of Evidence of Pharmacotherapies 208 randomly assigned to 1 of 4 11-week protocols for etoh and cocaine dependence: Naltrexone and Antabuse Antabuse and placebo Naltrexone and placebo Double placebo Results:

6. TREATMENT OF SUBSTANCE USE DISORDERS TX myths 1. 2. 3. Measuring outcomes - good studies use: ________________________

7. TREATMENT OF SUBSTANCE USE DISORDERS Outcome Studies Hazeldon study: N = 1,083 (71% retained)…53% abstinent at 1 yr. f/u Drug Abuse Treatment Outcome Study (DATOS) – natural tx in 4 settings: outpt. methadone clinics, outpatient drug-free, short-term inpatient, long-term residential: 1 year f/u data for outpt. methadone group Pre F/U N = 727 / 1,203 89.4%  27.8 heroin use (60 %) 41.9%  21.7 cocaine use *weekly or more drug use 17.1%  13.9 marijuana use 14.8%  16.3 alcohol use, 5+ drinks 28.6%  13.7 predatory illegal activity 25.2%  12.9 sexual behavior risk

8. 4 sessions in 12 weeks Therapist applies motivational psychology to examine effect of drinking on patient’s life, and develop and implement a plan to stop drinking Mobilize the person’s own commitment and motivation to change MET (Motivational Enhancement Therapy) 12 weekly sessions Patients introduced by therapist to the first steps of Alcoholics Anonymous and encouraged to attend meetings Acceptance of the disease of alcoholism and loss of control over drinking TSF (Twelve Step Facilitation) 12 weekly sessions Coping and drink-refusal skills taught by therapist to handle states and situations known to precipitate relapse Learn skills to achieve and maintain sobriety CBT (Cognitive Behavioral Therapy) FrequencyDescription Goal of Treatment Type of Treatment Project MATCH Treatment Conditions

9. Project MATCH Results: N = 1,726 outpatients (n=952) and aftercare (n=774) at 5 sites (one of largest clinical trials ever) 25% were women; 15% were minority group members 10 client characteristics studied: severity etoh, sociopathy, cognitive impairment, gender, meaning seeking, motivation, psych severity, etc. 90% of the participants were assessed at 1-year follow-up pre-post differences in drinking days per month (25  6) and drinks per “drinking” day (15  3) each of the 3 treatments worked about equally well in reducing drinking

10. TSF outpatients more likely to remain sober (24%) at 1 yr. than outpatients in CBT or MET (about 15%) only 1 “matching” prediction supported: outpatients with few or no psychiatric problems had more abstinent days in TSF tx than in CBT At 3-yr. follow-up: 36% of TSF clients abstinent vs. 27% MET and 24% CBT clients *** __________________________________ __________________________________

11. Principles of Effective Treatment http://www.nida.nih.gov/PODAT/PODAT1.html No single treatment is appropriate for all individuals. Treatment needs to be readily available. Effective treatment attends to multiple needs of the individual, not just his or her drug use. Clients with coexisting mental disorders should have both disorders treated in an integrated way. In order to meet the changing needs of the client, the treatment plan must be continually assessed and modified.

12. Remaining in treatment for an adequate period of time is critical for treatment effectiveness. Counseling (individual, couple, and/or group) and other behavioral therapies are critical components of effective treatment for addiction... Medical detoxification is only the first stage of addiction treatment and by itself does little to change long-term drug use. Medications are an important element of treatment for many patients, especially when combined with counseling and other behavioral therapies.

13. Treatment does not need to be voluntary to be effective Possible drug use during treatment must be monitored continuously. Treatment programs should provide assessment and counseling for HIV/AIDS, hepatitis B and C, tuberculosis and other infectious diseases to help patients modify or change behaviors that place themselves or others at risk of infection. Recovery from drug addiction can be a long-term process and frequently requires multiple episodes of treatment.

14. TREATMENT OF SUBSTANCE USE DISORDERS MOTIVATION AND STAGES OF CHANGE Pre-Contemplation____________ Contemplation____________ Preparation _________________________ Action _________________________ Maintenance _________________________

15. Specific Treatment Approaches to Engage Substance Misusers Intervention Motivational Interviewing –Assessment –Cost-benefit analysis –Feedback; focusing on discrepancies and change talk Working with Concerned Significant Others (CRAFT Program)

16. OUTLINE OF SERVICES Chemical Dependence Treatment Program A. A. Adolescent (ages 13-18) B. Adults Additional Specialty Areas A. Specialized Chronic Pain Tract B. Native American Program Treatment Options A. Detoxification 7 Medical Stabilization B. In-Patient Rehabilitiation C. Residential D. Partial Residential E. Intensive Out-Patient F. Chronic Pain Stabilization

17. OUTLINE OF SERVICES General Services A.Free, Confidential Assessments B.Emergency Consultation Services C.24 Hour Crisis Line D.Intervention Services E.Referrals F.Educational Programs Counseling Services A.Individualized Treatment Plans B.Group Therapy C.Individual Therapy D.Family Program E.Art Therapy F.Spiritual Counseling G.Recreational Therapy H.ROPES Course I.Relapse Prevention Program

18. Family members and patients participate in an intensive family program designed to help the patient and family members learn about chemical dependency and co-dependency. The Family Program is held each Sunday and Monday and begins with a group facilitated by a Licensed or Masters Level Counselor entitled “What to Expect from Treatment”.

19. Learn the Neurobiology of Addiction and Relapse Learn the Neurobiology of Addiction and Relapse Change old behaviors that the family has employed in responding to the alcoholic/chemically dependent family member; develop new adaptive strategies Change old behaviors that the family has employed in responding to the alcoholic/chemically dependent family member; develop new adaptive strategies Learn about co-dependency and enabling Learn about co-dependency and enabling Improve family communication by learning how to express emotions in an effective and appropriate way Improve family communication by learning how to express emotions in an effective and appropriate way Share with and draw support from other family members experiencing similar feelings, thoughts, and fears Share with and draw support from other family members experiencing similar feelings, thoughts, and fears Learn how to become open and honest in communicating emotions Learn how to become open and honest in communicating emotions Enjoy relationships free from chemical dependency Enjoy relationships free from chemical dependency

20. Provides a therapeutic outlet that does not solely rely on verbal ability Provides a therapeutic outlet that does not solely rely on verbal ability Teaches skills and lends insights which have beneficial application to daily life to include: Teaches skills and lends insights which have beneficial application to daily life to include: –A more positive self-image and enhance self-esteem –Effective teamwork and cooperative abilities –Improved communication and listening skills –Willingness to take appropriate risks –An ability to set and achieve goals –Improved problem-solving skills –Feelings of accomplishment and success