(c) McGraw-Hill 2011

1. Chapter 18
Treating Substance
Abuse and Dependence
© 2011 McGraw-Hill Higher Education. All rights reserved.

2. Treatment
 Hundreds of thousands of Americans
undergo treatment for substance abuse
and dependence each year
 A variety of treatment approaches are
used, often in combination
 Behavioral/psychosocial treatments
 Pharmacotherapies
 Different approaches reflect
 Different substance abuse problems
 Different theories about substance abuse
© 2011 McGraw-Hill Higher Education. All rights reserved.

3. Defining Treatment Goals
 Treatment goals are influenced by the
underlying theoretical view of substance
abuse
 Alcohol
 View that substance dependence is a biological
disease that someone either has or does not have
 Only acceptable treatment goal is complete
abstinence
 View that substance dependence represents one
end of a continuum of drinking
 A possible treatment goal is controlled social use
© 2011 McGraw-Hill Higher Education. All rights reserved.

4. Defining Treatment Goals
 Opioids
 View that substance dependence undermines the
physical and mental health of its victims
 Only acceptable treatment goal is abstinence (traditional
view)
 View that dependence on legal methadone is
preferable to dependence on illegal heroin
 Goal of treatment has changed from eliminating opioid use to
eliminating heroin use
 Tobacco
 Complete abstinence (most common goal) vs. cutting
down on smoking or switching to cigarettes lower in
tar and nicotine
© 2011 McGraw-Hill Higher Education. All rights reserved.

5. Defining Treatment Goals
 How to evaluate treatment
outcomes of reduced use as
opposed to abstinence?
 Researchers are beginning to
develop cost/benefit analyses
 Cost of treatment
vs.
 Cost savings from increased
employment and decreased crime
after treatment
© 2011 McGraw-Hill Higher Education. All rights reserved.

6. Alcoholics Anonymous and
Others
 Founded in 1935: A loose affiliation of local
groups that adhere to common methods
 Based on the disease model of dependence
 An alcoholic is biologically different from others, so
abstinence is the only appropriate goal
 The disease takes away a person’s control over his
or her own drinking behavior
 It removes the blame for the problem from the alcoholic
but not the responsibility for dealing with it
 Major approaches are group support and a
buddy system
© 2011 McGraw-Hill Higher Education. All rights reserved.

7. Alcoholics Anonymous and
Others
 Formal evaluations of AA have not been very
positive
 However, studying people who have court-ordered
referrals to AA might not be an appropriate
evaluation method
 A more appropriate evaluation might be to determine
which types of drinkers are most likely to benefit
from AA’s programs
 Evaluation is important because many treatment
programs follow the 12-step model of AA
 Betty Ford Center, Hazelden, Phoenix House
© 2011 McGraw-Hill Higher Education. All rights reserved.

8. Motivational Enhancement
Therapy
 Conventional wisdom about people
with substance abuse problems:
 Most substance abusers use the
defense mechanism of denial and are
unwilling to admit they have a problem
 Only when a user suffers serious
consequences (“hits bottom”) will he or
she be ready to seek help
 Problem with this perspective is
that very serious consequences
may occur before the abuser is
ready for treatment
© 2011 McGraw-Hill Higher Education. All rights reserved.

9. Motivational Enhancement
Therapy
 Motivational enhancement therapy
attempts to shift the focus away from
denial and toward motivation to change
 Motivational interviewing
 Used to boost the motivation to change of an
ambivalent or less ready substance abuser
 A nonconfrontational process of determining
the abuser’s current stage of change and
then helping the individual move forward
© 2011 McGraw-Hill Higher Education. All rights reserved.

10. Motivational Enhancement
Therapy
 Stages of change
 Precontemplation: Individual doesn’t recognize that
a problem exists
 Contemplation: Individual recognizes there is a
problem and begins to consider the possibility of
changing her or his behavior
 Preparation: Individual decides to change and
makes plans to change
 Action: Individual takes active steps toward change
 Maintenance: Individual engages in activities
intended to maintain the change
© 2011 McGraw-Hill Higher Education. All rights reserved.

11. Motivational Enhancement
Therapy
 Goals of motivational
interviews
 Help the client focus on
problem behaviors
 Help the client move forward
to the next stage of change
 Motivational enhancement therapy is probably
best conceptualized as preparation for other
therapies rather than as a stand-alone
treatment
© 2011 McGraw-Hill Higher Education. All rights reserved.

12. Contingency Management
 An approach in which individuals receive
immediate rewards for providing drug-free urine
samples
 Value of the rewards increases with consecutive
drug-free samples
 Clients also participate in weekly skill-building
counseling sessions
 Has produced consistent reduction in use
 Downside of approach is the cost of rewards
© 2011 McGraw-Hill Higher Education. All rights reserved.

13. Cognitive Behavioral Therapy
(CBT)
 An approach that combines cognitive therapy
techniques with behavioral skills training
 Individuals learn to identify and change
behaviors that could lead to relapse, such as
associating with drug users
 Evaluation
 Shown to be more effective than most therapies
 Considered challenging because it places significant demands
on patients
 Despite this, it remains one of the most widely used substance
abuse treatment strategy
© 2011 McGraw-Hill Higher Education. All rights reserved.

14. Pharmacotherapies
 Study of dependence as a brain disease
has focused research efforts on
developing medications for treatment
 Many experts believe that
pharmacotherapies alone will not cure a
chronic, relapsing, behavioral disorder like
substance abuse
 Pharmacotherapies can provide a window
of opportunity for behavioral/psychosocial
treatments by relieving withdrawal
symptoms
© 2011 McGraw-Hill Higher Education. All rights reserved.

15. Detoxification
 Detoxification is an initial and
immediate phase of treatment
 Medications are administered to
alleviate unpleasant and/or
dangerous withdrawal symptoms
that may appear following abrupt
cessation of drug use
 Some of these medications may also
be used during maintenance stage
© 2011 McGraw-Hill Higher Education. All rights reserved.

16. Maintenance
 Maintenance is a longer-term strategy
used to help a dependent individual avoid
relapse
 Three general categories of
pharmacotherapy for maintenance
 Agonist or substitution therapy
 Antagonist therapy
 Punishment therapy
© 2011 McGraw-Hill Higher Education. All rights reserved.

17. Maintenance
 Agonist or substitution therapy is used to
induce cross-tolerance to the abused drug
 Examples: methadone for heroin dependence,
nicotine replacement for tobacco dependence
 Agonists typically have safer routes of administration
and/or diminished psychoactive effects compared to
the original drug
 Substituting a longer-acting, pharmacologically
equivalent drug allows the user to be stabilized on
the agonist and then slowly tapered off it, avoiding
withdrawal symptoms
© 2011 McGraw-Hill Higher Education. All rights reserved.

18. Maintenance
 Antagonist therapy is used to prevent the user
from experiencing the reinforcing effects of the
abused drug
 Example: naltrexone, which blocks opioid effects
 Punishment therapy is used to produce an
aversive reaction following ingestion of the
abused drug
 Example: disulfiram for alcohol dependence
© 2011 McGraw-Hill Higher Education. All rights reserved.

19. Pharmacotherapies for Alcohol
 Detoxification phase
 Pharmacological therapies are important
because acute alcohol withdrawal
syndrome has serious effects
 Medical risks often require an inpatient
medical setting for alcohol detoxification
 Benzodiazepines are typically used
 Reduce autonomic hyperactivity and
prevent seizures
 Best choices are those with a slow onset
of action
© 2011 McGraw-Hill Higher Education. All rights reserved.

20. Pharmacotherapies for Alcohol
 Maintenance therapy
 Usually given for weeks or months rather
than indefinitely
 Three approved medications
 Disulfiram (Antabuse)
 Naltrexone
 Acamprosate
© 2011 McGraw-Hill Higher Education. All rights reserved.

21. Pharmacotherapies for Alcohol
 Disulfiram (Antabuse) causes unpleasant symptoms (headache,
vomiting, and breathing difficulties) if alcohol is consumed
 Inhibits aldehyde dehydrogenase, thereby increasing acetaldehyde
 Not very effective because most people don’t take the medication
 Naltrexone
 Reduces alcohol craving, days per week of drinking, and rate of
relapse—but hasn’t had a large impact on overall treatment success
 Unclear how it works; it may block opioid receptors and the reinforcing
effects of alcohol
 Acamprosate, a compound structurally similar to GABA
 Normalizes basal GABA concentrations
 Blocks the glutamate increases observed during alcohol withdrawal
 Recently approved, so effectiveness hasn’t been determined
© 2011 McGraw-Hill Higher Education. All rights reserved.

22. Pharmacotherapies for Nicotine
 Nicotine withdrawal symptoms (anxiety, depression, insomnia,
cigarette cravings) occur in most smokers who stop smoking
 Five nicotine replacement products are approved by the FDA
 Transdermal nicotine patch
 Nicotine gum
 Nicotine nasal spray
 Nicotine vapor inhaler
 Nicotine lozenge
 Smokers should stop smoking before using any of them to avoid
nicotine toxicity
 Use of nicotine replacement products has been shown to increase
quit rates in controlled clinical studies
 Success rates are probably lower in a real world setting
© 2011 McGraw-Hill Higher Education. All rights reserved.

23. Pharmacotherapies for Nicotine
 Bupropion (Zyban), a non-nicotine
pharmacotherapy for smoking cessation
 Approved by the FDA in 1997
 Also used in the treatment of depression
 Mechanisms of action haven’t been definitively
determined
 May inhibit reuptake of dopamine and norepinephrine and,
to a lesser extent, block acetylcholine receptors
 Has been shown to gradually decrease cigarette
craving and use
© 2011 McGraw-Hill Higher Education. All rights reserved.

24. Pharmacotherapies for Opioids
 Traditionally, anticholinergic drugs like belladonna were
used to treat opioid dependence
 Goal: To produce a state of delirium for several days so that
the dependent person would avoid experiencing withdrawal
 More recent version is “rapid opioid detoxification,” in
which a dependent person is anesthetized and given
an opioid antagonist that causes immediate withdrawal
 Person is released after 24 hours and enters a period of
counseling while continuing to take an opioid antagonist
 Criticisms of approach
 Medical risks of rapid withdrawal process
 Behavioral/psychosocial aftercare is often deemphasized
© 2011 McGraw-Hill Higher Education. All rights reserved.

25. Pharmacotherapies for Opioids
 Detoxification
 Medications given to reduce withdrawal symptoms
(nausea, vomiting, diarrhea, aches, pain)
 Methadone, a long-acting opioid
 Buprenorphine, a partial opioid agonist with a long duration
of action
 Maintenance
 Methadone maintenance is the most common form
of treatment for opioid dependence
 May continue for months or years
 Less data available on more recently approved
buprenorphine maintenance
© 2011 McGraw-Hill Higher Education. All rights reserved.

26. Pharmacotherapies for Opioids
 Naloxone, a short-acting opioid antagonist, is
used to treat opioid overdose
 Naltrexone, a long-acting opioid antagonist, is
approved for treating opioid dependence
 Has been shown to be effective, but it is appropriate
only for highly motivated individuals
 A once-per-month form is being studied; initial
findings are promising
© 2011 McGraw-Hill Higher Education. All rights reserved.

27. Pharmacotherapies for Cocaine
 Withdrawal symptoms
 Can include depression, nervousness, anhedonia (lack of
emotional response), fatigue, irritability, sleep and activity
disturbances, craving for cocaine
 Risk of relapse may be greatest during withdrawal period
 Reduced monoamine neurotransmitter activity may
underlie withdrawal symptoms
 Medications that increase monoamine neurotransmitter
activity have been tested but have not been found
useful in treating withdrawal symptoms or dependence
 Currently no approved pharmacotherapy for cocaine
dependence
© 2011 McGraw-Hill Higher Education. All rights reserved.

28. Pharmacotherapies for
Cannabis
 Withdrawal from cannabis
 People seeking treatment for cannabis dependence
often report withdrawal symptoms that make it
more difficult to maintain abstinence
 Symptoms may include irritability, anxiety, sleep
disruption, aches
 Many medications have been tested for relief
of cannabis withdrawal symptoms
 One drug has been found effective: oral ∆9-THC
 Currently no approved pharmacotherapy for
cannabis dependence
© 2011 McGraw-Hill Higher Education. All rights reserved.

29. Treatment: The Big Picture in the
United States
 Most frequently reported drugs for substance abuse
treatment admissions
 Alcohol (40 percent)
 Opioids (19 percent)
 Marijuana/hashish (16 percent)
 Cocaine (13 percent)
 Stimulants (8 percent, primarily methamphetamine)
 Abusers admitted for treatment
 Average age of those admitted with marijuana as the primary drug
of abuse is 24
 Sites of treatment
 47 percent treated as outpatients
 13 percent treated as hospital inpatients (detoxification)
 18 percent treated in a residential setting
© 2011 McGraw-Hill Higher Education. All rights reserved.

30. Treatment: The Big Picture in the
United States
 Substance abuse treatment development
should focus on
 More effective interventions for commonly abused
drugs
 Alcohol
 Opioids
 Marijuana
 Cocaine
 Treatment delivery on an outpatient basis
 Effective outpatient behavioral/psychosocial
interventions are needed to improve the overall
success of treatment
© 2011 McGraw-Hill Higher Education. All rights reserved.

31. Is Treatment Effective?
 Substance dependence is a
chronic illness
 Treatment doesn’t work for every
individual every time
 Condition may require continuing
care throughout life
 Studies show that treatment is
cost-effective by reducing crime
and increasing employment
 Treatment also saves lives in the
long term
© 2011 McGraw-Hill Higher Education. All rights reserved.

32. Chapter 18
Treating Substance
Abuse and Dependence
© 2011 McGraw-Hill Higher Education. All rights reserved.