Chapter 9 Treatment AD 2

Motivational Enhancement Therapy

A brief, non-confrontational, client- centered therapy designed to change specific problematic behaviors such as alcohol or drug use.

Twelve Step Facilitation

Based on the twelve steps of Alcoholics Anonymous (AA) Led by mental health professionals Targets motivation to adhere to the steps • During these sessions, providers will advocate abstinence, explain the basic concepts of the 12-steps and actively support and facilitate the patient's involvement in 12-step programs. TSF can be implemented in an individual or group format or including the patient's significant other. It has been used in acute treatment and as a method of providing support services for chronic disease management • TSF has been used to address addiction involving alcohol, marijuana and stimulants.• Evaluations of TSF are limited; however, several studies have found it to be comparable in effectiveness to psychosocial treatments such as CBT and MET. • It is listed in SAMHSA's National Registry of Evidence- based Programs and Practices and as an evidence-based approach by the National Institute on Drug Abuse (NIDA).

A Disease of the Brain

The most prevalent mind disorder is substance abuse. It causes more illness, death and social disruption than other chronic medical illness as well as costs our society more than any other medical condition.

Treatment

Treatment• Dr. Willenbring is especially distressed about patients who are treated for opioid addiction, then relapse in part because they are not given maintenance therapy with the drug Suboxone.• We have some pretty good drugs to help people with addiction problems, but doctors don't know how to use them," he said. "The 12-step community doesn't want to use relapse-prevention medication because they view it as a crutch."

Motivational Interviewing (MI)

a brief form of therapy, often used in areas of substance abuse and addiction, that allows clients to explore their desires, reasons, ability, and need for change

Affordable Care Act

law passed in 2010 to expand access to insurance, address cost reduction and affordability, improve the quality of healthcare, and introduce the Patient's Bill of Rights

Addiction involving other drugs

• A meta-analysis of 30 studies conducted in outpatient methadone treatment settings found that the inclusion of contingency management (CM) is related to fewer positive urine tests submitted by patients with addiction involving opioids.• CM also has been found to augment naltrexone treatment for addiction involving opioids by increasing patients' compliance with their treatment regimen.

What is Addiciton

• Addiction is a complex brain disease with significant behavioral characteristics. Nicotine, alcohol, illicit drugs and controlled prescription drugs all affect the pleasure and reward circuitry of the brain in similar ways. Over time, continued use of these substances can physically alter the structure and function of the brain, dramatically affect judgment and behavior and drive a compulsion to obtain and use them, even in the face of mounting negative consequences. Growing evidence also points to structural and functional differences in the brain and to genetic factors that may predispose certain individuals to addiction. • Risk factors for developing addiction include a genetic predisposition, structural and functional brain vulnerabilities, psychological factors and environmental influences. Whereas biological, psychological and environmental factors--such as impairments in the brain's reward circuitry, compensation for trauma and mental health problems, easy access to addictive substances, substance use in the family or media and peer influences--play a large role in whether an individual starts to smoke, drink, or use other drugs, genetic factors are more influential in determining who develops the disease of addiction. A factor that is particularly predictive of risk, however, is the age of first use; in 96.5 percent of cases, addiction originates with substance use before the age of 2130 when the brain is still developing and is more vulnerable to the effects of addictive substances.

Chronic Disease Management

• All chronic diseases--regardless of whether they are genetically based, driven by biological or environmental influences or originate from some combination of these factors--require long term, evidence-based medical management of the disease by qualified health professionals and may include pharmaceutical and/or psychosocial therapies as indicated, to assure that patients remain symptom free and that co-occurring health conditions and the patient's nutrition and exercise requirements are addressed.

Chronic Disease Management

• Although the reasons are not yet clear, some individuals may experience one episode in which their symptoms meet clinical diagnostic criteria for addiction and be non-symptomatic thereafter. • In many cases, however, addiction manifests as a chronic disease--a persistent or long-lasting illness--which requires ongoing professional treatment and management. This may be due to a preexisting brain dysfunction or to changes that occur in the brain in response to repeated exposure to addictive substances which increase the vulnerability of the individual to relapse, even after cessation of substance use.

Addiction involving other Drugs

• Another study found that patients on methadone maintenance treatment who received weekly community reinforcement approach (CRA) sessions demonstrated significantly greater reductions in drug problem severity than patients who received standard methadone maintenance services

Addiction involving Alcohol

• Another study found that six months after treatment completion, disulfiram patients in a community reinforcement approach (CRA) program spent significantly less time drinking than patients who used only disulfiram (abstinent 28.3 days vs. 8.0 days that month)

Psychosis Therapies

• Both MI and MET have proven efficacy in addressing adolescent and adult addiction and are cost-effective approaches to treating addiction involving nicotine, alcohol and other drugs. • Two main benefits of MI/MET are increased treatment retention and program completion, which are associated with improved treatment outcomes.

Psychosis Therapies

• CBT generally is used as a short-term intervention and can be tailored both to inpatient and outpatient programs via group or individual therapy. The therapy has been proven effective for adolescents and adults and for a variety of manifestations of substance addiction. • CBT has demonstrated efficacy for specific populations such as women with addiction and individuals with co-occurring disorders.

Psychosis Therapies

• CRA also assists patients in developing communication, problem-solving and drug refusal skills. CRA is based on the notion that patients must be taught life skills and shown that living substance free can be more rewarding than a life of addiction.

Psychosis Therapies

• Cognitive Behavioral Therapy (CBT). Cognitive Behavioral Therapy (CBT) involves training in social skills, self-control and stress management through activities such as role playing, behavioral modeling and feedback • It is designed to help patients identify, recognize and avoid thought processes, behaviors and situations that are associated with substance use; manage cravings; refuse offers of tobacco, alcohol or other drugs; and develop better problem-solving and coping skills.

Psychosis Therapies

• Community Reinforcement Approach (CRA). The Community Reinforcement Approach (CRA) is a multi-phase, intensive 24-week outpatient treatment for addiction involving alcohol and drugs other than nicotine. • Counseling sessions focus on improving family relations, learning skills to reduce substance use, acquiring vocational skills and developing recreational activities and social networks that can help to minimize the drive to engage in substance use.

Treatment

• Dr. Mark Willenbring, a former director of treatment and recovery research at the National Institute for Alcohol Abuse and Alcoholism, said in an interview, "You don't treat a chronic illness for four weeks and then send the patient to a support group. People with a chronic form of addiction need multimodal treatment that is individualized and offered continuously or intermittently for as long as they need it."

Addiction involving Alcohol

• In one study, patients with addiction involving alcohol who received daily doses of naltrexone were less likely than those taking placebos to relapse if they also participated in psychosocial therapies, including cognitive behavioral therapy (CBT) (38 percent vs. 60 percent) or motivational- enhancement therapy (MET) (44 percent vs. 56 percent) over the course of 12 weeks.

What is addiction?

• Less than Half of Treatment Admissions Result in Treatment Completion • In 2008,* less than half (42.1 percent) of discharges from formal addiction treatment services were of admissions in which treatment was completed.66 The highest completion rates were from venues to which there were the fewest admissions • 14.8 percent of admissions were to short- term residential services which had the highest completion rate of 54.8 percent • 11.4 percent of admissions were to longer- term residential treatment which had a completion rate of 45.5 percent • 73.8 percent of admissions were to non- residential services which had the lowest completion rate of 39.1 percent. • No data are available on the extent to which referrals were based on matching providers with individual treatment needs. • Most medical professionals who should be providing addiction treatment are not sufficiently trained to diagnose or treat it; • Most of those who are providing addiction treatment are not medical professionals and are not equipped with the knowledge, skills or credentials necessary to provide the full range of evidence-based services to address addiction effectively • Addiction treatment facilities and programs are not adequately regulated or held accountable for providing treatment consistent with medical standards and proven treatment practices.

Levels of Care (PPC-2R)Overall Structure of Levels of Care & Services

• Level 0.5- Early Intervention • Level I- Outpatient• Level II- Intensive Outpatient/Partial Hospitalization • Level III- Residential/Inpatient Treatment • Level IV- Medically Managed Intensive Inpatient Treatment

Psychosis Therapies

• Motivational Interviewing (MI), which can occur in inpatient or outpatient settings, is rooted in the idea that individuals with addiction often feel ambivalent about their substance use and the need to change their behaviors. • MI techniques help patients deal with this ambivalence and strengthen their commitment to engage in behavior change. Motivational Enhancement Therapy (MET) is an adaptation of MI that restricts the intervention to four sessions.

Addiction involving other Drugs

• Naltrexone patients who received contingency management in the form of vouchers in exchange for clean urinalyses, on average, stayed in treatment longer (7.4 weeks vs. 5.6 weeks), submitted more opioid-free urine samples (18.9 vs. 13.5) and were abstinent continuously over longer periods of time (49.1 days vs. 37.7 days) than patients who received naltrexone without a CM component.

Treatment

• Of the 23.5 million teenagers and adults addicted to alcohol or drugs, only about 1 in 10 gets treatment, which too often fails to keep them drug-free. Many of these programs fail to use proven methods to deal with the factors that underlie addiction and set off relapse.

Addiction involving Alcohol

• Patients in another study who received CBT for a three-month period were likelier to achieve abstinence by the end of the 12-week program if they also received daily doses of acamprosate (38 percent vs. 14 percent).

Sober Living Homes

• Sober Living Houses provide a substance-free living environment for individuals with addiction involving alcohol, illicit drugs and controlled prescription drugs. No formal treatment services are provided but residents are mandated or strongly encouraged to participate in mutual support programs and must comply with house rules which include maintaining abstinence, paying rent, participating in house chores and attending house meetings. Failure to comply with these rules results in dismissal from the home. • One study of the combination of participating in a sober living house and receiving outpatient treatment interviewed participants within their first week of entering the houses and again at six-, 12-, and 18-month follow-ups.• The study found significant improvements over time on measures of alcohol and other drug use, arrests and employment.

Therapeutic Communities

• The TC model, used primarily but not exclusively with the justice population, is a highly structured residential program that requires a long-term commitment (six to 24 months). • It is based on mutual support principles and incorporates behavior modification techniques, education classes and residential job duties.• This approach aims to re-socialize the patient to a substance-free, crime-free lifestyle through peer influence, personal responsibility and skill training. • TC participants commonly include individuals with relatively long histories of addiction, involvement in serious criminal activities and significantly impaired social functioning.• The mutual support aspect of TCs operates on a hierarchical basis; patients who have been involved in the program longer provide support and serve as role models for newer patients. • A large, national study found that patients enrolled for at least 90 days in a TC were significantly less likely to have used cocaine (28 percent vs. 55 percent), tested positive for drug use (19 percent vs. 53 percent), reported daily alcohol use (9 percent vs. 15 percent) or have spent time in jail (24 percent vs. 54 percent) a year after program participation than those who spent fewer than 90 days in the program.

Treatment

• The prevention and reduction of risky substance use and the treatment of addiction, in practice, bear little resemblance to the significant body of evidence-based practices that have been developed and tested; indeed only a small fraction of individuals receive interventions or treatment consistent with scientific knowledge about what works.• The moral model of addiction framed addiction primarily as a failure of personal responsibility or morality. It asserted that addiction could be addressed simply by requiring personal responsibility and accountability on the part of the person who is addicted. This approach has contributed to: The stigma associated with addiction, attaching blame to the individual, creating shame and embarrassment, increasing the likelihood of discrimination and decreasing the chances that the addicted individual will seek or receive effective treatment.

Therapeutic Communities

• The year following successful TC completion showed lasting effects along several indicators compared to the year prior to TC entry: the rate of weekly cocaine use fell from 66.4 percent to 22.1 percent; weekly heroin use, from 17.2 percent to 5.8 percent; heavy alcohol use, from 40.2 percent to 18.8 percent; illegal activity, from 40.5 percent to 15.9 percent; less than full-time employment, from 87.6 percent to 77.0 percent; and reported suicidal thoughts, from 23.6 percent to 13.2 percent.

Addiction involving other Drugs

• With regard to treatment for addiction involving opioids, incorporating family therapy into a treatment regimen that includes naltrexone therapy enhances treatment outcomes with regard to medication compliance; abstinence from opioids and other drugs during treatment and during a year of follow-up; and measures of drug-related, legal and family problems at one- year follow-up.