DSM IV Substance Dependence
A maladaptive pattern of substance use, leading to clinically significant impairment or distress, as manifested by three (or more) of the following, occurring at any time in the same 12-month period:
- tolerance, as defined by either of the following:
- a need for markedly increased amounts of the substance to achieve intoxication or desired effect
- markedly diminished effect with continued use of the same amount of the substance
- withdrawal, as manifested by either of the following:
- the characteristic withdrawal syndrome for the substance
- the same (or a closely related) substance is taken to relieve or avoid withdrawal symptoms
- the substance is often taken in larger amounts or over a longer period than was intended
- there is a persistent desire or unsuccessful efforts to cut down or control substance use
- a great deal of time is spent in activities necessary to obtain the substance (e.g., visiting multiple doctors or driving long distances), use the substance (e.g., chain-smoking), or recover from its effects
- important social, occupational, or recreational activities are given up or reduced because of substance use
- the substance use is continued despite knowledge of having a persistent or recurrent physical or psychological problem that is likely to have been caused or exacerbated by the substance (e.g., current cocaine use despite recognition of cocaine-induced depression, or continued drinking despite recognition that an ulcer was made worse by alcohol consumption)
The diagnosis should specify “With Physiological Dependence” (either item 1 or 2 is present) or “Without Physiological Dependence” (neither item 1 nor 2 is present).
Substance use and intoxication have grown to be one of the most expensive public health and safety issue in Los Angeles and Orange County. Los Angeles and Orange County devote millions of dollars annually in police, emergency medical, public health and public justice due to substance use and intoxication.
DSM IV Substance Abuse
A. A maladaptive pattern of substance use leading to clinically significant impairment or distress, as manifested by one (or more) of the following, occurring within a 12-month period:
- recurrent substance use resulting in a failure to fulfill major role obligations at work, school or home (e.g., repeated absences or poor work performance related to substance use; substance-related absences, suspensions, or expulsions from school; neglect of children or household)
- recurrent substance use in situations in which it is physically hazardous (e.g., driving an automobile or operating a machine when impaired by substance use)
- recurrent substance-related legal problems (e.g., arrests for substance-related disorderly conduct)
- continued substance use despite having persistent or recurrent social or interpersonal problems caused or exacerbated by the effects of the substance (e.g., arguments with spouse about consequences of intoxication, physical fights)
B. The symptoms have never met the criteria for substance dependence for this class of substance.
Substance use and related substance problems have grown to be one of the most expensive public health and safety issue in Los Angeles and Orange County. Los Angeles and Orange County devote millions of dollars annually in police, emergency medical, public health and public justice due to substance use and related substance problems.
Medical Problems Related to Addiction
Gastrointestinal: esophagitis, Mallory-Weiss tear, gastritis, peptic ulcer disease, fatty liver, alcohol-induced hepatitis, cirrhosis, acute or chronic pancreatitis
Cardiovascular: hypertension, cardiomyopathy, coronary artery disease
Neurological: Wernicke’s encephalopathy, alcohol-related dementia, cerebellar degeneration, peripheral neuropathy, stroke, seizures
Hematological: thrombocytopenia, anemia
Neoplastic: cancers of the esophagus, liver, and pancreas
Other: sexual dysfunction, sleep disorders, vitamin B deficiency, peripheral myopathy
Cardiovascular: coronary artery disease, vascular disease
Respiratory: chronic obstructive pulmonary disease
Neoplastic: cancers of the mouth, esophagus, and lung
Cardiovascular: ischemic heart disease, cardiac arrhythmias, cardiomyopathy, aortic dissection, myocardial infarction
Respiratory: spontaneous pneumothorax, pneumomediastinum, bronchitis, pneumonitis and bronchospasm (when smoked)
Neurological: seizures, stroke
Other: sinusitis, nasal irritation, septal bleeding and perforation (with intranasal use), HIV and hepatitis (with intravenous use), weight loss and malnutrition
Opioids (when used intravenously)
Gastrointestinal: acute and chronic viral hepatitis
Respiratory: tuberculosis (which may be treatment resistant)
Other: cellulitis, abscesses, osteomyelitis, HIV
Gastrointestinal disease; Cardiovascular disease; Neurological disease; Respiratory disease have grown to be some of the most expensive public health and medical issues in Los Angeles and Orange County. Los Angeles and Orange County devote millions of dollars annually in public health and medical services due to substance use and related gastrointestinal disease, cardiovascular disease, neurological disease, respiratory disease.
Addiction Treatment Interventions; SAMSHA
Family Behavior Therapy
Family Behavior Therapy Abstract: Family Behavior Therapy (FBT) is an outpatient behavioral treatment aimed at reducing drug and alcohol use in adults and youth along with common co-occurring problem behaviors such as depression, family discord, school and work attendance, and conduct problems in youth. This treatment approach owes its theoretical underpinnings to the Community Reinforcement Approach and includes a validated method of improving enlistment and attendance.
- Drug use
- Alcohol use
- Family relationships
- Employment/school attendance
- Conduct disorder symptoms
Drug and alcohol use in Los Angeles and Orange County has reached critical proportions affecting every aspect of life. Los Angeles and Orange County are also strongholds of some of the finest outpatient behavioral treatment providing solutions for drug and alcohol use disorders.
Matrix Model Abstract: The Matrix Model is an intensive outpatient treatment approach for stimulant abuse and dependence that was developed through 20 years of experience in real-world treatment settings. The intervention consists of relapse-prevention groups, education groups, social-support groups, individual counseling, and urine and breath testing delivered over a 16-week period. Patients learn about issues critical to addiction and relapse, receive direction and support from a trained therapist, become familiar w…
- Treatment retention
- Treatment completion
- Drug use during treatment
Los Angeles and Orange County strongholds of some of the finest intensive outpatient treatment providing solutions for drug and alcohol addiction. Relapse prevention is one of the most critical aspects of intensive outpatient treatment Los Angeles and Orange County due to widespread availability of drugs and trigger stimuli.
Motivational Enhancement Therapy
Motivational Enhancement Therapy Abstract: Motivational Enhancement Therapy (MET) is an adaptation of motivational interviewing (MI) that includes one or more client feedback sessions in which normative feedback is presented and discussed in an explicitly nonconfrontational manner. Motivational interviewing is a directive, client-centered counseling style for eliciting behavior change by helping clients to explore and resolve their ambivalence and achieve lasting changes for a range of problematic behaviors.
- Substance use
- Alcohol consumption
- Drinking intensity
- Marijuana use
- Marijuana problems
Motivational enhancement therapy (MET) is one of the more effective tools provided by Los Angeles and Orange County intensive outpatient and residential addiction treatment programs
Motivational Interviewing Abstract: Motivational Interviewing (MI) is a goal-directed, client-centered counseling style for eliciting behavioral change by helping clients to explore and resolve ambivalence. The operational assumption in MI is that ambivalent attitudes or lack of resolve is the primary obstacle to behavioral change, so that the examination and resolution of ambivalence becomes its key goal. MI has been applied to a wide range of problem behaviors related to alcohol and substance abuse as well as health promotion
- Alcohol use
- Negative consequences/problems associated with alcohol use
- Drinking and driving
- Alcohol-related injuries
- Drug use (cocaine and opiates)
- Retention in treatment
interviewing is one of the more effective tools provided by Los Angeles and Orange County intensive outpatient and residential addiction treatment programs
Phoenix Academy Abstract: Phoenix Academy (affiliated with Phoenix House Foundation, Inc.) is a therapeutic community (TC) model enhanced to meet the developmental needs of adolescents ages 13-17 with substance abuse and other co-occurring mental health and behavioral disorders. The Phoenix Academy model integrates residential treatment with an on-site public junior high and high school (grades 8-12). Some Phoenix Academy programs also include trade or technical training sponsored by local community colleges.
- Substance use
- Psychological functioning
Adolescents with substance abuse problems can be served in Los Angeles and Orange County intensive outpatient programs, or therapeutic community/ residential programs such as Phoenix Academy.
Relapse Prevention Therapy
Abstract: Relapse Prevention Therapy (RPT) is a behavioral self-control program that teaches individuals with substance addiction how to anticipate and cope with the potential for relapse. RPT can be used as a stand-alone substance use treatment program or as an aftercare program to sustain gains achieved during initial substance use treatment.
- Drinking behavior
- Smoking abstinence
- Cocaine use
- Marital adjustment
- Confidence in smoking cessation
Los Angeles and Orange County are center to widespread substance addiction or misuse. Relapse prevention is one of the most critical aspects of intensive outpatient treatment Los Angeles and Orange County due to widespread availability of drugs and trigger stimuli, which can result in relapse.
Twelve Step Facilitation Therapy
Abstract: Twelve Step Facilitation Therapy (TSF) is a brief, structured, and manual-driven approach to facilitating early recovery from alcohol abuse, alcoholism, and other drug abuse and addiction problems. TSF is implemented with individual clients over 12 to 15 sessions. The intervention is based on the behavioral, spiritual, and cognitive principles of 12-step fellowships such as Alcoholics Anonymous (AA) and Narcotics Anonymous (NA)
- Percentage of days abstinent from alcohol
- Adverse consequences of drinking
- Combined assessment of drinking and drinking problems
- Number of days before first drink/heavy drinking (“time to event”)
- Drinks per drinking day
- Alcoholics Anonymous involvement
Los Angeles and Orange County are hosts to some of the largest and most prominent twelve step meetings and memberships in the nation. The Twelve-Step Model is the most popular forms of treatment provided by Los Angeles and Orange County intensive outpatient and residential programs.
Cognitive Behavioral Therapy
CBTs for the treatment of substance use disorders are based on social learning theories regarding the acquisition and maintenance of the disorder. These therapies target two processes conceptualized as underlying substance abuse: 1) dysfunctional thoughts, such as the belief that the use of substances is completely uncontrollable, and 2) maladaptive behaviors, such as acceptance of offers to use drugs. Early versions of this approach were derived from cognitive therapy for depression and anxiety by Beck and Emery and placed primary emphasis on identifying and modifying dysfunctional thinking patterns. Other adaptations of this approach have broadened the focus of therapy to help the patient master an individualized set of coping strategies as an effective alternative to substance use. Typical cognitive strategies include fostering the patient’s resolve to stop using substances by exploring positive and negative consequences of continued use, recognizing seemingly irrelevant decisions that could culminate in high-risk situations, and identifying and confronting thoughts about substance use. Behavioral strategies are based on a functional analysis of substance use (i.e, understanding substance use in relation to its antecedents and consequences) and include the development of strategies for coping with craving, preparing for emergencies, and coping with relapse to substance use.
SOCIAL SKILLS TRAINING, an element of CBT, recognizes that alcohol and drug dependence commonly results in the interruption of normal developmental acquisition of social skills as well as the deterioration of previously learned social skills because of the interference of drug-seeking and drug-using behaviors. Social skills training targets an individual’s capacity for 1) effective and meaningful communication, 2) listening, 3) being able to imagine someone else’s feelings and thoughts to inform one’s own behavioral interactions, 4) being able to monitor and modify one’s own nonverbal communications, 5) being able to adapt to circumstances to maintain relationships, and 6) being assertive. This strategy has been successfully used as an adjunct to a more comprehensive treatment plan and can be delivered in a wide variety of outpatient treatment settings. It may be particularly useful in certain dually diagnosed populations, such as patients with schizophrenia and adolescents at risk for beginning substance abuse.
RELAPSE PREVENTION is a treatment approach in which CBT techniques are used to help patients develop greater self-control to avoid relapse. Specific relapse prevention strategies include discussing the patient’s ambivalence about the substance use disorder, identifying emotional and environmental triggers of craving and substance use, developing and reviewing specific coping strategies to deal with internal or external stressors, exploring the decision chain leading to reinitiation of substance use, learning from brief episodes of relapse (slips) about triggers leading to relapse, and developing effective techniques for early intervention. In more recent clinical trials, techniques drawn from cognitive therapy and relapse prevention have been combined with the aims of initiating abstinence and preventing relapse.
Cognitive Behavioral Therapy (CBT) and cognitive therapy is one of the most widespread and standard forms of treatment provided by Los Angeles and Orange County intensive outpatient and residential addiction treatment programs.
Motivational Enhancement Therapy
MET is the longer-term follow-up to an initial brief intervention strategy. It continues the use of motivational interviewing and moves a patient closer to a readiness to change substance use behaviors (reviewed in DiClemente et al. and Miller and Rollnick. It combines techniques from cognitive, client-centered, systems, and social-psychological persuasion approaches and may be provided by trained clinicians in substance abuse facilities, mental health clinics, and private practice offices. MET is characterized by an empathic approach in which the therapist helps to motivate the patient by asking about the pros and cons of specific behaviors, exploring the patient’s goals and associated ambivalence about reaching those goals, and listening reflectively to the patient’s responses. This treatment modality is effective even for patients who are not highly motivated to change, which gives it a practical advantage over other therapies for substance use disorders in many settings.
Motivation or the absence thereof is a crucial factor determining the outcome of treatment provided by Los Angeles and Orange County intensive outpatient and residential addiction treatment programs. Motivational Enhancement Therapy (MET), including motivational interviewing are critical strategies use by substance abuse facilities to treat the chronic disease of addiction and related relapse.
Behavioral therapies are based on basic principles of learning theory, which deals with the role of externally applied positive or negative contingencies on learning or unlearning of behaviors that can range from simple autonomic reactions such as salivation to complex behavioral routines such as purchasing drugs. When these theories are applied to substance use disorders, the target behavior is habitual excessive substance use, which is altered through systematic environmental manipulations that vary widely depending on the specific substance use behavior. These theories differ from those underlying CBTs by not recognizing cognition as a domain independent of behavior.
The shared goals of behavioral therapies are to interrupt the sequence of substance use in response to internal or external cues and substitute behaviors that take the place of or are incompatible with substance use. There are two broad classes of learning theory-based treatments: 1) those that are based on classical conditioning and focus more on antecedent stimuli such as cue exposure therapy and 2) those that are based on operant conditioning and focus more on consequences such as community reinforcement therapy. Representative behavioral approaches are briefly described here.
Substance use is one of the most widespread problems for which treatment is designed by Los Angeles and Orange County intensive outpatient and residential addiction treatment programs.
Contingency management therapy involves introducing rewards for therapeutically desired behaviors (e.g., attending therapy sessions, providing substance-negative urine samples) and/or aversive consequences for undesirable behaviors (e.g., failure to adhere to clinic rules0-. As an adjunctive treatment, contingency management has been used with a variety of substances of abuse, including cocaine, opiates, and marijuana. Incentives to be offered, behaviors to be reinforced, and the reinforcement schedule vary widely by substance and also depend on the role of contingency management within the larger treatment plan. Although most studies have centered on abstinence from substance use, contingency management procedures are potentially applicable to a wide range of target behaviors and problems, including treatment retention, adherence to treatment (e.g., retroviral therapies for individuals with HIV), and reinforcement of other treatment goals such as employment seeking or work attendance. Contingency management is effective when desired behaviors are rewarded with vouchers that can be exchanged for mutually agreed-on items such as movie tickets. Other reinforcers (e.g., free housing, direct compensation) can be substituted for vouchers.
The use of large but low-probability reinforcers (e.g., earning the chance to draw from a bowl and win prizes of varying magnitudes ranging from $1 to more than $100) is also effective and may reduce the total costs of contingency management approaches. Contingency contracting is a subtype of contingency management based on the use of predetermined positive or negative consequences to reward abstinence or punish, and thus deter, drug-related behaviors. Negative consequences of substance use may include notification of Treatment of Patients With Substance Use courts, employers, or family members. The effectiveness of this approach depends heavily on the concurrent use of frequent, random, supervised urine screening for substance use. When negative contingencies are based on the anticipated response of others (e.g., spouses, employers), the treating physician should obtain the patient’s written informed consent to contact these individuals at the time the contract is initiated.
Abstinence is one of the most widespread and standard goals of treatment provided by Los Angeles and Orange County intensive outpatient and residential addiction treatment programs. Several treatment program, primarily in the public sector in Los Angeles and Orange County provides contingency management.
The community reinforcement approach (CRA) is based on the theory that environmental reinforcers for substance use perpetuate substance use disorders and that, at the same time, patients with substance use disorders lack positive environmental reinforcers for sober activities and pleasures. CRA aims to provide individuals with substance use disorders with natural alternative reinforcers by rewarding their involvement in the family and social community; thus, family members or peers play a role in reinforcing behaviors that demonstrate or facilitate abstinence. In CRA, emphasis is placed on improving environmental contingencies for activities of a sober lifestyle to make that type of lifestyle preferable to a substance-dependent lifestyle. In addition to individual behavioral treatment and contingency management, the multifaceted CRA treatment package typically includes conjoint marital therapy, training in finding a job, counseling on substance-free social and recreational activities, and a substance free social club. CRA is often applied with contingency management incentives (e.g., vouchers for recreation or food) that are used to reward evidence of sober behavior. CRA has been shown to be effective in treating alcohol dependence, with adjunctive disulfiram treatment increasing its effectiveness. CRA can be clinic or office based, but it is largely practiced in residential or partial hospitalization programs, therapeutic communities, and community residential facilities.
Substance use disorders and recovery are so widespread in Los Angeles and Orange County, more resources and activities are needed to provide for a growing need.
Cue Exposure & Relaxation Therapy
Cue exposure treatment involves exposing a patient to cues that induce craving while preventing actual substance use and, therefore, the experience of substance-related reinforcement. Cue exposure can also be paired with relaxation techniques and drug-refusal training to facilitate the extinction of classically conditioned craving. As an alternative, relaxation training has been used alone to provide a nonsubstance response to counteract dysphoric affects or anxiety.
Aversion therapy involves coupling substance use with an unpleasant experience such as mild electric shock, pharmacologically induced vomiting, or exaggerated effects of the substance. This treatment seeks to eliminate substance use behaviors by pairing them with punishment.
Psychodynamic & Interpersonal Therapies
Psychodynamic psychotherapies vary but generally attribute symptom formation and personality characteristics to traumas and deficits during an individual’s development that result in unconscious psychological conflict, faulty learning, and distortions of intrapsychic structures as well as internal object relations and that have a profound effect on interpersonal relationships.
These developmental events and their sequelae are inextricably interconnected to the individual’s underlying neurobiology (as determined by genetic and other influences), which can in turn be altered by life experience, including learning, psychological events, and psychotherapy. Systematic testing of the efficacy of psychodynamic treatments for substance use disorders has occurred only with supportive-expressive therapy, a comparatively brief psychodynamically oriented treatment based on the use of interpretation and a supportive therapeutic relationship to modify negative views of the self and others. Two trials have supported the efficacy of supportive-expressive therapy for methadone-maintained, opioid-dependent patients. However, an additional randomized trial found that combined individual and group drug counseling was superior to a combination of individual support-expressive therapy and group drug counseling in treating patients with cocaine dependence. IPT for substance use disorders is based on the concept that dysfunctional social relationships either cause or prevent recovery from a substance use disorder. By discovering the relation between interpersonal problems and substance use, the patient can move toward making changes aimed at building a social network that is supportive of recovery. Clinical study of IPT for substance use disorders has been limited.
Psychodynamic and Interpersonal Therapy is a common form of treatment provided by Los Angeles County and Orange County mental health therapists and counselors. Stress management, insight and interpersonal behavior are critical factors contributing to adopting a clean and sober life in Los Angeles County and Orange County.
Group therapy is viewed as an integral and valuable part of the treatment regimen for many patients with a substance use disorder. Many different types of therapies have been used in a group format with this population, including CBT, IPT, and behavioral marital, modified psychodynamic, interactive, rational emotive, Gestalt, and psychodrama therapies. Group therapies permit efficient use of therapist time. In addition, aspects of group therapy may make this modality more effective than individual treatment for individuals with a substance use disorder. For example, given the social stigma attached to having lost control of substance use, the presence of other group members who acknowledge having a similar problem can provide comfort. In addition, other group members who are further along in their recovery can act as models, illustrating that attempts to stop substance use are not futile. These more experienced group members can offer a wide variety of coping strategies that go beyond the repertoire known even by the most skilled individual therapist. Furthermore, group members frequently can act as “buddies” who offer continued support outside of group sessions in a way that most professional therapists do not.
Finally, the public nature of group therapy provides a powerful incentive to individuals to avoid relapse. The ability to publicly declare the number of days sober coupled with the fear of having to publicly admit to relapse is a strong force that helps group members fight a disorder that is characterized by a breakdown of internalized control mechanisms. Individuals with substance use disorders have been characterized as having poorly functioning internal self-control mechanisms, and the group process can provide a robust source of external control. Moreover, because the group is composed of individuals recovering from substance use disorders, members may be better at detecting each other’s concealed substance use or early relapse signals than would an individual therapist who may not have personal experience with a substance use disorder.
Although clinical trials of group therapy for substance use disorders are comparatively rare, the available data suggest that the efficacy of group treatment is comparable with that of individual therapies. No compelling empirical evidence is available to document the advantages or disadvantages of choosing group or individual treatment for substance use disorders. Because many patients have experience with group or individual therapy, patient preferences should be considered when choosing between the two types of treatment delivery or when developing a combined treatment program.
Group therapy is one of the most widespread and standard forms of treatment provided by Los Angeles County and Orange County intensive outpatient and residential addiction treatment programs. Group support and interpersonal behavior is a critical factor contributing to adopting a clean and sober life in Los Angeles County and Orange County.
Dysfunctional families, characterized by impaired communication among family members and an inability of family members to set appropriate limits or maintain standards of behavior, are associated with poor short- and long-term treatment outcome for patients with substance use disorders. Family therapy may be delivered in a formal, ongoing therapeutic relationship or through periodic contact. Goals of family therapy include obtaining information about the patient’s current attitudes toward substance use, treatment adherence, social and vocational adjustment, level of contact with substance-using peers, and degree of abstinence, as well as encouraging family support for abstinence, maintaining marital and family relationships, and improving treatment adherence and long-term outcome. They may also include behavioral contracting to maintain treatment (e.g., contracting with a partner for disulfiram treatment) or increasing positive incentives associated with sober family activities. Even the brief involvement of family members in the treatment program can enhance treatment engagement and retention.
Controlled studies have shown positive outcomes of involving non-alcohol-abusing family members in the treatment of an alcohol-abusing individual. More recent studies have demonstrated the effectiveness of family involvement in substance use disorder treatment for both women and men, including patients on methadone maintenance (170). Family therapy, often in combination with other approaches, has also been studied extensively and has shown good evidence for efficacy in adolescents.
Different theoretical orientations of family therapy include structural, strategic, psychodynamic, systems, and behavioral approaches. Family interventions include those focused on the nuclear family; on the patient and his or her spouse or partner; on concurrent treatment for patients, spouses or partners, and siblings; on multifamily groups; and on social networks. Of the many types of family therapy used to treat substance use disorders, the preponderance of clinical trial evidence has been obtained for the behavioral and strategic approaches. The support for behavioral couples treatment is particularly strong.
Family intervention is indicated in circumstances in which a patient’s abstinence upsets a previously well-established but maladaptive style of family interaction and in which other family members need help adjusting to a new set of individual and family goals, attitudes, and behaviors. Family therapy that addresses interpersonal and family interactions leading to conflict or enabling behaviors can reduce the risk of relapse for patients with high levels of family involvement. A major role for family and couples intervention is to enlist concerned significant others to foster treatment seeking and retention in family members who are unmotivated to change substance abuse behaviors. As reviewed by Miller et al., most attention has been paid to behavioral coping strategies, 12-step approaches, and confrontational interventions, all of which are associated with high rates of treatment entry for patients who receive the intervention. However, in helping family members engage their significant others in treatment, concerned significant others and identified patients are more likely to follow through and show better results with less confrontational approaches, including CRA and community reinforcement and family training, than with more traditional interventions. Couples and family therapy are also useful for promoting psychological differentiation of family members, providing a forum for the exchange of information and ideas about the treatment plan, developing behavioral management contracts and ground rules for continued family support, and reinforcing behaviors that help prevent relapse and enhance the prospects for recovery.
There is also some evidence that these approaches can improve the psychosocial functioning and decrease the likelihood of substance use in children living with a parent abusing alcohol or other substances.
Twelve Step & Mutual Help Supports
The most widely available self-help groups (also called mutual help groups) are based on the 12- step approach, originally embodied in AA, which emphasizes the concept of substance dependence as an incurable, progressive disease that has physical, emotional, and spiritual components. The 12-step programs firmly endorse the need for abstinence and consider themselves lifelong programs of recovery, even though initial success is attained one day at a time. The importance of recognizing and relying on a “higher power” or a power greater than the individual is a central element of these programs. Also key are the 12 steps of recovery, which focus first on surrender and acceptance of one’s disease, second on a personal inventory, third on making amends and personal change, and finally on bringing the message to others. In addition, 12-step groups help members with relapse prevention by providing role models, social support, social strategies for maintaining a sober lifestyle, and opportunities for structured and unstructured substance-free social events and interactions. Members of self-help groups can attend meetings on a self-determined or prescribed schedule, which, if necessary, could be every day or even more than once a day. Periods associated with high risk for relapse (e.g., weekends, holidays, evenings) are particularly appropriate for attendance. A sponsor who is compatible with the patient can provide important guidance and support during the recovery process, particularly when the patient is facing periods of emotional distress and increased craving. The straightforward advice and encouragement about avoiding relapse from a recovering sponsor as well as his or her personalized support are important features of 12-step groups. For clinicians who are treating patients who report involvement in self-help groups, it is useful to ask if they are attending meetings, if they have obtained a sponsor, and if they are attending other activities associated with the self-help group (e.g., self-help group-sponsored social gatherings, retreats).
Another significant advantage to 12-step groups is their broad availability. AA is a worldwide organization with an estimated 2.2 million members in 150 countries, and 12-step groups have expanded to include treatment of nearly every type of substance use (Cocaine Anonymous, Marijuana Anonymous, Methadone Anonymous, Narcotics Anonymous, Nicotine Anonymous, “Crystal Meth” Anonymous). Self-help groups based on the 12-step model are also available for family members and friends (e.g., Al-Anon, Alateen, Nar-Anon) and provide group support and education about the disorder, with the goal of reducing maladaptive enabling behavior in family and friends.
In general, active participation in self-help groups has been correlated with better outcomes. AA has been effective for both men and women and appears to be particularly useful for those with more severe alcohol dependence. Other recent research has suggested that 12-step groups may also benefit patients dependent on substances such as cocaine. For patients concurrently receiving professional substance abuse treatment, there is growing empirical evidence that improved treatment outcomes are associated with participation in self-help groups. Furthermore, several studies support the efficacy of professional treatment, including TSF therapy and individual drug counseling, that enhances a patient’s motivation to participate in 12-step programs. These findings have important clinical implications, given that these approaches are similar to the dominant model applied in most community treatment programs. Thus, for many patients, even those who may still be actively using substances, referral to a 12-step program can be helpful at all stages in the treatment process.
An individual’s refusal to participate in a self-help group is not synonymous with his or her resistance to treatment in general. Despite their many potential benefits, self-help groups are not useful for all patients. Some individuals’ apparent resistance to self-help group participation can be addressed by individualizing the choice of a group to the patient’s needs. For example, young people generally do better in groups that include age-appropriate peers in addition to some older recovering members. Patients who require psychotropic medications for co-occurring psychiatric disorders should be directed to groups in which this activity is recognized and supported as useful treatment rather than as another form of substance abuse. The spiritual tenets of traditional 12-step programs can be a deterrent to participation for individuals who do not embrace these ideas. Although not widely available, alternative self-help groups such as Women for Sobriety, Secular Organizations for Sobriety, and Self-Management and Recovery Training have been developed to address this problem and may be an option for some patients.
The efficacy of brief interventions has been studied mostly in connection with alcohol use disorders. The interventions were initially designed to facilitate the treatment of alcohol abuse or dependence in a setting other than a substance abuse treatment facility (e.g., primary care clinic). More recent evidence suggests that brief interventions are also effective with other substance use disorders, including cannabis, opioid, and nicotine dependence and in special populations such as adolescents, patients with co-occurring psychiatric and substance use disorders, and patients in the military.
The A-FRAMES model is the core structure of a brief intervention: Assessment, providing objective Feedback, emphasizing that Responsibility for change belongs to the patient, giving clear Advice about the benefits of change, providing a Menu of options for treatment to facilitate change, using Empathic listening, and emphasizing and encouraging Self-efficacy with the patient. Despite the short time required to implement a brief intervention, treatment facilities that do not specialize in substance abuse treatment often experience difficulties in using this strategy, including inadequate time available during face-to-face encounters and clinicians’ negative attitudes toward substance use.
Brief Intervention and brief therapies are some of the most widespread and standard forms of help provided to substance abuse patients by Los Angeles and Orange healthcare providers.
Self-help therapies guided by written, programmed, or Internet-based instruction have been shown to be effective for heavy users of legal substances (i.e., alcohol, nicotine) who do not meet criteria for a substance use disorder. The target population for such approaches typically includes students or general medical patients rather than individuals who are seeking treatment for a substance use disorder.
Self-help manuals and behavioral self-control training teach patients how to 1) set goals for substance reduction or cessation, 2) monitor progress toward achievement of these goals, 3) reward oneself for progress, 4) learn new coping skills that will facilitate substance reduction or abstinence, and 5) perform functional analysis of behaviors associated with substance use. These therapies are available as manual-guided self-help programs, manual-guided therapies with a clinician, and computer-guided programs. They are therefore available for home use as well as office- and clinic-based use.
Although these approaches are sometimes helpful for those at high risk for developing a substance use disorder or substance-related medical consequences, such minimal therapies may not be sufficient for treatment-seeking patients who already have a substance use disorder.
Self-guided therapy or self help is one of the most widespread and standard forms of help sought by residents of Los Angeles and Orange County residents with substance abuse problems.
The use of hypnotherapy for substance use disorders has been most studied as an aid in the cessation of cigarette smoking, with its usual goal being to implant unconscious suggestions that will deter use of a substance, such as “smoking will be unpleasant.” Despite the widespread use of hypnosis in this context, there is little scientific validation to support its effectiveness in the treatment of nicotine dependence.
Hypnosis or hypnotherapy is one of the most widespread and standard forms of treatment provided by Los Angeles and Orange County alternative care professionals.
Addiction Treatment; Personal Characteristics
In planning and implementing treatment, a clinician should consider several variables with regard to patients: comorbid psychiatric and general medical conditions, gender-related factors, age, social milieu and living environment, cultural factors, gay/lesbian/bisexual/transgender issues, and family characteristics. Given the high prevalence of comorbidity of substance use disorders and other psychiatric disorders, the diagnostic distinction between substance use symptoms and those of other disorders should receive particular attention, and specific treatment of comorbid disorders should be provided. In addition to pharmacotherapies specific to a patient’s substance use disorder, various psychotherapies may also be indicated when a patient has a co-occurring psychiatric disorder, psychosocial stressors, or other life circumstances that exacerbate the substance use disorder or interfere with treatment. A patient’s cessation of substance use may also be associated with changes in his or her psychiatric symptoms or the metabolism of medications (e.g., altered antipsychotic metabolism via cytochrome P450 1A2 with smoking cessation) that will necessitate adjustment of psychotropic medication doses.
In women of childbearing age, the possibility of pregnancy needs to be considered. Each of the substances discussed in this practice guideline has the potential to affect the fetus, and psychosocial treatment to encourage substance abstinence during pregnancy is recommended. With some substances, concomitant agonist treatment may be preferable to continued substance use. In pregnant smokers, treatment with nicotine replacement therapy (NRT) may be helpful [II]. For pregnant women with an opioid use disorder, treatment with methadone or buprenorphine [II] can be a useful adjunct to psychosocial treatment.
Los Angeles and Orange County Gay, Lesbian, Bisexual Transgender and cultural minority communities seek treatment at programs which are gay friendly or culturally informed/ sensitive.
Addiction Treatment Goals
General Addiction Treatment Principles
Individuals with substance use disorders are heterogeneous with regard to a number of clinically important features and domains of functioning. Consequently, a multimodal approach to treatment is typically required. Care of individuals with substance use disorders includes conducting a complete assessment, treating intoxication and withdrawal syndromes when necessary, addressing co-occurring psychiatric and general medical conditions, and developing and implementing an overall treatment plan. The goals of treatment include the achievement of abstinence or reduction in the use and effects of substances, reduction in the frequency and severity of relapse to substance use, and improvement in psychological and social functioning.
Psychosocial Addiction Treatments
Psychosocial treatments are essential components of a comprehensive treatment program [I]. Evidence-based psychosocial treatments include cognitive-behavioral therapies (CBTs, e.g., relapse prevention, social skills training), motivational enhancement therapy (MET), behavioral therapies (e.g., community reinforcement, contingency management), 12-step facilitation (TSF), psychodynamic therapy/interpersonal therapy (IPT), self-help manuals, behavioral self-control, brief interventions, case management, and group, marital, and family therapies. There is evidence to support the efficacy of integrated treatment for patients with a co-occurring substance use and psychiatric disorder; such treatment includes blending psychosocial therapies used to treat specific substance use disorders with psychosocial treatment approaches for other psychiatric diagnoses (e.g., CBT for depression).
Addiction Treatment Settings
Treatment settings vary with regard to the availability of specific treatment modalities, the degree of restricted access to substances that are likely to be abused, the availability of general medical and psychiatric care, and the overall milieu and treatment philosophy. Patients should be treated in the least restrictive setting that is likely to be safe and effective. Commonly available treatment settings include hospitals, residential treatment facilities, partial hospitalization and intensive outpatient programs, and outpatient programs. Decisions regarding the site of care should be based on the patient’s ability to cooperate with and benefit from the treatment offered, refrain from illicit use of substances, and avoid high-risk behaviors as well as the patient’s need for structure and support or particular treatments that may be available only in certain settings. Patients move from one level of care to another based on these factors and an assessment of their ability to safely benefit from a different level of care.
Hospitalization; Addiction Detoxification & Inpatient Treatment
Hospitalization is appropriate for patients who 1) have a substance overdose who cannot be safely treated in an outpatient or emergency department setting; 2) are at risk for severe or medically complicated withdrawal syndromes (e.g., history of delirium tremens, documented history of very heavy alcohol use and high tolerance); 3) have co-occurring general medical conditions that make ambulatory detoxification unsafe; 4) have a documented history of not engaging in or benefiting from treatment in a less intensive setting (e.g., residential, outpatient); 5) have a level of psychiatric comorbidity that would markedly impair their ability to participate in, adhere to, or benefit from treatment or have a co-occurring disorder that by itself would require hospital level care (e.g., depression with suicidal thoughts, acute psychosis); 6) manifest substance use or other behaviors that constitute an acute danger to themselves or others; or 7) have not responded to or were unable to adhere to less intensive treatment efforts and have a substance use disorder(s) that endangers others or poses an ongoing threat to their physical and mental health.
Addiction Residential Treatment
Residential treatment is indicated for patients who do not meet the clinical criteria for hospitalization but whose lives and social interactions have come to focus predominantly on substance use, who lack sufficient social and vocational skills, and who lack substance-free social supports to maintain abstinence in an outpatient setting. Residential treatment of ?3 months is associated with better long-term outcomes in such patients. For patients with an opioid use disorder, therapeutic communities have been found effective.
Addiction Partial Hospitalization & Intensive Outpatient Treatment
Partial hospitalization should be considered for patients who require intensive care but have a reasonable probability of refraining from illicit use of substances outside a restricted setting. Partial hospitalization settings are frequently used for patients leaving hospitals or residential settings who remain at high risk for relapse. These include patients who are thought to lack sufficient motivation to continue in treatment, have severe psychiatric co-morbidity and/or a history of relapse to substance use in the immediate post-hospitalization or post-residential period, and are returning to a high-risk environment and have limited psychosocial supports for abstaining from substance use. Partial hospitalization programs are also indicated for patients who are doing poorly despite intensive outpatient treatment.
Partial hospitalization and intensive outpatient programs can provide an intensive, structured treatment experience for individuals with substance use disorders who require more services than those generally available in traditional outpatient settings. Although the terms “partial hospitalization,” “day treatment,” and “intensive outpatient” programs may be used nearly interchangeably in different parts of the country, the ASAM patient placement criteria define structured programming in partial hospitalization programs as 20 hours per week and in intensive outpatient programs as 9 hours per week. Partial hospitalization programs provide ancillary medical and psychiatric services, whereas intensive outpatient programs may be more variable in the accessibility of these services. Some patients enter these programs directly from the community. Alternatively, these programs are sometimes used as “step-down” programs for individuals leaving hospital or residential settings who are at a high risk of relapsing because of problems with motivation, the presence of frequent cravings or urges to use a substance, poor social supports, immediate environmental cues for relapse and/or availability of substances, and co-occurring medical and/or psychiatric disorders. The goal of such a “step-down” approach is to stabilize patients by retaining them in treatment and providing more extended intensive outpatient monitoring of relapse potential and co-occurring disorders. Partial hospitalization and intensive outpatient programs may also be used as a brief “step-up” in treatment for an outpatient who has had a relapse but who does not require medical detoxification or who has entered into a high-risk period for relapse because of life circumstances or recurrence of a co-occurring medical and/or psychiatric symptom (e.g., depressed mood, increased pain).
The treatment components of partial hospitalization programs may include some combination of individual and group therapy, vocational and educational counseling, family meetings, medically supervised use of adjunctive medications (e.g., opioid antagonists, antidepressants), random urine screening for substances of abuse, and treatment for any co-occurring psychiatric disorders. Intensive outpatient programs use individual therapy, group therapy, family therapy, and urine toxicology but vary in the amount of other therapeutic components used. An advantage of intensive outpatient programs is the availability of evening programs that accommodate day-shift employees. The availability of weekend programs varies for both partial hospitalization and intensive outpatient programs. Both kinds of programs aim to prepare the individual for transition to less intensive outpatient services and increased self-reliance through the practice and mastery of relapse prevention skills and the active use of self-help programs. Limited data are available for the efficacy of partial hospitalization and intensive outpatient programs. Randomized, controlled trials have demonstrated that some individuals who would ordinarily be referred for residential- or hospital-level care do just as well in partial hospitalization care. One study comparing a more time-intensive day hospital program to an intensive outpatient program that was actually less time intensive found no differences in outcome for cocaine-dependent individuals, and another study comparing intensive with traditional outpatient treatment of the same population found no differences in outcome.
Addiction Outpatient Treatment
Outpatient treatment of substance use disorders is appropriate for patients whose clinical condition or environmental circumstances do not require a more intensive level of care [I]. As in other treatment settings, a comprehensive approach is optimal, using, where indicated, a variety of psychotherapeutic and pharmacological interventions along with behavioral monitoring [I]. Most treatment for patients with alcohol dependence or abuse can be successfully conducted outside the hospital (e.g., in outpatient or partial hospitalization settings) [II], although patients with alcohol withdrawal must be detoxified in a setting that provides frequent clinical assessment and any necessary treatments [I]. For many patients with a cocaine use disorder, clinical and research experience suggests the effectiveness of intensive outpatient treatment in which a variety of treatment modalities are simultaneously used and in which the focus is the maintenance of abstinence [II]. The treatment of patients with nicotine dependence or a marijuana use disorder.
Outpatient treatment settings include but are not limited to mental health clinics, integrated dual-diagnosis programs, private practice settings, primary care clinics, and substance abuse treatment centers, including opioid treatment programs. For individuals with primary nicotine dependence or a marijuana use disorder, treatment is always provided in an outpatient setting. For individuals with other substance use disorders, outpatient treatment is appropriate when clinical conditions or environmental and social circumstances do not require a more intensive level of care.
As in other treatment settings, the optimal outpatient approach is a comprehensive one that includes a variety of psychotherapeutic and pharmacological interventions along with behavioral monitoring, where indicated. The evidence base for empirically supported outpatient treatments is larger for alcohol, nicotine, and opioid dependence treatments than for other substance dependence treatments. In addition to medication therapies, outpatient treatments with strong evidence of effectiveness include CBTs (e.g., relapse prevention, social skills training), MET, behavioral therapies (e.g., community reinforcement, contingency management), TSF, psychodynamic therapies/IPT, self-help manuals, behavioral self-control, brief interventions, case management, and group, marital, and family therapies.
Many specific outpatient treatments have been designed to enhance an individual’s participation in treatment and sense of self-efficacy regarding the reduction or cessation of problematic substance use. As in the case of residential and partial hospitalization programs, high rates of attrition can be problematic in outpatient settings, particularly in the early phase (i.e., the first 6 months). Because intermediate and long-term outcomes are highly correlated with retention in treatment, individuals should be strongly encouraged to remain in treatment. Clinicians should also encourage and attempt to integrate into treatment a patient’s participation in self-help programs where appropriate.
Aftercare occurs after an intense treatment intervention (e.g., hospital or partial hospitalization program) and generally includes outpatient care, involvement in self-help approaches, or both. The clinician should consider the possibility that cognitive impairment may be present in recently detoxified patients when determining their next level of care. Research on aftercare has examined different treatment models, including eclectic, medically oriented, motivational, 12- step, cognitive-behavioral, group, and marital strategies. Given the chronic, relapsing nature of many types of substance use disorders, especially those requiring hospitalization, it is expected that aftercare will be recommended with few exceptions. In fact, if addiction is reconceptualized along the lines of a chronic rather than an acute disease model, as recommended by McLellan et al., the distinction between a “treatment episode” and “aftercare” should be removed and the different modalities of care (e.g., inpatient, outpatient) be reconsidered as part of a continuous, long-term treatment plan.
Addiction Case Management
Case management, by definition, exists as an adjunctive treatment. The goals of case management interventions are to provide advocacy and coordination of care and social services and to improve patient adherence to prescribed treatment and follow-up care. Case management initially provides psycho-education about the patient’s diagnosis and treatment as well as assessment and stabilization of basic necessities required for the individual to actively participate in treatment (e.g., housing, utilities, income, health insurance, transportation). Beyond this, case managers aid individuals in maintaining stability and understanding and adhering to prescribed treatment. The variability in case management models has complicated research on the effectiveness of this approach. Nevertheless, studies show that case management interventions are effective for individuals with an alcohol use disorder or co-occurring psychiatric and substance use disorders and for adolescents with substance use disorders.
Legally Mandated Addiction Treatment
Treatment of substance use disorders may be legally mandated under a variety of circumstances, including substance-related criminal offenses such as driving under the influence of alcohol or drugs. Drug court programs recognize the effectiveness of diverting offenders with lesser drug related convictions from correctional facilities into court-mandated community programs for the treatment of substance use disorders. Standard procedures for drug court programs include 1) assessment of individual substance use treatment needs, 2) appropriate referral for treatment after arrest, 3) periodic monitoring of adherence to treatment through the use of clinician report and mandatory drug testing, 4) reduction in the severity of charges contingent on successful utilization of programs for the treatment of substance use disorders, and 5) aftercare planning for maintaining sobriety in the community. For offenses related to driving under the influence of alcohol or drugs, state and community sanctions include incarceration, license suspension, driver’s education, and community service requirements. Some evidence indicates that more severe sanctions lead to less recidivism for intoxicated drivers with high blood alcohol content readings.
Despite the high frequency at which substance use disorders and criminal behaviors co-occur, it has been estimated that only 1%-20% of substance abusers receive adequate treatment while incarcerated. The most studied effective treatment programs for incarcerated individuals are therapeutic communities.
Employee Assistance Programs
Employee assistance programs (EAPs) provide an employment-based treatment setting and referral platform for employees with substance use disorders. EAPs differ according to workplace size and location. A critical difference for substance use treatment received through an EAP versus through an alternate community outpatient setting is the definition of successful intervention outcome. Whereas most community settings define successful outcome as a reduction of substance use and related medical and social problems, an EAP defines and measures success primarily through job performance. This reflects the employer’s need to serve and retain an employee while simultaneously protecting the workplace from inadequate job performance and attributable losses. EAPs are cost-effective in the short term, but post-treatment follow-up rates are poor.
Relapse Prevention & Treatment Compliance
Because individuals with substance use disorders are often ambivalent about giving up their substance use, it can be useful to monitor their attitudes about participating in treatment and adhering to specific recommendations. These patients often deny or minimize the negative consequences attributable to their substance use; this tendency is often erroneously interpreted by clinicians and significant others as evidence of dishonesty. Even patients entering treatment with high motivation to achieve abstinence will struggle with the reemergence of craving for a substance or preoccupation with thoughts about attaining or using a substance. Moreover, social influences (e.g., substance-using family or friends), economic influences (e.g., unemployment), medical conditions (e.g., chronic pain, fatigue), and psychological influences (e.g., hopelessness, despair) may make an individual more vulnerable to a relapse episode even when he or she adheres to prescribed treatment. For these reasons, it can be helpful for clinicians and patients to anticipate the possibility that the patient may return to substance use and to agree on a corrective plan of action should this occur. If the patient is willing, it can be helpful to involve significant others in preventing the patient’s relapse and prepare significant others to manage relapses should they occur.
Supporting patients in their efforts to reduce or abstain from substance use positively reinforces their progress. Overt recognition of patient efforts and successes helps to motivate patients to remain in treatment despite setbacks. Clinicians can optimize patient engagement and retention in treatment through the use of motivational enhancement strategies and by encouraging patients to actively partake in self-help strategies. Monitoring programs, such as EAPs and impaired-physician programs, can sometimes help patients adhere to treatment.
Early in treatment a clinician may educate patients about cue-, stress-, and substance-induced relapse triggers. Patients benefit from being educated in a supportive manner about relapse risk situations, thoughts, or emotions; they must learn to recognize these as triggers for relapse and learn to manage unavoidable triggers without resorting to substance-using behaviors.
Participation in AA or similar self-help group meetings can also support patients’ sobriety and help them avoid relapse. Many other strategies can also help prevent relapse. Social skills training is targeted at improving individual responsibility within family relationships, work related interactions, and social relationships. During the early recovery phase, it can be helpful to encourage patients to seek new experiences and roles consistent with a substance-free existence (e.g., greater involvement in vocational, social, or religious activities) and to discourage them from instituting major life changes that might increase the risk of relapse. Facilitating treatment of co-occurring psychiatric and medical conditions that significantly interact with substance relapse is a long-term intervention for maintaining sobriety .
Therapeutic strategies to prevent relapse have been well studied and include teaching individuals to anticipate and avoid substance-related cues (e.g., assessing individual capacity to avoid relapse in the presence of substance-using peers), training individuals how to monitor their affective or cognitive states associated with increased craving and substance use, behavioral contingency contracting, training individuals in cue extinction and relaxation therapies to reduce the potency of substance-related stimuli and modulate craving intensity, and supporting patients in the development of coping skills and lifestyle changes that support sobriety. Behavioral techniques that enhance the availability and perceived value of social reinforcement as an alternative to substance use or reward for remaining abstinent have also been used.
If relapse does occur, individuals should be praised for even limited success and encouraged to continue in or resume treatment. Clinicians may help patients analyze relapses as well as periods of sobriety from a functional and behavioral standpoint and use what is learned to adjust the treatment plan to fit the individual’s present needs. For chronically relapsing substance users, medication therapies may be necessary adjuncts to treatment.