Addiction Treatment Approaches
Alcohol Addiction Treatment
- Naltrexone blocks opioid receptors that are involved in the rewarding effects of drinking and the craving for alcohol. It reduces relapse to heavy drinking, defined as four or more drinks per day for women and five or more for men. Naltrexone cuts relapse risk during the first 3 months by about 36 percent but is less effective in helping patients maintain abstinence.
- Acamprosate (Campral®) acts on the gamma-aminobutyric acid (GABA) and glutamate neurotransmitter systems and is thought to reduce symptoms of protracted withdrawal, such as insomnia, anxiety, restlessness, and dysphoria. Acamprosate has been shown to help dependent drinkers maintain abstinence for several weeks to months, and it may be more effective in patients with severe dependence.
- Disulfiram (Antabuse®) interferes with degradation of alcohol, resulting in the accumulation of acetaldehyde, which, in turn, produces a very unpleasant reaction that includes flushing, nausea, and palpitations if the patient drinks alcohol. The utility and effectiveness of disulfiram are considered limited because compliance is generally poor. However, among patients who are highly motivated, disulfiram can be effective, and some patients use it episodically for high-risk situations, such as social occasions where alcohol is present. It can also be administered in a monitored fashion, such as in a clinic or by a spouse, improving its efficacy.
- Topiramate is thought to work by increasing inhibitory (GABA) neurotransmission and reducing stimulatory (glutamate) neurotransmission. Its precise mechanism of action in treating alcohol addiction is not known, and it has not yet received FDA approval. Topiramate has been shown in two randomized, controlled trials to significantly improve multiple drinking outcomes, compared with a placebo. Over the course of a 14-week trial, topiramate significantly increased the proportion of patients with 28 consecutive days of abstinence or non-heavy drinking. In both studies, the differences between topiramate and placebo groups were still diverging at the end of the trial, suggesting that the maximum effect may not have yet been reached. Importantly, efficacy was established in volunteers who were drinking upon starting the medication.
These are shown to be effective when combined with behavioral treatment.
Tobacco Addiction Treatment
- Nicotine Replacement Therapy (NRT): A variety of formulations of nicotine replacement therapies now exist, including the transdermal nicotine patch, nicotine spray, nicotine gum, and nicotine lozenges. Because nicotine is the main addictive ingredient in tobacco, the rationale for NRT is that stable low levels of nicotine will prevent withdrawal symptoms—which often drive continued tobacco use—and help keep people motivated to quit.
- Bupropion (Zyban®) was originally marketed as an antidepressant (Wellbutrin®). It has mild stimulant effects through blockade of the reuptake of catecholamines, especially norepinephrine and dopamine. A serendipitous observation among depressed patients was the medication’s efficacy in suppressing tobacco craving, promoting cessation without concomitant weight gain. Although bupropion’s exact mechanisms of action in facilitating smoking cessation are unclear, it has FDA approval as a smoking cessation treatment.
- Varenicline (Champix®) is the most recently FDA-approved medication for smoking cessation. It acts on a subset of nicotinic receptors (alpha-4 beta-2) thought to be involved in the rewarding effects of nicotine. Varenicline acts as a partial agonist/antagonist at these receptors—this means that it mildly stimulates the nicotine receptor, but not sufficiently to allow the release of dopamine, which is important for the rewarding effects of nicotine. As an antagonist, varenicline also blocks the ability of nicotine to activate dopamine, interfering with the reinforcing effects of smoking, thereby reducing cravings and supporting abstinence from smoking.
These are shown to be effective when combined with behavioral treatment.
Opioid Addiction Treatment
- Methadone maintenance treatment is usually conducted in specialized settings (e.g., methadone maintenance clinics). These specialized treatment programs offer the long-acting synthetic opioid medication methadone at a dosage sufficient to prevent opioid withdrawal, block the effects of illicit opioid use, and decrease opioid craving.Combined with behavioral treatment: The most effective methadone maintenance programs include individual and/or group counseling, as well as provision of or referral to other needed medical, psychological, and social services.
- Buprenorphine is a partial agonist (it has both agonist and antagonist properties) at opioid receptors that carries a low risk of overdose. It reduces or eliminates withdrawal symptoms associated with opioid dependence but does not produce the euphoria and sedation caused by heroin or other opioids.Buprenorphine is available in two formulations: Subutex® (a pure form of buprenorphine) and the more commonly prescribed Suboxone® (a combination of buprenorphine and the opioid antagonist naloxone). The unique formulation with naloxone produces severe withdrawal symptoms when addicted individuals inject it to get high, lessening the likelihood of diversion.Physicians who provide office-based buprenorphine treatment for detoxification and/or maintenance treatment must have special accreditation. These physicians are also required to have the capacity to provide counseling to patients when indicated or, if they do not, to refer patients to those who do.Office-based treatment of opioid addiction is a cost-effective approach that increases the reach of treatment and the options available to patients. Many patients have life circumstances that make office-based treatment a better option for them than specialty clinics. For example, they may live far away from treatment centers or have working hours incompatible with the clinic hours. Office-based addiction treatment is being offered by primary care physicians, psychiatrists, and other specialists, such as internists and pediatricians.Patients stabilized on adequate, sustained dosages of methadone or buprenorphine can function normally. They can hold jobs, avoid the crime and violence of the street culture, and reduce their exposure to HIV by stopping or decreasing injection drug use and drug-related high-risk sexual behavior. Patients stabilized on these medications can also engage more readily in counseling and other behavioral interventions essential to recovery and rehabilitation.Naltrexone is a long-acting synthetic opioid antagonist with few side effects. An opioid antagonist blocks opioids from binding to their receptors and thereby prevents an addicted individual from feeling the effects associated with opioid use. Naltrexone as a treatment for opioid addiction is usually prescribed in outpatient medical settings, although initiation of the treatment often begins after medical detoxification in a residential setting. To prevent withdrawal symptoms, individuals must be medically detoxified and opioid-free for several days before taking naltrexone. The medication is taken orally either daily or three times a week for a sustained period. When used this way, naltrexone blocks all the effects, including euphoria, of self-administered opioids. The theory behind this treatment is that the repeated absence of the desired effects and the perceived futility of using the opioid will gradually diminish opioid craving and addiction. Naltrexone itself has no subjective effects (that is, a person does not perceive any particular drug effects) or potential for abuse, and it is not addictive. However, patient noncompliance is a common problem. Therefore, a favorable treatment outcome requires an accompanying positive therapeutic relationship, effective counseling or therapy, and careful monitoring of medication compliance. Many experienced clinicians have found naltrexone best suited for highly motivated, recently detoxified patients who desire total abstinence because of external circumstances. Professionals, parolees, probationers, and prisoners in work-release status exemplify this group.Combined with behavioral treatment: Motivational incentives, such as the offering of prizes or rewards for maintaining abstinence, have been shown to enhance the treatment compliance and efficacy of naltrexone for opioid addiction.
Behavioral Therapies & Addiction Treatment
Cognitive-Behavioral Therapy and Addiction Treatment
(Alcohol, Marijuana, Cocaine, Methamphetamine, Nicotine)
Cognitive-behavioral therapy was developed as a method to prevent relapse when treating problem drinking, and later was adapted for cocaine-addicted individuals. Cognitive-behavioral strategies are based on the theory that learning processes play a critical role in the development of maladaptive behavioral patterns. Individuals learn to identify and correct problematic behaviors by applying a range of different skills that can be used to stop drug abuse and to address a range of other problems that often co-occur with it.
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Cognitive-behavioral therapy generally consists of a collection of strategies intended to enhance self-control. Specific techniques include exploring the positive and negative consequences of continued use, self-monitoring to recognize drug cravings early on and to identify highrisk situations for use, and developing strategies for coping with and avoiding high-risk situations and the desire to use. A central element of this treatment is anticipating likely problems and helping patients develop effective coping strategies.
Research indicates that the skills individuals learn through cognitive-behavioral approaches remain after the completion of treatment. In several studies, most people receiving a cognitive-behavioral approach maintained the gains they made in treatment throughout the following year.
Current research focuses on how to produce even more powerful effects by combining cognitive-behavioral therapy with medications for drug abuse and with other types of behavioral therapies. Researchers are also evaluating how best to train treatment providers to deliver cognitive-behavioral therapy.
Addiction Treatment: Community Reinforcement Approach Plus Vouchers (Alcohol, Cocaine)
Community Reinforcement Approach (CRA) Plus Vouchers is an intensive 24-week outpatient therapy for treatment of cocaine and alcohol addiction. The treatment goals are twofold:
- To maintain abstinence long enough for patients to learn new life skills to help sustain it
- To reduce alcohol consumption for patients whose drinking is associated with cocaine use
Patients attend one or two individual counseling sessions each week, where they focus on improving family relations, learning a variety of skills to minimize drug use, receiving vocational counseling, and developing new recreational activities and social networks. Those who also abuse alcohol receive clinic-monitored disulfiram (Antabuse) therapy. Patients submit urine samples two or three times each week and receive vouchers for cocainenegative samples. The value of the vouchers increases with consecutive clean samples. Patients may exchange vouchers for retail goods that are consistent with a cocaine-free lifestyle.
This approach facilitates patients’ engagement in treatment and systematically aids them in gaining substantial periods of cocaine abstinence. The approach has been tested in urban and rural areas and used successfully in outpatient treatment of opioid-addicted adults and with inner-city methadone maintenance patients with high rates of intravenous cocaine abuse.
Addiction Treatment: Contingency Management Interventions/Motivational Incentives (Alcohol, Stimulants, Opioids, Marijuana, Nicotine)
Research has demonstrated the effectiveness of treatment approaches using contingency management principles, which involve giving patients in drug treatment the chance to earn low-cost incentives in exchange for drug-free urine samples. These incentives include prizes given immediately or vouchers exchangeable for food items, movie passes, and other personal goods. Studies conducted in both methadone programs and psychosocial counseling treatment programs demonstrate that incentive-based interventions are highly effective in increasing treatment retention and promoting abstinence from drugs.
Some concerns have been raised that a prize-based contingency management intervention could promote gambling—as it contains an element of chance—and that pathological gambling and substance use disorders can be comorbid. However, studies have shown no differences in gambling over time between those assigned to the contingency management conditions and those in the usual care groups, indicating that this prize-based contingency management procedure did not promote gambling behavior.
Addiction Treatment: Motivational Enhancement Therapy (Alcohol, Marijuana, Nicotine)
Motivational Enhancement Therapy (MET) is a patient-centered counseling approach for initiating behavior change by helping individuals resolve ambivalence about engaging in treatment and stopping drug use. This approach employs strategies to evoke rapid and internally motivated change, rather than guiding people stepwise through the recovery process. This therapy consists of an initial assessment battery session, followed by two to four individual treatment sessions with a therapist. In the first treatment session, the therapist provides feedback to the initial assessment battery, stimulating discussion about personal substance use and eliciting self-motivational statements. Motivational interviewing principles are used to strengthen motivation and build a plan for change. Coping strategies for high-risk situations are suggested and discussed with the patient. In subsequent sessions, the therapist monitors change, reviews cessation strategies being used, and continues to encourage commitment to change or sustained abstinence. Patients sometimes are encouraged to bring a significant other to sessions.
Research on MET suggests that its effects depend on the type of drug used by participants and on the goal of the intervention. This approach has been used successfully with alcoholics to improve both treatment engagement and treatment outcomes (e.g., reductions in problem drinking). MET has also been used successfully with adult marijuana-dependent individuals in combination with cognitive-behavioral therapy, comprising a more comprehensive treatment approach. The results of MET are mixed for participants abusing other drugs (e.g., heroin, cocaine, nicotine, etc.) and for adolescents who tend to use multiple drugs. In general, MET seems to be more effective for engaging drug abusers in treatment than for producing changes in drug use.
Addiction Treatment: The Matrix Model (Stimulants)
The Matrix Model provides a framework for engaging stimulant (e.g., methamphetamine and cocaine) abusers in addiction treatment and helping them achieve abstinence. Patients learn about issues critical to addiction and relapse, receive direction and support from a trained therapist, become familiar with self-help programs, and are monitored for drug use through urine testing. The therapist functions simultaneously as teacher and coach, fostering a positive, encouraging relationship with the patient and using that relationship to reinforce positive behavior change. The interaction between the therapist and the patient is authentic and direct but not confrontational or parental. Therapists are trained to conduct treatment sessions in a way that promotes the patient’s self-esteem, dignity, and self-worth. A positive relationship between patient and therapist is critical to patient retention.Treatment materials draw heavily on other tested treatment approaches and, thus, include elements of relapse prevention, family and group therapies, drug education, and self-help participation. Detailed treatment manuals contain worksheets for individual sessions; other components include family education groups, early recovery skills groups, relapse prevention groups, combined sessions, urine tests, 12-step programs, relapse analysis, and social support groups.A number of studies have demonstrated that participants treated using the Matrix Model show statistically significant reductions in drug and alcohol use, improvements in psychological indicators, and reduced risky sexual behaviors associated with HIV transmission.
Addiction Treatment: 12-Step Facilitation Therapy (Alcohol, Stimulants, Opiates)
Twelve-step facilitation therapy is an active engagement strategy designed to increase the likelihood of a substance abuser becoming affiliated with and actively involved in 12-step self-help groups and, thus, promote abstinence. Three key aspects predominate: acceptance, which includes the realization that drug addiction is a chronic, progressive disease over which one has no control, that life has become unmanageable because of drugs, that willpower alone is insufficient to overcome the problem, and that abstinence is the only alternative; surrender, which involves giving oneself over to a higher power, accepting the fellowship and support structure of other recovering addicted individuals, and following the recovery activities laid out by the 12-step program; and active involvement in 12-step meetings and related activities. While the efficacy of 12-step programs (and 12-step facilitation) in treating alcohol dependence has been established, the research on other abused drugs is more preliminary but promising for helping drug abusers sustain recovery. NIDA has recognized the need for more research in this area and is currently funding a community-based study to examine the impact of 12-step facilitation therapy for methamphetamine and cocaine abusers.
Addiction Treatment: Behavioral Couples Therapy
(BCT) is a therapy for drug abusers with partners. BCT uses a sobriety/ abstinence contract and behavioral principles to reinforce abstinence from drugs and alcohol. It has been studied as an add-on to individual and group therapy and typically involves 12 weekly couple sessions, lasting approximately 60 minutes each. Many studies support BCT’s efficacy with alcoholic men and their spouses; four studies support its efficacy with drug-abusing men and women and their significant others. BCT also has been shown to produce higher treatment attendance, naltrexone adherence, and rates of abstinence than individual treatment, along with fewer drug-related, legal, and family problems at 1-year followup.
Recent research has focused on making BCT more community-friendly by adapting the therapy for delivery in fewer sessions and in a group format. Research is also being done to demonstrate cost-effectiveness and to test therapy effectiveness according to therapist training.
Addiction Treatment: Behavioral Treatments for Adolescents
Drug-abusing and addicted adolescents have unique treatment needs. Research has shown that treatments designed for and tested in adult populations often need to be modified to be effective in adolescents. Family involvement is a particularly important component for interventions targeting youth. Below are examples of behavioral interventions that employ these principles and have shown efficacy for treating addiction in youth.
Addiction Treatment: Multisystemic Therapy
MST addresses the factors associated with serious antisocial behavior in children and adolescents who abuse alcohol and other drugs. These factors include characteristics of the child or adolescent (e.g., favorable attitudes toward drug use), the family (poor discipline, family conflict, parental drug abuse), peers (positive attitudes toward drug use), school (dropout, poor performance), and neighborhood (criminal subculture). By participating in intensive addiction treatment in natural environments (homes, schools, and neighborhood settings), most youths and families complete a full course of treatment. MST significantly reduces adolescent drug use during treatment and for at least 6 months after treatment. Fewer incarcerations and out-of-home juvenile placements offset the cost of providing this intensive service and maintaining the clinicians’ low caseloads.
Addiction Treatment: Multidimensional Family Therapy for Adolescents
MDFT for adolescents is an outpatient family- based addiction treatment for teenagers. MDFT views adolescent drug use in terms of a network of influences (individual, family, peer, community) and suggests that reducing unwanted behavior and increasing desirable behavior occur in multiple ways in different settings. Addiction treatment includes individual and family sessions held in the clinic, in the home, or with family members at the family court, school, or other community locations.
During individual sessions, the therapist and adolescent work on important developmental tasks, such as developing decision-making, negotiation, and problem-solving skills. Teenagers acquire vocational skills and skills in communicating their thoughts and feelings to deal better with life stressors. Parallel sessions are held with family members. Parents examine their particular parenting styles, learning to distinguish influence from control and to have a positive and developmentally appropriate influence on their children.
Addiction Treatment: Brief Strategic Family Therapy
BSFT targets family interactions that are thought to maintain or exacerbate adolescent drug abuse and other co-occurring problem behaviors. Such problem behaviors include conduct problems at home and at school, oppositional behavior, delinquency, associating with antisocial peers, aggressive and violent behavior, and risky sexual behavior. BSFT is based on a family systems approach to addiction treatment, where family members’ behaviors are assumed to be interdependent such that the symptoms of any one member (the drug-abusing adolescent, for example) are indicative, at least in part, of what else is going on in the family system. The role of the BSFT counselor is to identify the patterns of family interaction that are associated with the adolescent’s behavior problems and to assist in changing those problem-maintaining family patterns. BSFT is meant to be a flexible approach that can be adapted to a broad range of family situations in various settings (mental health clinics, drug abuse treatment programs, other social service settings, and families’ homes) and in various addiction treatment modalities (as a primary outpatient intervention, in combination with residential or day treatment, and as an aftercare/continuing-care service to residential treatment).