Treatment of Substance Use Disorders
In a recent edition of the American Psychiatric Association Diagnostic and Statistical Manual (DSM-IV), substance use disorders (SUDs) were divided into two distinct categories–substance abuse and substance dependence. An individual could receive a current diagnosis of either abuse or dependence (not both) for a single drug class. A current SUD refers to continued use of the substance within the past 12 months that has resulted in problems and symptoms (1 symptom required for abuse, 3 for dependence). Drug classes for which an individual could be diagnosed with a SUD include: alcohol, cannabis, nicotine, opioids, inhalants, hallucinogens, amphetamine, caffeine, cocaine, and sedatives. An example diagnosis would be “cannabis abuse” or “amphetamine dependence”. Substance Dependence was considered the more severe use disorder; it’s criteria included physiological and tolerance and withdrawal, as well as continued use despite incurring health consequences.
In the updated (2013) DSM-5, SUDs are not characterized by abuse vs. dependence. Without this distinction, an individual would receive the “use disorder” diagnostic label, referring to the specific drug class (for example, “cannabis use disorder”). See updated symptom criteria for substance use disorders.
Basic Principles of SUD Treatment
Most professionals recognize a dynamic interplay of factors as contributing to addictive tendencies involving alcohol and other substances. This is why, in addition to detoxification and inpatient rehab, psychosocial treatments are critical for recovery from a substance use disorder. Psychosocial treatments are programs that can target components of the social and cultural structures surrounding the patient and the problematic psychological and behavioral patterns of patient.
Overall, appropriate choice and context of therapy will depend on several factors, including the severity of the substance use problem, patient motivation to stop using, level of dysfunction in the patient’s sociocultural environment, patient’s cognitive functioning and level of impulse control, and presence of co-occurring mental illness in the patient. Oftentimes, a mental health professional will incorporate feedback from the patient as well as individuals close to the patient, when devising a treatment plan. Accumulating research supports positive reinforcement over punishment for treating addiction.
Residential Treatment (During Early Remission)
First 12-months’ post-cessation period is considered the early remission phase. Because social and cultural components of the patient’s old familiar environment has likely served as a previous trigger for using drugs and drinking, temporary relocation in a semi-controlled or monitored sober community can be a great ally to the patient during their early remission phase. This is especially the case if the individual aims to stay completely abstinent from drugs long-term, as opposed to cutting down or reducing harm resulting from their use.
Sober-living community homes (sometimes called “halfway houses” – although this term is no longer used) are semi-controlled residences where the patient can live among other people who are in recovery. Sometimes these are court-mandated in the case when the patient has committed a crime. Still, a sober living home can serve as a vital psychosocial intervention for patients’ progressive entry into society. Oftentimes, residents will receive alcohol and drug counseling. In addition, the patient has a chance to receive beneficial social support from other residents who are in recovery and who may be able to relate to them. Additionally, the patient is included in regular, ongoing collaborative activities, such as group meals and recreational day trips that can serve as reinforcement for their efforts to remain sober.
Psychological and Behavioral Treatments
Follow-up (mostly outpatient) treatment may be warranted even after the patient has become clean and sober. Strictly behavioral psychosocial interventions for relapse prevention often involve drug-testing and reward incentives. Many court-mandated programs are highly structured with a focus on case management. These may require a team of various professionals to collaborate on each case. For example, a patient may be assigned a case manager or probation officer; social worker; psychiatrist (M.D. who can provide medication); and a therapist providing psychotherapy. Psychotherapy can be provided by a doctorate-level licensed psychologist or by a master’s level therapist or social worker under their supervision. Various forms of psychotherapy exist for treatment of substance use disorders, each with a different primary focus. For example, psychotherapy can teach stress-coping skills to the patient, target relationship dynamics and communication, reinforce motivation to remain sober, or target underlying psychological problems, such as symptoms of anxiety and depression. Specific psychosocial treatments for substance use disorders that are backed by clinical research evidence.
Several psychological treatments have received support from scientific studies and have been deemed appropriate by the American Psychological Association (Division 12) for treating substance use disorders. These include:
1. Motivational Interviewing (MI) is not a treatment of substance use disorders per se. Rather, it is an intentionally goal-directed, collaborative, and empathetic communication technique therapists can use to leverage clients’ motivation for behavior change. MI evokes clients’ internal motivation for changing problematic patterns in their life, while highlighting their intrinsic strengths and resources. It is usually practiced in a face-to-face format with client and therapist. Dr. Miller designed MI specifically for substance use clients in 1983, but it has been applied successfully in other difficult-to-treat populations. Miller noticed that many of his clients with current or past SUDs displayed similar characteristics, such as reluctance, defensiveness, and ambivalence about change, and the need to work around these barriers in his practice.
2. Motivational Enhancement Therapy (MET) is ideal for individuals who are not yet ready for making changes in their lives. It merges the strategic communication style of MI (intended to evoke clients’ own internal motivation for change) with psychological counseling (intended to support and provide new insight to apprehensive or defensive patients). In this way, MET ultimately evokes clients’ ambivalence about change, which can hopefully lead to serious contemplation and preparation for making changes in the future. Such treatments are common in sober living homes.
3. Prize-Based Contingency Management (CM) is a behavioral treatment which evolved from early research on reward and behavior. Treatment of substance use disorders always involves: (1) frequently monitoring of the clients’ behavior, and (2) reinforcing positive behavior using monetary or other tangible rewards. For example, while patients must provide drug-negative urine samples, they have the opportunity to win prizes ranging from $1 to $100 in value. In some formats, patients can escalate their chances to win prizes by sustaining their drug abstinence. Usually, CM treatments are in effect for 8-24 weeks, and CM is typically provided as an add on to other treatment, such as cognitive behavioral therapy or 12-step meetings. CM is especially encouraged for cocaine use disorder patients.
4. Seeking Safety is a popular group treatment used in the Veterans Affairs healthcare system. It is meant for dually-diagnosed individuals with a SUD and posttraumatic stress disorder (PTSD). PTSD involves exposure to a traumatic (life-threatening) event that results in lasting anxiety and avoidance of reminders of the event. Seeking safety acknowledges the close relationship between SUDs and PTSD, wherein patients can be motivated to use drugs as a coping strategy for managing their PTSD-related distress. Seeking safety, thus, targets both disorders with the rationale that for these patients to successfully stop their substance use patterns, they first need to learn new ways to “feel safe.” Along with the goal of providing support and empathy to patients with complicated pasts, Seeking safety teaches substance-alternative coping skills for tuning their anxiety levels down.
5. Friend Care is a post-care program that capitalizes on the beneficial impact of community support on substance use recovery. Patients meet for 6 months with facility staff as outpatients, where they receive counseling, information on community resources, and other as-needed services for optimizing their social, emotional, and occupational functioning in daily life.
6. Guided Self-Change (GSC) is an integrative treatment of substance use disorders, combining cognitive behavioral therapy (CBT) with motivational counseling. The motivational component is described above (see motivational interviewing). CBT involves patient “self-monitoring” or tracking their current substance use habits and “high-risk” circumstances for use. With this increased awareness, patients strategize in therapy ways they can alter certain thoughts and behaviors that lead to problematic patterns. The ultimate goal of GSC can vary from relapse prevention to harm reduction with controlled or reduced substance use. For this reason, it is ideal for mild or low-severity patients.
7. Research On Other Forms of Treatment of Substance Use Disorders, either for use as an alternative or adjunct to another evidence-based treatment, are underway by researchers. It is important to continue to investigate interventions for difficult-to-treat problems, such as drug addiction. In addition, there is a need to tailor treatments to meet the specific needs of patients. Some research suggests that best treatment may vary from one drug class to another. For example, to date, clinical trials have determined CBT with specific counseling around weight management (especially for smokers concerned about post-quit weight gain) as the most effective (nicotine) smoking cessation treatment. As another example, while CM can be generally applied to SUDs with positive effects, its effects appear especially large in cocaine use disorders.
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