Evidence-Based Reviews

Substance abuse: 12 principles to more effective outpatient treatment

Current Psychiatry. 2002 June;1(6):16-24

References

1. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. Treatment episode data set (TEDS): 1994-1999. National admissions to substance abuse treatment services. DASIS series: S-14. DHHS publication no. (SMA) 01-3550. Rockville, MD: Department of Health and Human Services, 2001.

2. Substance Abuse and Mental Health Services Administration, Office of Applied Studies. 1999 uniform facility data set. DASIS series: S-12. Rockville, MD: Department of Health and Human Services, 2001.

3. Festinger DS, Lamb RJ, Kirby KC, Marlowe DB. The accelerated intake: a method for increasing initial attendance to outpatient cocaine treatment. J Applied Behav Analysis 1996;29(3):387-9.

4. Dackis CA, Gold MS. Psychiatric hospitals for treatment of dual diagnosis. In: Lowinson JH, ed. Substance abuse: A comprehensive textbook. 2nd ed. Baltimore: Williams & Wilkins, 1992;467-85.

5. McLellan AT, Luborsky L, et al. An improved diagnostic instrument for substance abuse patients, The Addiction Severity Index. J Nervous Mental Dis 1980;168:26-33.

6. Marlowe DB, Kirby KC, et al. Assessment of coercive and noncoercive pressures to enter drug abuse treatment. Drug & Alcohol Dependence 1996;42(2):77-84.

7. Prochaska JO, DiClemente CC. The transtheoretical approach: crossing traditional boundaries of therapy. Homewood, IL: Dow Jones, Irwin, 1984.

8. Miller WR, Rollnick S. Motivational interviewing: Preparing people to change addictive behavior. New York: Guilford Press, 1991.

9. National Institute on Drug Abuse. Beyond the therapeutic alliance: keeping the drug-dependent individual in treatment. Research monograph 165, NTIS 97-181606, Rockville, MD: National Institutes of Health, 1997.

10. Connors GJ, DiClemente CC, Dermen KH, et al. Predicting the therapeutic alliance in alcoholism treatment. J Studies Alcohol 2000;61(1):139-49.

11. Barber JP, Luborsky L, Gallop R, et al. Therapeutic alliance as a predictor of outcome and retention in the National Institute on Drug Abuse Collaborative Cocaine Treatment Study. J Consult Clin Psychol 2001;69(1):119-24.

12. Mercer D, Woody G. Individual drug counseling. National Institute on Drug Abuse (NIDA) manual #3: Therapy manuals for drug addiction. (NIH pub. no. 99-4380). Bethesda, MD: National Institutes of Health, 1999.

13. McKay JR, Alterman AI, McLellan AT, Snider EC. Treatment goals, continuity of care, and outcome in a day hospital substance abuse rehabilitation program. Am J Psychiatry 1994;151(2):254-9.

14. Simpson DD, Brown BS. Treatment retention and follow-up outcomes in the Drug Abuse Treatment Outcome Study (DATOS). Psychol Addictive Behaviors 1998;11(4):294-307.

15. McLellan T, Kleber H, O’Brien C. Drug dependence, a chronic medical illness: implications for treatment, insurance and outcomes evaluation. JAMA 2000;284:1689-95.

16. National Institute on Drug Abuse. Principles of drug addiction treatment: a research-based guide (NIH publication no. 00-4180). Rockville, MD: National Institutes of Health, 1999.

17. McLellan AT, Hagan TA, Levine M, et al. Supplemental social services improve outcomes in public addiction treatment. Addiction 1998;93:1489-99.

18. Hughes JR. Treatment of smoking cessation in smokers with past alcohol/drug problems. J Substance Abuse Treatment 1993;10:181-7.

19. DuPont RL, Shiraki S. Recent research in twelve step programs. In: Miller NS, ed. Principles of Addiction Medicine Chevy Chase, MD: American Society of Addiction Medicine, 1994.

20. Crits-Christoph P, Siqueland L, Blaine J, et al. Psychosocial treatments for cocaine dependence: National Institute on Drug Abuse Collaborative Cocaine Treatment Study. Arch Gen Psychiatry 1999;57(6):493-502.

21. McCrady BS, Miller WR (eds) Research on Alcoholics Anonymous New Brunswick, NJ: Rutgers Center of Alcohol Studies, 1993.

22. Nowinski J, Baker S, Carroll KM. Twelve-Step facilitation therapy manual: A clinical research guide for therapists treating individuals with alcohol abuse and dependence. NIAAA Project MATCH Monograph Series, vol. 1. DHHS Pub. No. (ADM)92-1893. Rockville, MD: National Institute on Alcohol Abuse and Alcoholism, 1992.

23. Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse: results from the epidemiologic catchment area (ECA) study. JAMA 1990;264(19):2511-18.

24. Carroll KM. Integrating psychotherapy and pharmacotherapy in substance abuse treatment. In: Rotgers F, Keller DS, Morgenstern J, eds. Treating substance abuse: theory and technique. New York: Guilford Press, 1996.

25. Carroll KM, Nich C, Ball SA, et al. Treatment of cocaine and alcohol dependence with psychotherapy and disulfiram. Addiction (in press).

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28. McCrady BS, Noel NE, Abrams DB, et al. Comparative effectiveness of three types of spouse involvement in outpatient behavioral alcoholism treatment. J Studies Alcohol 1986;47:459-67.

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Principle 7: Match services with treatment needs

Outcomes improve when treatment services meet individual needs.¹⁷ Medical, psychiatric, psychosocial, legal, and housing problems can distract patients from the work of therapy. It is important to match each patient’s problems and needs with appropriate treatment settings, interventions, and services, according to the NIDA’s Principles of Drug Addiction Treatment.¹⁶ Creating flexible, responsive programs means more work for the treatment team, but it enhances the quality of care.

Treating concomitant psychiatric illness often requires innovations in outpatient treatment programs. For example, psychiatrists must avoid undermining treatment by inappropriately prescribing addictive agents such as benzodiazepines. At the same time, drug counselors may benefit from education about the potential benefits of medications in treating co-occuring disorders and craving. Coordinated delivery of psychiatric and rehabilitative treatment requires open communication in regularly scheduled multidisciplinary team meetings.

Principle 8: Monitor abstinence

Routine urine drug screens, Breathalyzer tests—administered at least weekly— and/or other laboratory tests to confirm self-reported abstinence can improve treatment outcomes. Regular drug and alcohol monitoring provides an objective indicator of progress, serves as a deterrent, and can help motivate the patient to withstand drug urges.

Individuals attempting abstinence from one substance have better outcomes if they abstain from all addictive substances¹⁸ (although tobacco use is controversial and requires further research). Even so, patients often continue to use addictive substances during treatment. Patients struggling with abstinence should not be discharged from treatment programs for manifesting the symptoms for which they are seeking treatment.

Substance-dependent individuals progress at different rates during treatment, and creative strategies to enhance motivation and retention can ultimately produce positive results. Outpatient clinics should consider different treatment tracks for patients at different stages of readiness for recovery.

Box 2

ADDICTION RESOURCES ON THE WEB

Substance Abuse and Mental Health Services Administration and Center for Substance Abuse Treatment www.health.org
National Institute on Drug Abuse www.nida.nih.gov
National Institute on Alcohol Abuse and Alcoholism www.niaaa.nih.gov
Center on Addiction and Substance Abuse www.casacolumbia.org
Join Together (an organization that advocates community-based efforts to reduce, prevent, and treat substance abuse) www.jointogether.org
12-step resources www.onlinerecovery.org and www.healingresource.org

Principle 9: Use 12-step and other community supports

Patients who participate in 12-step programs and treatments have better outcomes than those who do not.^19-21 Still, patients in early recovery may find it difficult to join community-based support groups, such as Alcoholics Anonymous (AA). Patients are often ambivalent about—or strongly opposed to—joining AA because of embarrassment, negative experiences, or inadequate preparation for joining a 12-step fellowship. Substance abusers who are ambivalent about recovery often dispute 12-step directives on total abstinence, sweeping lifestyle changes, and the need to “give up control” over treatment recommendations. Common issues in early recovery include:

how to select a 12-step home group and a sponsor;
how to overcome uneasiness associated with being in a 12-step group;
how to address any discomfort the patient may feel with the religious nature of 12-step meetings.²²

Patients’ resistance to 12-step treatment should be explored and addressed. Sometimes all they need is encouragement and help in finding a sponsor. Those with more difficult concerns may need a different approach. For example, social phobia is common in alcoholics and can be exacerbated by 12-step meetings; symptoms often respond to beta-adrenergic blockade. Patients with schizophrenia and those with paranoid features often do poorly in 12-step treatment if their paranoid symptoms cannot be successfully managed.

Principle 10: Manage medications

To avoid drug interactions, all prescribers involved with the patient’s care should coordinate their medication management efforts. Many substance abusers suffer from co-occurring psychiatric conditions²³ for which psychiatric medications are standard treatment.^24,25 In addition, medical detoxification is often necessary for heroin, alcohol, and sedative/hypnotic-dependent individuals. These treatments, which are beyond the scope of this article, are best integrated with drug rehabilitation.

Various medications for addiction have been reported to improve outcome:

Agonist treatment with methadone, a long-acting opioid, can reduce heroin use, crime, and the risk of illnesses such as AIDS and viral hepatitis that are associated with IV drug use.
Buprenorphine, a partial opioid receptor agonist with similar benefits, may soon be approved for the treatment of opiate dependence in outpatient settings.²⁶
Naltrexone, an opioid receptor antagonist, has long been proposed as a treatment for opiate dependence and has been shown to be effective in alcoholism.²⁷

No effective pharmacologic treatment is available for cocaine dependence, although this is the focus of extensive government-sponsored research.

Principle 11: Educate about addiction and recovery

A wealth of accurate, free information about addiction and recovery is available through Web sites (Box 2) and other sources.