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1. Goals of Treatment

A multimodal treatment approach is typically required, since individuals with substance use disorders are clinically and functionally heterogeneous. The primary aims of treatment include motivating the patient to change and helping the patient learn, practice, and internalize changes in attitudes and behavior conducive to relapse prevention. Additional goals of treatment include the following:

Help the patient reduce use of the substance or achieve complete abstinence.

  • Abstinence is associated with the best long-term outcomes.

  • Many patients are unable or unwilling to achieve abstinence and simply wish to reduce use to controlled levels.

  • Controlled use may decrease associated morbidity but is unrealistic for many patients and may dissuade them from working toward abstinence.

Help the patient reduce the frequency and severity of substance use episodes.

Improve psychological and social functioning.

  • Repair disrupted relationships and enhance familial and interpersonal relationships that will support an abstinent lifestyle.

  • Develop social and vocational skills.

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2. Assessment

Obtain information from the patient and, with the patient'€™s permission, from collateral sources (e.g., available family members, friends, current and past treaters, employers) as appropriate.

If necessary, depending on the clinical circumstances and patient motivation, conduct the assessment across multiple sessions.

Recognize that some groups of individuals may be at increased risk of having a substance use disorder (e.g., nicotine dependence in gay, lesbian, and bisexual individuals and in patients with schizophrenia) or may be more likely to have undetected or undertreated substance use disorders (e.g., elderly individuals).

Include in the assessment the items described in Table 1.

Consider using empirically validated screening tools for substance use disorders (e.g., CAGE [Have you ever felt the need to Cut down on drinking, been Annoyed by others'€™ criticism of your drinking, felt Guilty about drinking, needed an Eye-opener drink first thing in the morning?], Alcohol Use Disorders Identification Test, Drug Abuse Screening Test) to help identify unrecognized substance use disorders.

Consider using qualitative or quantitative screening of blood, breath, or urine to identify recent substance use.

Consider whether diagnostic tests are indicated to assess for the presence or absence of pregnancy (in women of childbearing age) or general medical conditions that are common among individuals with substance use disorders.

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Table Reference Number
Table 1. Items to Include in an Assessment
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3. Treatment Settings

Treat in the least restrictive setting that is likely to be safe and effective.

The particular substance used will determine the medical risks associated with substance use, intoxication, and withdrawal and influence the safety of specific treatment settings.

Choose a site of care based on the patient'€™s

  • ability to cooperate with and benefit from the treatment offered,

  • ability for self-care,

  • ability to refrain from illicit use of substances,

  • ability to avoid high-risk behaviors,

  • need for structure, support, and supervision,

  • social environment (which may be supportive or high risk),

  • history of response in particular settings,

  • need for particular treatments or treatment intensity that may be available only in certain settings,

  • need for specific treatments for co-occurring general medical or psychiatric conditions,

  • ability to access a particular treatment setting, and

  • preference for a particular treatment setting.

Move from one level of care to another on the basis of the factors above and an assessment of the patient'€™s ability to benefit from a different level of care.

Table 2 suggests appropriate treatment settings for different patient-related factors.

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Table Reference Number
Table 2. Treatment Settings
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4. Formulation and Implementation of a Treatment Plan

Develop and implement a strategy to achieve abstinence.

If abstinence is not the patient'€™s current goal, use motivational approaches to encourage abstinence in the future.

Use specific pharmacological and psychosocial treatments in the context of an organized treatment program that combines different treatment modalities.

Apply principles of psychiatric management to coordinate the use of multiple clinicians and modalities used in individual, group, family, and self-help settings.

Tailor the treatment plan to individual needs and preferences.

  • Consider patient preferences for specific treatment approaches.

  • Choose treatments that take into consideration the patient'€™s characteristics and clinical status.

  • Use the patient'€™s needs to adjust treatment duration, which may vary from a few months to many years.

Intensify monitoring for substance use and consider whether adjustments in the treatment plan are needed during periods of high risk of relapse.

High risk periods include

  • early stages of treatment,

  • times of transition to less intensive levels of care,

  • first year following cessation of active treatment, and

  • periods with increased social facilitation of substance use (e.g., holiday parties), significant symptoms of psychiatric or general medical conditions, intensified life stress, or lifestyle changes.

Consider including individuals in the patient'€™s family or support network as part of treatment planning.

  • Assist the patient in maintaining existing relationships or repairing troubled ones.

  • Reinforce education about the substance use disorder and its treatment.

  • Collaborate with the family and support network in monitoring the patient'€™s progress.

  • Incorporate family into the treatment of children and adolescents whenever possible.

Consider recommending participation in self-help groups.

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5. Pharmacological Treatments

For selected patients, medications may be used for the following purposes:

To treat intoxication states.

To decrease or eliminate withdrawal symptoms in an effort to reduce craving and risk of relapse.

  • Substitute an agonist for the particular class of substance being used (e.g., methadone or buprenorphine for opioids, nicotine replacement therapies for tobacco, benzodiazepines for alcohol).

  • Consider using other medications that may also decrease withdrawal symptoms (e.g., clonidine for opioid withdrawal).

To decrease the reinforcing effects of abused substances.

Consider using medications that block the subjective and physiological effects of subsequently administered drugs (e.g., the opioid antagonist naltrexone to block effects of opioids).

To promote abstinence and prevent relapse.

Consider use of medications such as

  • Disulfiram, which can discourage alcohol use by the patient'€™s knowledge of its unpleasant drug-drug interaction.

  • Naltrexone, which decreases alcohol craving presumably through the effects of opioid receptors in mediating the reinforcing effects of alcohol.

  • Acamprosate, which is presumed to promote abstinence from alcohol use by decreasing neuronal hyperexcitability.

  • Bupropion, which decreases nicotine craving and urges to smoke.

To treat co-occurring psychiatric conditions.

  • Address co-occurring psychiatric disorders to improve adherence and success with substance use disorder treatment.

  • See the section "Modify the plan of substance use disorder treatment to address other aspects of co-occurring psychiatric disorders" (below) for additional considerations in the treatment of substance use disorders in the presence of other co-occurring psychiatric disorders.

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6. Psychosocial Treatments

Psychosocial treatments are an essential component of a comprehensive treatment program. Integrating or blending psychosocial treatments can be helpful when patients have co-occurring substance use and other psychiatric disorders. Depending on the specific substance use disorder being treated (see sections C, D, E, F, and G), the availability of specific psychosocial treatments, and patient preference, choose among the following:

Cognitive behavioral therapies (CBTs)

Goals of CBTs

  • Alter dysfunctional cognitive processes that lead to maladaptive behaviors.

  • Intervene in the chain of events leading to substance use.

  • Help reduce acute or chronic craving.

  • Promote and reinforce the development of effective social skills and behaviors.

Types of CBTs

  • Standard cognitive therapy—modifies maladaptive thinking patterns to reduce negative feelings and behavior (e.g., substance use).

  • Social skills training—improves an individual'€™s capacity for effective and meaningful communication through listening to others, imagining others'€™ feelings and thoughts, monitoring and modifying one'€™s own nonverbal communications, adapting to circumstances to maintain relationships, and being assertive.

  • Relapse prevention—employs cognitive behavioral techniques to help patients develop self-control to avoid relapse.

Motivational enhancement therapy

Motivates the patient to change by empathically asking about the pros and cons of specific behaviors and exploring the patient'€™s goals and associated ambivalence.

Behavioral therapies

  • Contingency management rewards abstinence (e.g., with vouchers) or punishes drug-taking (e.g., by notification of courts, employers, or family members) as measured by random, supervised urine, saliva, or hair-follicle monitoring.

  • Community reinforcement provides patients with natural alternative reinforcers to abstinence through social community involvement (e.g., with family, peers).

  • Cue exposure and relaxation techniques expose a patient to cues that induce craving while preventing actual substance use in order to facilitate extinction of classically conditioned craving.

12-step facilitation

Promotes abstinence by utilizing a brief, structured, manual-driven professionally supervised format to enhance a patient'€™s motivation and facilitate participation in 12-step programs.

Psychodynamic and interpersonal therapies

May facilitate abstinence, especially when combined with other treatment modalities (e.g., pharmacotherapies and self-help groups).

Group therapy

  • Can be supportive, therapeutic, and educational.

  • Increases accountability by providing opportunities for the group to respond to early warning signs of relapse.

Family therapy

Dysfunctional families are associated with poor short- and long-term patient outcome. The goals of family therapy include the following:

  • Encourage family support for abstinence.

  • Obtain information about the patient's clinical status.

  • Maintain marital relationships.

  • Address interpersonal and family interactions that lead to conflict or that enable substance use behaviors.

  • Reinforce behaviors that help prevent relapse and enhance the prospects for recovery.

Self-help and 12-step-oriented programs

  • Alcoholics Anonymous (AA) and other 12-step-oriented programs provide tools to help participants maintain sobriety, including the 12 steps, group identification, mutual help and sharing of their experiences, strength, and hope with one another.

  • Encouraging participation in self-help groups can be an important adjunct to treatment for some but not all patients.

  • Refusal to participate is not synonymous with resistance to treatment in general.

  • Patients who require psychoactive medications (e.g., lithium, antidepressants) should be directed to groups that are supportive of such treatment.

  • Self-guided therapies monitoring alcohol or tobacco use may be helpful in primary care populations but tend to be less useful in patients presenting to specialized substance use disorder treatment programs.

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7. Clinical Features Influencing Treatment

Consider whether the plan of treatment needs to be modified on the basis of individual patient characteristics described in Table 3.

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Table Reference Number
Table 3. Individual Patient Characteristics That May Influence Treatment

Show sensitivity to cultural differences and incorporate cultural beliefs about healing and recovery to improve outcomes in ethnic minority groups.

Recognize that use of multiple substances is common and can complicate assessment and treatment.

  • Signs and symptoms of intoxication or withdrawal may be an amalgamation of effects from two or more substances.

  • The time courses of withdrawal syndromes resulting from two or more substances may overlap.

  • Detoxification from two or more substances may be needed simultaneously.

  • Pharmacological treatments for one substance use disorder may result in drug interactions with another substance of abuse.

  • Treatment plans should incorporate specific therapies to address each individual substance use disorder as well as consider whether integrative treatment approaches are indicated.

Consider whether the treatment plan requires modification on the basis of co-occurring general medical conditions.

  • Be alert for signs and symptoms of medical conditions that may be associated with specific substance use disorders (see Table 4).

  • Recognize that nicotine replacement therapies (NRTs) and bupropion appear to be safe and effective when used to treat nicotine dependence in patients with co-occurring general medical conditions.

  • Check for potential interactions between abused substances and prescribed medications to treat co-occurring conditions (e.g., effects of smoking on metabolism of drugs via cytochrome P450 1A2, metronidazole, and alcohol use).

  • Check for potential interactions between medications used to treat substance use disorders and those used to treat co-occurring conditions (e.g., naltrexone and opioid treatment of pain).

  • Recognize that pain from general medical conditions is often inadequately treated in individuals with substance use disorders.

  • Address issues such as lack of health care access and a chaotic lifestyle that may limit the capability of individuals with substance use disorders to receive appropriate treatment for co-occurring medical disorders.

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Table Reference Number
Table 4. Medical Disorders Associated With Specific Substances

Consider the benefits and risks for the individual patient when choosing medications to treat co-occurring disorders.

  • Consider the recommended treatment for the co-occurring disorder in the absence of a substance use disorder.

  • Consider the safety, tolerability, and abuse potential of each medication.

  • Determine whether modifications in medication or dose are needed because of potential drug-drug interactions.

  • Review additional considerations as described in Table 5.

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Table Reference Number
Table 5. Treatments for Other Co-occurring Psychiatric Disorders in Patients With Substance Use Disorders

Modify the plan of substance use disorder treatment to address other aspects of co-occurring psychiatric disorders.

  • Address the augmented risk for suicidal and aggressive behaviors during substance intoxication or withdrawal in individuals with other co-occurring psychiatric disorders.

  • Incorporate indicated psychosocial as well as pharmacological therapies to address each disorder.

  • Integrate psychosocial and pharmacological treatments of substance use disorders and co-occurring psychiatric disorders.

  • Consider whether early stages of treatment may need to be more intensive than when treating individuals with substance use disorders alone (e.g., earlier use of nicotine replacement, supplemental use of nicotine patch with other nicotine replacement therapies or group or individual behavioral therapy with smoking cessation).

  • Consider the potential effects of substance cessation on the symptoms of the co-occurring psychiatric disorder when timing treatment efforts.

  • Attend to insomnia, which is common and may predict relapse; although evidence is limited, CBT or sedating psychotropic medications (e.g., trazodone, gabapentin) may be considered.

  • Address factors that may be more likely to influence treatment adherence in individuals with co-occurring disorders (e.g., concern about medication interactions, cognitive impairment, limited motivation, lack of peer and social support).

  • Consider whether treatment could be enhanced through approaches such as assertive community treatment, stage-based motivational models, social skills or money management training, contingency techniques, and recovery-oriented perspectives.

  • Encourage attendance at 12-step groups that support appropriate use of psychotropic medications.

Consider the possibility of pregnancy in women of childbearing age as part of the treatment planning process.

  • Use a therapeutic approach that is supportive and maintains patient confidentiality.

  • To women who request it, provide education and counseling to help them make an informed decision about continuing or terminating a pregnancy.

Modify the treatment of pregnant women to optimize the well-being of the patient and the fetus.

  • Encourage abstinence from substance use.

  • Ensure adequacy of maternal nutrition.

  • Encourage participation in prenatal care.

  • Work with the patient'€™s obstetrician to reduce the risk of obstetrical complications (e.g., low birth weight with nicotine dependence; effects on fetal growth and later behavioral, cognitive, or academic deficits with marijuana dependence; fetal alcohol spectrum disorder with alcohol use disorders; placental blood flow abnormalities, neonatal abstinence syndrome, and premature labor and delivery with cocaine use disorders; miscarriage, preeclampsia, low birth weight, premature labor and delivery, stillbirth, and neonatal abstinence syndrome with opioid use disorders).

  • Motivate the patient to remain in treatment and use aggressive relapse prevention strategies after delivery to decrease relapse risk.

  • Counsel women who are likely to return to a substance-abusing milieu about long-term community treatment options and harm-reduction behaviors.

  • Arrange for appropriate postnatal care when necessary.

  • Consider referring the patient for education in parenting skills.

Choose treatments in pregnant women based on consideration of the risks and benefits of treatments for the fetus as well as the patient.

  • Psychosocial treatments are generally considered initially in treating pregnant women.

  • Agonist therapy (e.g., nicotine replacement therapy in smokers, methadone or buprenorphine in opioid-dependent women) is preferable and likely to be associated with fewer risks to the fetus than continued substance use.

  • Compared with continued heroin use, methadone maintenance is still considered the treatment of choice for women who are unable to remain substance-free, because it has a long history of use and improves infant outcomes. Buprenorphine may also be useful in treating pregnant women with opioid dependence and may be less likely to cause neonatal abstinence syndrome.

  • Narcotic antagonist therapy (e.g., naloxone, naltrexone) is not recommended, because it can contribute to spontaneous abortion, premature labor, and stillbirth.

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8. Confidentiality

Provide treatment in a context that respects patients'€™ privacy and confidentiality.

  • Restrict disclosures of information from treatment records to circumstances in which there is

    • written patient consent,

    • information needed relating to a medical emergency,

    • court authorization,

    • a need to protect or warn third parties of potential harm by the patient,

    • disclosure in response to a crime committed at the treatment program or against program staff, or

    • reporting of suspected child abuse or neglect or, in some jurisdictions, suspected abuse of elderly individuals.

  • Be aware of federal law and regulations that mandate strict confidentiality for information about patients being treated for substance use disorders (i.e., 42 U.S.C. Sections 290 dd-3 and ee-3; 42 C.F.R. Part 2) and those that address privacy in individuals with co-occurring psychiatric disorders (i.e., HIPAA [Health Insurance Portability and Accountability Act of 1996]).

  • Be familiar with local and state reporting laws concerning the HIV/AIDS status of a patient in substance abuse treatment and the reporting of possible abuse and neglect of children, other dependents, or elderly individuals who may be at risk in the families of substance users.

Table Reference Number
Table 1. Items to Include in an Assessment
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Table 2. Treatment Settings
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Table 3. Individual Patient Characteristics That May Influence Treatment
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Table 4. Medical Disorders Associated With Specific Substances
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Table 5. Treatments for Other Co-occurring Psychiatric Disorders in Patients With Substance Use Disorders

References

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