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Although many of the principles presented in this section apply to all substances reviewed in this guideline (i.e., nicotine, alcohol, marijuana, cocaine, and opioids), not all principles are applicable to the treatment of every substance use disorder. This is particularly true for nicotine dependence treatment, as nicotine dependence rarely causes the behavioral or social harm seen with other substance dependencies.

Individuals with substance use disorders are heterogeneous with regard to a number of clinically important features:

  • The number and type of substances used

  • The individual's genetic vulnerability for developing a substance use disorder(s)

  • The severity of the disorder, the rapidity with which it develops, and the degree of associated functional impairment(s)

  • The individual's awareness of the substance use disorder as a problem

  • The individual's readiness for change and motivation to enter into treatment for the purpose of change

  • The associated general medical and psychiatric conditions (either co-occurring or induced by substance use)

  • The individual's strengths (protective and resiliency factors) and vulnerabilities

  • The social, environmental, and cultural context in which the individual lives and will be treated

It is clinically helpful when assessing patients to use a spectrum that includes use, misuse, abuse, and dependence. The latter two terms represent formal diagnostic categories. Use of a substance may or may not be clinically significant. If use of a substance is thought to be potentially clinically significant but does not meet diagnostic criteria for abuse or dependence, it may be characterized as "misuse," although this is not a formal diagnostic category. Even when functional impairment is absent or limited, substance misuse can be an early indicator of an individual's vulnerability to developing a chronic substance use disorder. Brief early interventions can effectively reduce this progression (1–3), although follow-up reinforcement appears necessary for sustained utility. Most individuals presenting or referred for treatment of a substance use disorder, however, have been unable to stop using substances on their own. They often exhibit functional impairments across many categories (e.g., health, social and family, occupational, financial, legal) and have a history of chronic or relapsing episodes of problematic substance use. This practice guideline refers primarily to the care of such individuals.

As with treatment models for chronic diseases, treatment for individuals with substance use disorders occurs in temporal phases that include initial assessment, acute intervention, and long-term intervention and/or maintenance, with frequent reassessment during episodic flares in substance use (4). During the assessment phase, the specific variables associated with an individual's substance use are evaluated (e.g., genetic vulnerability, environmental influences, behavioral patterns of use, positive and negative consequences of use, associated conditions that trigger or otherwise interact with use, risk of withdrawal). In addition, the level of risk for morbidity or mortality associated with substance use is determined. Immediate intervention to provide safety to the patient in a medically monitored environment is recommended for individuals who present with high-risk intoxication or withdrawal states or altered mental states (e.g., psychosis, suicidality, agitation) that are associated with a risk of danger to self or others. After the patient is stabilized, the patient's immediate needs regarding safety and stability should be addressed to prepare the patient to enter into comprehensive, long-term treatment of the substance use disorder and its associated conditions. Such acute interventions may be focused on goals such as preserving health, achieving financial security, and finding stable housing. It is recommended that individuals in the patient's family or social network be included in the treatment process so they may learn about the disorder, help monitor the patient's progress, and assist in the patient's maintaining existing relationships or repairing troubled ones (5).

Depending on the clinical circumstances and an individual's readiness for change (6), treatment strategies may emphasize providing motivational enhancement, teaching risk-reduction behaviors and skills, helping the patient achieve abstinence and learn relapse prevention skills, or combining substitution agonist therapies (e.g., methadone or buprenorphine for opioid-dependent individuals, NRTs for tobacco-dependent individuals) with therapy to help the patient acquire relapse prevention skills. In addition, individuals with substance use disorders often require multimodal treatment to address associated conditions that have contributed to or resulted from the substance use disorder. Specific pharmacological and psychosocial treatments for patients with a substance use disorder are reviewed separately in this guideline; however, in practice they are often implemented together, as combined treatments lead to better treatment retention and outcomes (7).

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A. Goals of Treatment

The evidence to date suggests that substance-dependent individuals who achieve sustained abstinence from the abused substance have the best long-term outcomes (8, 9). Psychiatrists will, however, frequently encounter individuals who wish to reduce their substance use to a "controlled" level (i.e., use without apparent functional consequences). Although some of these individuals, particularly those with less severe problems, may be helped to reach a stable level of use (e.g., "controlled" drinking) that does not cause morbidity (10), a goal of "controlled" substance use is unrealistic for most individuals presenting with a substance use disorder. Furthermore, setting "controlled" use as a primary goal of treatment may initially dissuade individuals from working toward abstinence. However, treatment may be initially facilitated by the clinician's accepting the patient's goal for moderation while sharing with the patient any reservations the clinician may have about the likelihood of success. If the clinician believes that any level of substance use for the individual carries a risk of acute or chronic negative consequences, he or she should share with the patient this concern and the belief that long-term abstinence would be the best course of action. In certain circumstances it may be reasonable, however, for an individual to begin treatment by setting a short-term goal of reducing or containing dangerous substance use as a first step toward achieving the longer-term goal of sustained abstinence (11).

The goals for treating a substance use disorder begin with engaging the patient in treatment and may ultimately progress to the patient's achieving and maintaining complete abstinence from all problematic substances. Along this treatment spectrum or timeline, an individual and his or her physician may develop immediate goals involving risk reduction, such as reducing the frequency and quantity of substances taken, abstaining from some (but not all) substances according to assessment of risk (e.g., abstaining from injected heroin without abstaining from cannabis use), or limiting substance use to lower-risk situations (e.g., continuing to drink at home but avoiding drinking in other environments or driving while drinking). The guiding elements of treatment planning consist of ongoing efforts to reduce the patient's substance use and prevent a return to previously dangerous patterns of use. It is essential to complement this approach with parallel setting of goals to repair an individual's functional decline and develop new pathways for safe, sober pleasures. These issues are outlined below.

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1. Treatment retention and substance use reduction or abstinence as initial goals of treatment

The ideal outcome for most individuals with substance use disorders is total cessation of substance use. Nonetheless, many individuals are either unable or unmotivated to reach this goal, particularly in the early phases of treatment and/or after a relapse to substance use. Such individuals can still be helped to minimize the direct and indirect negative effects of ongoing substance use. The interventions discussed in this practice guideline may result in substantial reductions in the general medical, psychiatric, interpersonal, familial/parental, occupational, or other difficulties commonly associated with substance abuse or dependence. For example, reductions in the amount or frequency of substance use, substitution of a less risky substance, and reduction of high-risk behaviors associated with substance use may be achievable goals when abstinence is initially unobtainable (12, 13). Engaging an individual to participate and remain in treatment that may eventually lead to further reductions in substance use and its associated morbidity is a critical early goal of treatment planning and is often enhanced by motivational interviewing techniques (14).

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2. Reduction in the frequency and severity of substance use episodes

Reduction in the frequency and severity of substance use episodes is a primary goal of long-term treatment (15). The individual is educated about common types of substance use triggers, such as environmental cues, stress, and exposure to a priming substance (16, 17). The individual is then helped to develop skills to prevent substance use; these skills include identifying and avoiding high-risk situations as well as developing alternative responses to situations in which substance use may occur. Individuals are at a greater risk of using substances when any of the following are present: 1) craving or urges to use a substance due to acute or protracted withdrawal states and/or classically conditioned responses to cues associated with substance use (18–20); 2) easy access to substances; 3) social facilitation of substance use (e.g., holiday parties, association with other substance users); 4) negative affective states; 5) negative life events, or any significant, even positively viewed, life event if the event carries with it a significant increase in responsibility (e.g., marriage, the birth of a child, beginning school or a new job, work promotion); 6) physical discomfort; 7) unstructured time or boredom; or 8) nonadherence to prescribed treatment. Many clinicians do not recognize that individuals with substance use disorders have a chronic condition and may have future episodes of substance use. Therefore, the clinician may become discouraged when an individual doing well in treatment over an extended period of time resumes substance use. A useful clinical strategy is to explicitly anticipate the reality of future substance use and plan a strategy for recovery in the event of substance use relapse; such a strategy helps both the patient and the clinician optimally manage and contain the negative consequences resulting from a return to substance use.

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3. Improvement in psychological, social, and adaptive functioning

Substance use disorders are associated with impairments in psychological development and social adjustment, family and social relations, school and work performance, financial status, health, and personal independence (e.g., as a result of legal charges associated with substance use, suspension of the individual's driver's license after being convicted of driving under the influence of an intoxicating substance) (21). For optimal outcome, the treatment of a substance use disorder may also include strategies that target repair of damages or losses that resulted from the individual's substance use; aid in developing effective interpersonal, vocational, and proactive coping skills; and enhance familial and interpersonal relations that will support an abstinent lifestyle. It is particularly important to provide comprehensive treatments when individuals have co-occurring psychiatric or general medical conditions that significantly influence relapse risk (e.g., chronic pain, depression, anxiety, impaired cognition, and impulse control disorders) (22–24).

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B. Assessment

The term "substance use disorder" encompasses a number of different substances and disorders (i.e., abuse, dependence, intoxication, withdrawal, and psychiatric syndromes and disorders that result from substance use). Substance abuse and substance dependence are two disorders that are frequently encountered, and their criteria are applicable across substances. The criteria for these disorders are presented in Tables 1 and 2. However, it is beyond the scope of this practice guideline to describe all the substance use disorders, and the reader is referred to DSM-IV-TR for a full description.

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Table Reference Number
Table 1. DSM-IV-TR Criteria for Substance Abuse
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Table Reference Number
Table 2. DSM-IV-TR Criteria for Substance Dependence

A clinician's approach to assessing a substance use disorder will differ depending on the context in which an individual presents for treatment. An individual who recognizes the presence of a substance use disorder may present willingly for treatment and be amenable to a thorough assessment (as outlined below). However, many individuals will not be similarly motivated, and retaining them in treatment may require adapting the assessment process to their level of insight and motivational state. For example, individuals with benzodiazepine dependence will often present for treatment of an anxiety disorder but have no motivation to reduce their benzodiazepine use. Likewise, individuals with bipolar disorder will often present with a co-occurring substance use disorder but may not identify or recognize substance use as problematic (e.g., the use of alcohol at night to facilitate sleep onset). In such cases, educational efforts to help the individual recognize the substance use disorder as a problem may be helpful. This may involve extending the assessment phase over time rather than attempting to acquire all the patient's information at once so that the clinician can tailor the intervention to the patient's particular stage of change (25).

In an alternative scenario, an individual may be coerced into an assessment by frustrated family members or drug treatment diversion programs within the justice system. Such individuals may be resentful of the assessment process and have no motivation for changing their behavior other than the stipulations of family or the court system. Under these conditions, the clinician must attempt to establish an alliance with the individual in order to be viewed as a valuable source of information and aid rather than as a punitive extension of the referring sources. Retaining the individual in treatment will also take precedence over treating the disorder but may not always be possible. A full assessment of the individual's substance use disorder(s) may need to be gathered in pieces over time, with details being added to the initial picture when the individual is more comfortable sharing information pertinent to the pattern of his or her substance use and more motivated to contemplate change.

All individuals undergoing a psychiatric evaluation should be screened for a substance use disorder, regardless of their age, presentation, or referral source. Several empirically validated screening tools are available that do not require extensive training or time to use during an initial assessment. Commonly used screens include the four-item CAGE screen for alcohol abuse (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?) (26), the 10-item Alcohol Use Disorders Identification Test (27), and the Drug Abuse Screening Test, a 20-item self-report assessment that screens for commonly abused substances other than alcohol (28). If screening instruments or other assessment questions reveal that an individual has ever used substances, it is important to obtain a history of current and past substance use, including the frequency of substance use and the quantity of the substance used per using episode. The clinician should also inquire about the individual's current caffeine and nicotine use, past cigarette use in pack-years (defined as the number of packs per day multiplied by the number of years of smoking), and, for current smokers, the time from waking in the morning to their first cigarette.

It is also important for the assessing clinician to inquire about specific substance misuse if an individual's work is associated with increased risk because of occupational demands, privileged access to controlled substances, or a desire to enhance performance. For example, firefighters, police, and emergency personnel have a high prevalence of alcohol dependence related to job stress (29). Misuse of prescription substances or anesthetics is common among health care or veterinary medicine personnel; when compared with other physicians who misuse substances, anesthesiologists have been shown to be more likely to misuse opioids (30). Synthesis and misuse of controlled substances have also been observed in medicinal chemists. Anabolic steroid hormone precursors may be misused by athletes, and stimulant drugs may be misused by commercial truck drivers attempting to stay awake longer or by models and actors wanting to lose weight. Cocaine use appears to be a hazard among staff in restaurants and the entertainment industry. The clinician will also want to ask about other situations in an individual's history that may put him or her at higher risk for substance misuse, such as a history of trauma, psychiatric disorders, or chronic medical conditions.

In evaluating an individual with a suspected or confirmed substance use disorder, a comprehensive psychiatric evaluation is essential. Information should be sought from the individual and, with the individual's consent, available family members and peers, current and past health professionals, employers, and others as appropriate. The goals of the assessment are to establish a multiaxial DSM-IV-TR diagnosis, including identification of current and past substance use disorders as well as other comorbid psychiatric and physical disorders, and to identify other factors that are important to developing a treatment plan. Specific elements of the assessment may include the following:

  1. A systematic inquiry into the mode of onset, quantity, frequency, and duration of substance use; the escalation of use over time; the motivation for use; the specific circumstances of the individual's substance use (e.g., where, with whom, how much, by what route of administration); the desired effect of the substance used; the most recent dose of each substance used; the time elapsed since the most recent use; the degree of associated intoxication; the severity of associated withdrawal syndromes; and the subjective effects of all substances used, including substances other than the individual's "drug of choice." As the psychiatrist elicits the individual's substance use history, he or she should also determine if the individual meets DSM-IV-TR criteria for abuse or dependence (see Tables 1 and 2) for each substance used. Because many patients entering treatment for a specific substance use disorder are using more than one substance, assessment should routinely include questions about the use of multiple substances, including which substances are used in combination, in what order, and for what effect. Use of over-the-counter and prescription medications should also be ascertained. If prescription medications are being used, it is important to learn if the medication has been prescribed for the individual or for someone else.

  2. A history of any prior treatment for a substance use disorder, including the characteristics of the treatment such as setting; context (e.g., voluntary or involuntary); modalities used; duration and, if applicable, dose of treatment; adherence to treatment; and short-term (3-month), intermediate (1-year), and longer-term outcomes as measured by subsequent substance use, level of social and occupational functioning achieved, and other outcome variables. Previous efforts to control or stop substance use outside of a formal treatment setting should also be discussed. For individuals who had previous treatment or periods of abstinence, additional history may include the duration of abstinence, the factors that promoted or helped sustain abstinence, the impact of abstinence on psychiatric functioning, the circumstances surrounding relapse (e.g., whether the relapse was related to withdrawal symptoms, exacerbation of a psychiatric disorder, or psychosocial stressors), the individual's attitude toward prior treatment, nontreatment experiences, and expectations about future treatments.

  3. A comprehensive general medical and psychiatric history, including mental status and physical examination, to ascertain the presence or absence of co-occurring psychiatric or general medical disorders as well as signs and symptoms of intoxication or withdrawal. Psychological or neuropsychological testing may also be indicated for some individuals (e.g., to assess an individual's level of cognitive impairment). When a clinician is attempting to ascertain an individual's current medication use, he or she should specifically ask about prescribed and nonprescribed medications, including vitamins and herbal products.

  4. Qualitative and quantitative blood and urine screening for substances of abuse and laboratory tests for abnormalities that may accompany acute or chronic substance use. These tests may also be used during treatment to monitor for potential relapse. For some substances, such as alcohol and nicotine, breath tests may also be useful.

  5. Screening for infectious and other diseases often found in substance-dependent individuals (e.g., human immunodeficiency virus [HIV], tuberculosis, hepatitis). Such individuals, particularly those with evidence of compromised immune function, are at high risk for these diseases.

  6. A complete family and social history, including information on familial substance use or other psychiatric disorders; social factors contributing to the development or perpetuation of the substance use disorder (e.g., social facilitation of substance use); financial or legal problems; social supports, including peer relationships; school or vocational adjustment; and other functional impairments. When obtaining the family and social history, the psychiatrist may also wish to ask for permission to speak to family members, friends, or other significant people in the individual's life who may be able to provide important information regarding the individual's substance use disorder. In evaluating the impact of the individual's current living environment on his or her ability to adhere to treatment and refrain from substance use, it is important to determine whether and how household members and friends have supported or interfered with prior attempts at abstinence. The substance use status of others in the household and close friends (e.g., never used substances, former substance user, current substance user) should also be considered. If others in the household are currently using substances, their willingness to quit at the same time as the individual or to refrain from substance use in the presence of the individual should be assessed.

  7. Individual preferences, motivations, and barriers for treatment. Individuals vary in their treatment preferences regarding pharmacotherapy, group therapy, individual therapy, and self-help treatments. Working with the individual's preferences is likely to lead to better treatment adherence and outcomes (31). For individuals who have a co-occurring psychiatric disorder, exacerbation of psychiatric symptoms can be an additional barrier (31, 32).

When a clinician is assessing a new patient and establishing a diagnosis, it is often difficult to distinguish between psychiatric symptoms resulting from substance use and those from a co-occurring psychiatric disorder. Anxiety, depression, mania, and psychosis are all commonly induced by various substances and can be observed with chronic use as well as during specific substance-induced states, including intoxication and withdrawal. Evaluation of psychiatric symptoms in substance-using individuals can be enhanced with repeated, longitudinal psychiatric assessments. As part of the initial assessment, it may also be useful to draw a timeline of all substances used and all psychiatric symptoms and/or disorders and to include in this timeline all prior treatments. This timeline approach can help determine the chronology of symptom development (i.e., whether the signs and symptoms predate or follow the onset of repetitive substance use), the presence or absence of symptoms during extended substance-free periods (e.g., 3 months or more), and the impact of each disorder on the presentation, clinical course, and outcome of the other(s).

The probability that an individual with a substance use disorder has a co-occurring psychiatric disorder and not a substance-induced psychiatric disorder is increased if at least one first-degree relative has a documented history of a similar disorder, the individual's symptoms are not typically observed in conjunction with the use of a particular substance, there is a clear history that psychiatric symptoms preceded the onset of the substance use disorder, or the symptoms were evident during extended substance-free periods. Such a distinction is relevant when a clinician must decide whether to treat the psychiatric symptoms with medications and determine how long to maintain a medication once it is started. For example, individuals with certain substance-induced psychotic symptoms, such as paranoia resulting from the use of stimulants or phencyclidine (PCP), may benefit from the short-term use of an antipsychotic medication. Conversely, symptoms of depression and anxiety coexisting with a substance use disorder may initially be addressed in psychosocial treatment but may require medication management if they do not improve over time.

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C. Treatment Settings

Individuals with substance use disorders may receive care in a variety of settings. Treatment settings vary according to the availability of resources (e.g., the presence or absence of medical monitoring, the specialization of services and therapy provided, the availability of psychiatric consultation), the freedom allowed the individual (e.g., locked versus open unit), the intensity of treatment duration/participation, and the milieu philosophy driving the primary interventions (e.g., medical model, educational, 12-step, peer support, faith based). Because treatment best occurs in a system that encourages cessation of all harmful substance use (33), consideration should be given to making treatment sites smoke free (33, 34). Although most studies indicate that smoking cessation does not increase alcohol relapse and may aid recovery in substance-dependent patients (35–37), one study found that smoking cessation worsened drinking outcomes in a group of alcohol-dependent patients (38).

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1. Factors affecting choice of treatment setting

Individuals should be treated in the least restrictive setting that is likely to prove safe and effective. Decisions regarding the site of care should be based on the individual's 1) capacity and willingness to cooperate with treatment; 2) ability for self-care; 3) social environment (which may be supportive or high risk); 4) need for structure, support, and supervision to remain safe and abstinent; 5) need for specific treatments for co-occurring general medical or psychiatric conditions; 6) need for particular treatments or an intensity of treatment that may be available only in certain settings; and 7) preference for a particular treatment setting. In addition, the choice of setting should be guided by the particular substance(s) used, the medical risks associated with use of the substance(s), the accessibility of appropriate levels of care, and the stated goals of the individual's treatment plan (as described in Sections III through VII and as determined by the individual's clinical status).

Patients should be moved from one level of care to another on the basis of these factors; the decision to move to a less intensive level of care should consider these factors plus the clinician's assessment of a patient's readiness and ability to benefit from the less restrictive setting. To appropriately match patients and treatment settings, many clinicians, health insurers, hospitals, and treatment agencies use the American Society of Addiction Medicine (ASAM) patient placement criteria (39). These criteria provide an algorithm for placement that represents expert consensus and that is updated as additional evidence becomes available on treatment outcomes and levels of care.

Studies comparing the short-term, intermediate, and long-term benefits of treatment in various settings (i.e., inpatient, residential, partial hospitalization, outpatient) have a variety of methodological problems, including heterogeneity of individual populations, high dropout rates, lack of controlled trials, inappropriate comparison of outcomes after time-limited treatment interventions, and reliance on individual self-reports uncorroborated by data from collateral sources (40). Stated treatment goals, program features, and outcome measures vary across studies (41). A common finding among different treatments available for substance use disorders is that retention in treatment improves outcomes (42–45).

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2. Commonly available treatment settings and services

Settings and services used in the treatment of substance use disorders may be considered as points along a continuum of care from most to least intensive. The specific factors leading to the choice of a particular setting for an individual patient are described below. The choice of a treatment setting may also be influenced by availability, given that communities differ in the variety of treatment services they offer and certain specialized treatment settings (e.g., dual-diagnosis partial hospitalization care) may not be widely available. For individuals with primary nicotine dependence or marijuana use disorders, treatment occurs in outpatient settings; information presented about other treatment settings may not be applicable to these populations.

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a) Hospitals

The range of services available in hospital-based programs typically includes emergency detoxification and stabilization during withdrawal; assessment and treatment of general medical and psychiatric conditions; group, individual, and family therapies; psychoeducation; motivational counseling; and social service facilitation of follow-up care in available community services (46, 47). Psychiatric hospitals may offer dual-diagnosis inpatient units that specialize in the stabilization of co-occurring psychiatric and substance use disorders. For patients admitted to hospital-level care for other reasons (general medical or psychiatric), smoking cessation programs may also be available.

Hospital-based treatment settings may be secure (i.e., locked) or may permit individuals and visitors to come and go in a monitored but generally less restrictive fashion. Secure hospital settings should be considered for individuals with co-occurring psychiatric conditions whose clinical state would ordinarily require such a unit (e.g., actively suicidal individuals). Individuals with poor impulse control and judgment who in the presence of an "open door" are likely to leave the program or obtain or receive drugs on the unit are also candidates for a secure unit. In some states, individuals can reside on a secure unit in "conditional voluntary" status, which requires written notice and a time delay (e.g., 3 days) before the patient's request for discharge is approved or another disposition (e.g., commitment) is implemented. Such restrictions can provide a useful period of delay in which poorly motivated individuals can reconsider their wish to leave a program prematurely.

The available data do not support the notion that hospitalization per se has specific benefits over other treatment settings beyond the ability to address treatment objectives that require a medically monitored environment (48, 49). There is consensus (e.g., ASAM patient placement criteria) that individuals in one or more of the following categories may require hospital-level care:

  1. Individuals with drug overdoses who cannot be safely treated in an outpatient or emergency department setting (e.g., individuals with severe respiratory depression, individuals in a coma)

  2. Individuals in withdrawal who are at risk for a severe or complicated withdrawal syndrome (e.g., individuals dependent on multiple substances, individuals with a history of delirium tremens) or cannot receive the necessary medical assessment, monitoring, and treatment in a less intensive setting

  3. Individuals with acute or chronic general medical conditions that make detoxification in a residential or ambulatory setting unsafe (e.g., individuals with severe cardiac disease)

  4. Individuals with a documented history of not engaging in or benefiting from treatment in a less intensive setting (e.g., residential, outpatient)

  5. Individuals with marked psychiatric comorbidity who are an acute danger to themselves or others (e.g., individuals who have depression with suicidal thoughts, acute psychosis)

  6. Individuals manifesting substance use or other behaviors who are an acute danger to themselves or others

  7. Individuals who have not responded to less intensive treatment efforts and whose substance use disorder(s) poses an ongoing threat to their physical and mental health

In general, the duration of hospital-based treatment should be dictated by the individual's current need to receive treatment in a restrictive setting and his or her capacity to access, safely participate in, and benefit from treatment in a less restrictive setting.

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b) Partial hospitalization programs and intensive outpatient programs

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 (39) 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 (50). 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 (51, 52). One study (53) 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 (54).

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c) Residential treatment

Residential treatment is indicated primarily for individuals who do not meet clinical criteria for hospitalization but whose lives and social interactions have come to focus exclusively on substance use and who currently lack sufficient motivation and/or substance-free social supports to remain abstinent in an ambulatory setting. For these individuals, residential facilities provide a safe and substance-free environment in which residents learn individual and group living skills for preventing relapse. As in the case of hospital-based programs, residential treatment programs frequently provide psychosocial, occupational, and family assessment; psychoeducation; an introduction to self-help groups; and referral for social or vocational rehabilitative services where necessary (55). Many residential programs provide their own individual, group, and vocational counseling programs but rely on affiliated partial hospitalization or outpatient programs to supply the psychosocial and psychopharmacological treatment components of their programs. Residential treatment settings should have access to general medical and psychiatric care that is required to meet individual needs.

The duration of residential treatment should be dictated by the length of time necessary for the patient to meet specific criteria that would predict his or her successful transition to a less structured, less restrictive treatment setting (e.g., outpatient care). These criteria may include a demonstrated motivation to continue in outpatient treatment, the ability to remain abstinent even in situations where substances are potentially available, the availability of a living situation and associated support system conducive to remaining substance free (e.g., family, substance-free peers), sufficient stabilization of any co-occurring general medical or psychiatric disorder so that the patient is considered suitable for outpatient aftercare, and the availability of adequate follow-up care.

In some areas, particularly urban centers, residential treatment programs specifically designed for adolescents, pregnant or postpartum women, or women with young children are available (56, 57).

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d) Therapeutic communities

Individuals with opioid, cocaine, or multiple substance use disorders may benefit from referral to a long-term residential therapeutic community. These programs are generally reserved for individuals with a low likelihood of benefiting from outpatient treatment, such as individuals who have a history of multiple treatment failures or whose profound impairment in social relational skills or ability to attain and sustain employment impede adherence to outpatient treatment (58). Rather than viewing substance abuse as an illness (as defined by the disease concept), therapeutic community theory views it as a deviant behavior; that is, it is seen as a symptom of pathological development in personality structure, social relating, and educational and economic skills (reviewed by De Leon in reference 59). The therapeutic community milieu provides individual, social, and vocational rehabilitation through the community method of social learning. It is a highly structured, substance-free community setting in which the primary interventions are behavioral modeling, supportive peer confrontation, contingency management, community recreation, and work therapy designed to facilitate adherence to social norms and substance-free lifestyles (44).

Therapeutic communities are characteristically organized along strict hierarchies, with newcomers being assigned to the most menial social status and work tasks. Residents achieve higher status and take on increasing responsibility as they demonstrate that they can remain substance free and conform to community rules. Supportive confrontation, individually and in groups, is a primary intervention used to break through denial about the role of substance use in one's life, identify maladaptive behaviors and coping styles that lead to interpersonal conflict and vocational failure, suggest alternative ways of handling disturbing affects, and encourage the development of attitudes and beliefs that are incompatible with continued substance use.

Data regarding the effectiveness of traditional long-term (2-year commitment) therapeutic communities are limited by the fact that only 15%–25% of individuals admitted voluntarily complete a program, with maximum attrition occurring in the first 3 months (60, 61). Retention rates differ with program sites (62), and retention lengths predict outcomes on abstinence and lack of criminal recidivism indexes, with 2-year postcompletion success rates at 90% for graduates, 50% for dropouts completing >1 year, and 25% for dropouts completing <1 year (44, 63).

Cost-containment concerns and increasing knowledge of dual-diagnosis needs have led to modifications of the traditional therapeutic community model. Shorter-term programs (e.g., 3–12 months) and nonresidential programs are offered for those with fewer social and vocational impairments. The expanded availability of social services has allowed improved treatment of special populations (e.g., dual-diagnosis, HIV-positive, single-parent, adolescent) in the therapeutic community setting, and some methadone maintenance programs are provided in this setting.

Potential voluntary applicants to a residential therapeutic community setting should have some understanding of the severity of their substance use disorder and a readiness to change their lifestyle; they should also have a willingness to conform to the structure of the therapeutic community and to temporarily sever ties with family and friends while they assimilate into the community environment. An individual's violation of community rules or shirking of work responsibilities is disclosed to all community members and may be grounds for discharge.

Therapeutic community settings have provided some of the better studied and more successful programs for treating incarcerated substance abusers (64). This has influenced the development of standardized staff training curricula (65).

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e) Community residential facilities

Community residential facilities are commonly known as "halfway houses" or "sober houses," with the former typically offering more structure and supervision. They provide an outpatient substance-free housing environment as a transitional setting for individuals in recovery who are not yet able to manage independent housing without a significant risk for relapse. Some studies have shown that for patients with multiple service needs (e.g., vocational, housing, transportation), the provision of stable housing in the form of long-term community residential facilities leads to significantly improved substance use outcomes (66–68). This benefit has been demonstrated for adult substance users of both sexes. Community residential facilities show more variability in substance use outcomes for youth and adolescents (69); this may be related to inadequate matching of services to individual needs.

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f) Aftercare

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 (see Section II.F). 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. (4), 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.

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g) Outpatient settings

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 (70–74). In addition to medication therapies (see Section II.E), 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 (see Section II.F).

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 (42, 43, 45). Clinicians should also encourage and attempt to integrate into treatment a patient's participation in self-help programs where appropriate (see Section II.F.9) (75).

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h) 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 (76). Case management initially provides psychoeducation 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 (77, 78). Nevertheless, studies show that case management interventions are effective for individuals with an alcohol use disorder (79) or co-occurring psychiatric and substance use disorders (80) and for adolescents with substance use disorders (81).

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i) Legally mandated 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 (82). 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 (83).

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 (84). The most studied effective treatment programs for incarcerated individuals are therapeutic communities (see Section II.C.2.d) (64).

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j) 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 (85). EAPs are cost-effective in the short term (86, 87), but posttreatment follow-up rates are poor (88).

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D. Psychiatric Management

Successful treatment of substance use disorders may involve the use of multiple specific treatments, the choice of which may vary for any one individual over time, and may involve clinicians from a variety of backgrounds. Psychiatric management entails the ongoing process of choosing from among various treatments, monitoring patients' clinical status, and coordinating different treatment components. The frequency, intensity, and focus of psychiatric management must be tailored to meet each patient's needs, and the type of management is likely to vary over time, depending on the patient's clinical status.

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1. Motivating change

In recent years, there has been a great deal of research and clinical emphasis on the clinician's role in motivating patients with substance use disorders to change their behaviors. Motivational interviewing techniques (49) were developed specifically for the treatment of patients with a substance use disorder. These involve the use of an empathic, nonjudgmental, and supportive approach to examining the patient's ambivalence about changing addictive behaviors. Understanding the patient's stage of readiness to change (precontemplation, contemplation, preparation, action, or maintenance stage) (25) allows the clinician to determine what motivational strategies are most appropriate for the patient at that time. One of the goals of motivational interviewing is to elicit the patient's reasons for change and assist the patient in moving through the subsequent stages of change (89).

Other techniques involved in motivating change include A-FRAMES (see Section II.F.10) and METs. Manuals describing these techniques are available (49, 90).

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2. Establishing and maintaining a therapeutic framework and alliance

An essential feature of psychiatric management of patients with a substance use disorder is the establishment and maintenance of a therapeutic alliance wherein the psychiatrist empathically obtains the necessary diagnostic and treatment-related information, gains the confidence of the patient and perhaps significant others, and is available in times of crisis. The frequency and duration of treatment contacts should be sufficient to engage the patient and, where appropriate, significant others in a sustained effort to participate in all relevant treatment modalities and, where appropriate, self-help groups. Within the context of this alliance, the primary goal of treatment is to help the patient learn, practice, and internalize changes in attitudes and behaviors that are conducive to relapse prevention (91, 92). The strength of the therapeutic alliance has been found to be a significant predictor of psychotherapy outcome (93). For example, several studies of individuals with substance use disorders have found that a stronger patient-clinician alliance predicts less substance use and better psychological functioning by the patient (94–96), although one of these studies found no association between therapeutic alliance strength and treatment retention for patients enrolled in a methadone maintenance program (96). Despite the finding of this one study, the chronic and relapsing nature of substance use disorders highlights the importance of establishing a therapeutic relationship so that patients will return for additional treatment, if necessary (33, 97–99). Ackerman and Hilsenroth (100) reviewed therapist attributes and strategies that facilitate a positive therapeutic alliance for all patient populations. They found that being flexible, honest, respectful, confident, warm, and open all contributed to the development of a positive therapeutic alliance. The most effective strategies for developing such an alliance included exploration, reflection, highlighting past therapy successes, providing accurate interpretation, facilitating the expression of affect, and attending to the patient's experience.

A review of the literature on effective characteristics of therapists concluded that the characteristic most associated with patient retention and reduced substance use is strong interpersonal skills (101). Safran and Muran (102) reviewed techniques for repairing ruptures in the therapeutic alliance, such as clarifying misunderstandings, helping patients learn that they can express their needs in an individuated fashion and assert themselves without destroying the therapeutic relationship, and changing the tasks and goals to be more relevant to the patient's current needs. Limit setting has an important role in treatment of substance use disorders and may be particularly important for individuals with co-occurring personality disorders (103, 104).

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3. Assessing safety and clinical status

The psychiatric assessment establishes a diagnosis and provides a baseline determination of a patient's clinical status. Ongoing evaluation of the patient's safety is also critical, as the patient's clinical status may change over time. It is particularly important to assess patients for suicidal or homicidal thoughts or other dangerous behavior—such as driving while under the influence of substances, domestic violence, or child abuse or neglect—that may need to be addressed through a change in the treatment plan or care setting.

Because relapse to substance use is common and inconsistently reported by patients (particularly when use is met with negative consequences or a judgmental response), breath, blood, saliva, and urine testing are helpful in the early detection of relapse. These tests are often initially conducted on a frequent and random schedule, as many substances and their metabolites may be detected for only a few days after use. Random urine screening for recent (i.e., within the last 1–3 days) substance use may be supplemented by nonrandom testing when recent substance use is suspected.

Methods of urine screening vary as to levels of sensitivity, specificity, and cost. The psychiatrist should be familiar with the applicability and sensitivity of the available analytic methods and collection procedures used in local laboratories, and he or she should specify the suspected type of substance used when requesting testing. Direct supervision of a patient's voiding or the use of other procedures (e.g., temperature-sensitive cups) will help to increase the validity and reliability of the test results.

The decision to test a patient's breath, blood, or urine depends on the type of substance use suspected, the substance's duration of action, the sensitivity of the test used, and the clinical setting in which care is being rendered. For example, blood testing is useful for assessing very recent substance use because it reflects current blood levels, and breath testing is useful for detecting alcohol intoxication and generally gives results comparable to those from blood tests. However, breath testing for alcohol is frequently preferred because the results are immediate and it is a noninvasive and low-cost procedure. Breath testing can also detect carbon monoxide, an indicator of smoking, as recent as a few hours before the test (105).

Urine testing is useful for detecting substance use over the preceding 5-day period for common substances of abuse (cocaine, opiates, cannabis, amphetamines, benzodiazepines, and PCP); however, certain opioids (buprenorphine, oxycodone, hydrocodone, and fentanyl) cannot be detected with routine methods and require special assays. Alcohol can be detected for up to 24 hours in urine, whereas ethyl glucuronide (EtG), a minor metabolite of alcohol, can be detected in the urine for 2–3 days after alcohol ingestion (106–108). Because EtG is produced by in vivo metabolism of alcohol prior to excretion in urine, the assay for EtG is highly sensitive and specific and is sometimes used in monitoring programs. Finally, there is some evidence that certain state markers can be used to detect recent alcohol use (e.g., elevation of carbohydrate-deficient transferrin, mean corpuscular volume, or -glutamyl transpeptidase).

Results from some studies have indicated that more intensive monitoring of substance use may increase recovery rates from a substance use disorder, as has been demonstrated with physicians and pilots (109–111). Ongoing assessment of the substance use disorder and psychiatric status is also necessary to ensure that the patient is receiving the appropriate treatment(s) and to monitor the patient's response to treatment (i.e., to determine the optimal dose of a medication, evaluate its efficacy, and detect treatment-emergent side effects). Co-occurring psychiatric disorders may complicate the treatment of the substance use disorder (111) and require the addition of specific treatments (e.g., an antidepressant medication for a patient with co-occurring major depressive disorder). An ongoing longitudinal assessment of the patient may be critical to the accurate diagnosis of a co-occurring condition (see Section II.B).

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4. Managing intoxication

In general, acutely intoxicated patients require a safe, monitored environment in which they can receive decreased exposure to external stimulation, as well as reassurance, reorientation, and reality testing. Clinical assessment involves ascertaining which substances have been used; the route of administration, dose, and time since the last dose; whether the level of intoxication is waxing or waning; and other diagnostic information, as has been already described. Management of acute intoxication may also be directed toward hastening the removal of substances from the body, which may be accomplished through gastric lavage (in the case of substances that have been recently ingested) or techniques that increase the excretion rate of substances or their active metabolites. Medications that antagonize the actions of the abused substances may be used to reverse their effect. Examples include the administration of naloxone to patients who have overdosed with heroin or other opioids or flumazenil to patients who have overdosed with benzodiazepines.

Many patients use multiple substances simultaneously to enhance, ameliorate, or otherwise modify the degree or nature of their intoxication or to relieve withdrawal symptoms. Intoxication with alcohol and cocaine, the use of heroin and cocaine ("speedball"), and the combined use of alcohol, marijuana, and/or benzodiazepines by opioid-dependent patients are particularly frequent. When intoxication with multiple substances is present, the effects of each substance need to be taken into consideration in managing the patient. More information on the management of alcohol, cocaine, and opioid intoxication can be found in the specific section for each substance (Sections IV.C.1, VI.C.1, and VII.C.2, respectively).

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5. Managing withdrawal

Not all individuals who are intoxicated or using substances will develop withdrawal symptoms. Withdrawal syndromes usually occur in physically dependent individuals who discontinue or reduce their substance use after a period of heavy and regular use. Patients using multiple substances (including alcohol and nicotine) are at risk for withdrawal from each substance. Factors that predict the severity of a withdrawal syndrome include 1) type of substance used, 2) time elapsed since last use, 3) metabolic rates of the substance, 4) dissociation rates of the substance from receptor sites, 5) synergistic effects or drug-drug interactions from the concomitant use of other prescribed or nonprescribed medications, 6) the presence or absence of concurrent general medical or psychiatric disorders, and 7) past withdrawal experiences (especially for alcohol). More information on the management of withdrawal from alcohol, cocaine, and opioids can be found in the specific section for each substance (Sections IV.C.2, VI.C.2, and VII.C.3, respectively).

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6. Reducing the morbidity and sequelae of substance use disorders

The clinician should engage the patient and, when appropriate, significant others in developing a comprehensive treatment plan to address problems in biological, psychological, and social functioning. Coordination with a patient's primary care physician may also be important in the medical management of patients with substance use disorders (112).

Substance use disorders are commonly associated with substance-related medical morbidity. Although an individual patient's presentation may warrant specific screening and intervention, a number of baseline screening tests are frequently recommended based on epidemiological studies documenting the high risk for co-occurring medical disorders. For example, electrolyte panels and complete blood counts may be considered for those with severe substance dependence of any type because of the high correlation of substance dependence with poor nutritional status. For women of childbearing age, testing for pregnancy is an important part of medical screening. Tuberculin skin testing may be appropriate because of substance users' increased risk for tuberculosis exposure and to address public health concerns. Blood pressure monitoring may be advisable for substance users because of associated hypertension (e.g., with alcohol, nicotine, and stimulants) and hypotension (e.g., dehydration associated with poor self-care) risks. For individuals with specific substance use disorders, additional laboratory and other screening tests may be considered. These include the following:

  • Alcohol use. Hepatic panel to screen for liver toxicity and functioning; complete blood count to determine mean corpuscular volume, which can be increased with hepatic toxicity, thiamine, folate, and vitamin B12 deficiency, as well as the direct effects of alcohol on hematopoiesis; stool sampling for occult blood reflecting gastritis, peptic ulcerative disease, or esophageal varices; mental status examination to detect cognitive functioning deficits

  • Nicotine dependence. Examination of lymph nodes, mouth, and throat to assess for occult cancer and pulmonary disease; auscultation of chest and lungs; chest X-ray; pulmonary function testing, if warranted; electrocardiogram because of increased risk for cardiovascular disease; urine or blood cotinine level

  • Injection drug use. Blood testing for blood-borne and sexually transmitted diseases, such as HIV, hepatitis B and C virus, and syphilis; skin examination for cellulitis; complete blood count to detect occult infection; genital examination and sampling for chlamydia, gonococcal disease, and human papilloma virus

Even if not initially caused by substance use, co-occurring medical disorders may be exacerbated by substance use, such as respiratory disease worsened by nicotine use; cardiovascular disease worsened by cocaine, alcohol, or nicotine use; hepatic disease aggravated by alcohol abuse; and seizure disorder exacerbated by withdrawal from alcohol, benzodiazepines, or other sedatives. In addition, individuals with substance use disorders frequently neglect preventive health care and follow-up medical care (113). All substance use disorders can be a cause for nonadherence to prescribed medications. Delayed dosing, missed dosing, or overuse of prescribed medications may occur during intoxication and withdrawal states. To finance substance use, individuals may sell prescribed medications (e.g., opiate analgesics) or avoid filling prescriptions to save insurance copayments. "Downward drift" and homelessness among substance-dependent individuals also often curtails their access to medical and dental care.

Individuals with a co-occurring psychiatric disorder are particularly vulnerable to the self-neglect and morbidity associated with substance use, possibly resulting in exacerbation of depression and suicidal thinking, worsening of psychosis, destabilization of bipolar disorder, and increased impulsivity leading to high-risk behaviors. Nonadherence to prescribed medication occurs frequently in those with a substance use disorder and further exacerbates these sequelae. Such individuals are best served by being referred to an integrated psychiatric and substance use disorder treatment program (114). Psychiatrists are often the only medical contacts for patients with co-occurring psychiatric and substance use disorders and therefore are important resources for the facilitation of appropriate medical screening, referral for medical care, and follow-up with medical care (115).

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7. Facilitating adherence to a treatment plan and preventing relapse

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 (49, 116) and by encouraging patients to actively partake in self-help strategies. Monitoring programs, such as EAPs and impaired-physician programs (86, 111, 117), can sometimes help patients adhere to treatment.

Early in treatment a clinician may educate patients about cue-, stress-, and substance-induced relapse triggers (17, 118). 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 (119–121).

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 (122, 123). 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 (124).

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.

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8. Providing education about substance use disorders and their treatment

Patients with substance use disorders should receive education and feedback about their disorder, prognosis, and treatment. Clinicians are responsible for educating patients and their significant others about the etiology and nature of substance use, the benefits of abstinence, the risk of switching addictions (e.g., to other substances, to addictive behaviors such as compulsive gambling), the identification of relapse triggers, the availability of treatment options, and the role of family and friends in aiding or impeding recovery. When appropriate, psychiatrists may provide education about the effects of alcohol and other substances on the brain, the positive changes that occur with abstinence, substance-related medical problems (e.g., hepatitis C virus), and the effects of smoking, alcohol, and other substances on fetal development. Education on reducing behavioral harm may include advice about the use of sterile needles, procedures for safer sex, contraceptive options, and the availability of treatment services for drug-exposed newborns. Patients may also be directed to other educational resources. For example, public health services for the treatment of nicotine dependence are offered free of charge and are available by telephone (e.g., the "telephone quitlines" for individual states sponsored by the Centers for Disease Control and Prevention [CDC], available at http://www.cdc.gov/tobacco/quitlines.htm), on the Internet (e.g., the CDC's Tobacco Information and Prevention Source, available at http://www.cdc.gov/tobacco/), and by mail. As in all clinical settings, patient education is best delivered with due consideration to the individual's educational background and cultural setting.

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9. Facilitating access to services and coordinating resources among mental health, general medical, and other service systems

In all aspects of patient management, the psychiatrist may work collaboratively with members of other professional disciplines, community-based agencies, treatment programs, and lay organizations to coordinate and integrate the patient's care and address the patient's social, vocational, educational, and rehabilitative needs. This is particularly important for patients lacking resources or the capacity for self-care because of a psychiatric or medical disorder. Case management services are aimed at such coordination of care (125).

In treating an individual with significant comorbidities or treatment-resistant disorders (e.g., chronic pain syndromes, personality disorders, cognitive impairment, chronic suicidality), it may be important for the treating clinician to consult with colleagues and experts in specialty care. In some cases, it may be necessary to place patients in a highly supervised setting to protect them and society from their dangerous behaviors associated with substance use.

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E. Somatic Treatments

Medication therapies for substance use disorders are effective adjuncts to behavioral therapies and self-help groups; the settings for medication therapies include hospitals, partial hospitalization and intensive outpatient programs, and a variety of outpatient settings including primary care clinics, mental health clinics, substance use disorder treatment facilities, and private practice offices.

The types of accepted and effective medication strategies used in the treatment of specific substance use disorders are discussed in greater detail in later sections of this practice guideline. The following sections describe the general principles of these main categories of medication interventions: 1) medications to treat intoxication states, 2) medications to treat withdrawal syndromes, 3) agonist maintenance therapies, 4) antagonist therapies, 5) abstinence-promoting and relapse prevention therapies, and 6) medications to treat co-occurring psychiatric conditions.

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1. Medications to treat intoxication states

Most clinicians treating patients with substance use disorders do not direct medical treatment of life-threatening intoxication states, because this role belongs to trained emergency physicians. However, clinicians who treat patients with substance use disorders should be able to recognize potentially dangerous intoxication states so they can make a rapid referral to emergency services. This section briefly describes potentially dangerous states of substance intoxication and emergency medication therapies.

In general, there are two types of medication interventions for acute intoxication and overdose: the administration of specific antagonists (e.g., naloxone for acute opioid overdose, flumazenil for acute benzodiazepine overdose complicated by ingestion of multiple substances) and therapies that stabilize the physical effects of substance overdose (e.g., anticholinergics, adrenergic pressor agents, anti-arrhythmics, anticonvulsants). Other adjunctive supportive treatments for overdose include establishing an adequate airway, decreasing the risk of aspiration (e.g., positioning the patient on his or her side, use of a cuffed endotracheal tube), and, if indicated, providing ventilatory support and hemodialysis. Hemodialysis or lavage therapies may also be used to enhance elimination of ingested substances.

The syndrome of acute opioid overdose is recognizable by respiratory depression, extreme miosis, and stupor or coma (126). Pulmonary edema may also be observed. Naloxone is a competitive antagonist at all three types of opiate receptors (mu, kappa, and sigma) and has no intrinsic agonist activity (127). It is clinically indicated to rapidly reverse a known or suspected opioid overdose (126, 128). Because of its poor bioavailability from significant hepatic first-pass effects, naloxone is typically administered intravenously, but it may also be given intramuscularly, subcutaneously, or endotracheally if intravenous access is unattainable (126). The dosing of naloxone varies depending on whether the patient is known to be opioid dependent as well as on the extent of respiratory depression. For example, in patients with CNS but not respiratory depression, an initial dose of 0.05–0.4 mg i.v. is recommended. The lower dose is used for opioid-dependent individuals, who will show withdrawal symptoms within minutes of being given the medication (129). For any person who presents with significant respiratory depression, the initial suggested dose is 2.0 mg i.v., regardless of the individual's drug use history; a beneficial response should occur within 2 minutes. Repeated doses can be administered every 3 minutes until respiratory or CNS depression is completely reversed or until a maximum dose of 10 mg i.v. has been given (128). If no response is observed after administration of the 10 mg of naloxone, the diagnosis of opioid overdose should be reconsidered. Because naloxone is rapidly absorbed by the brain and then quickly redistributed and eliminated from the body, its activity in the brain is short-lived (126, 130). Thus, further monitoring and infusion of additional naloxone are needed to continue antagonizing the effects of severe opioid overdose, particularly if longer-acting opioids have been ingested (128, 131). Monitoring for opioid withdrawal symptoms is also indicated because patients may experience significant distress that can last for several hours after reversal of an opioid overdose with an antagonist (129).

Acute sedative-hypnotic overdose is recognizable by slurred speech, loss of coordination, and confusion and, in a severe overdose, stupor, respiratory depression, and coma. Flumazenil is a potent benzodiazepine-specific antagonist that competes at central synaptic GABA receptor sites in a dose-dependent manner (132). In addition, it may antagonize the sedative effects of other compounds that act through GABA receptors, such as zolpidem, zaleplon, and eszopiclone (133). However, it does not antagonize benzodiazepine effects at peripheral GABAergic (e.g., renal, cardiac) receptor sites (134). Like naloxone, flumazenil has poor bioavailability and a brief duration of activity and is administered by repeated boluses or through continuous intravenous infusion. Although it can be used as a low-dose (2 mg i.v.) diagnostic probe for suspected benzodiazepine overdose or in the reversal of benzodiazepines given for diagnostic or therapeutic procedures, flumazenil must be carefully administered to benzodiazepine-dependent patients and patients who have ingested mixed substances to avoid the production of withdrawal seizures (135). Flumazenil can also affect cerebral hemodynamics and is not recommended for situations in which intracranial pressure may already be increased (e.g., in the case of a head injury) (135). For these reasons, as well as cost, flumazenil is not recommended for uncomplicated benzodiazepine overdose that can be successfully managed by supportive ventilation therapies.

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2. Medications to treat withdrawal syndromes

Patients who develop tolerance to a particular substance also develop cross-tolerance to other substances in the same pharmacological class. Physicians can take advantage of cross-tolerance in the treatment of withdrawal states by replacing the abused substance with a medication that is in the same pharmacological class. Examples of this include the use of methadone or buprenorphine in the treatment of opioid withdrawal, benzodiazepines in the treatment of alcohol and sedative-hypnotic withdrawal, and NRTs in the treatment of nicotine dependence (136–141).

Other medications are used to ameliorate indirect withdrawal-related symptoms. For example, clonidine is an 2-adrenergic agonist that is useful in treating opioid withdrawal symptoms as well as anxiety syndromes (129, 142). Nonspecific symptoms of withdrawal such as headache and stomach upset may also require treatment using medications such as acetaminophen and histamine2-receptor antagonists, respectively.

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3. Agonist maintenance therapies

Opioid agonist maintenance therapy may be the primary tool available to engage an opioid-dependent individual in treatment because it relieves unpleasant withdrawal syndromes and craving associated with abstinence. The central and subjective effects of agonist therapies render these agents more acceptable to opioid-dependent patients than antagonist therapies, and adherence with treatment with agonist therapies is greater than with antagonist therapies.

Opioid agonist maintenance therapies (described further below) include methadone, a long-acting potent agonist at the mu opiate receptor sites (126), and buprenorphine, a potent long-acting compound that acts as a partial opioid agonist at mu receptor sites (126) and that is prescribed alone or with naloxone (in a combination tablet). An additional opioid agonist therapy, l--acetylmethadol (LAAM), has an extended duration of action and high intrinsic activity at the mu opiate receptor, but it has been withdrawn from the U.S. market by its manufacturer because of the risk of cardiac arrhythmia.

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4. Antagonist therapies

Antagonist therapies are used to block or otherwise counteract the physiological and/or subjective reinforcing effects of substances. The narcotic antagonist naltrexone blocks the subjective and physiological effects of subsequently administered opioid drugs (e.g., heroin) (143, 144) without tolerance developing to its antagonist effect (145) (see Sections VII.C.1.c and IX.E.1.b). Compared with naloxone, naltrexone has good oral bioavailability (126) and a relatively long half-life; it is also available in a long-acting injectable preparation that may improve treatment adherence.

Mecamylamine, a nicotine antagonist, has also been studied, but its effectiveness remains unclear (146, 147).

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5. Abstinence-promoting and relapse prevention therapies

For promoting abstinence and preventing relapse in patients with substance use disorders, certain medications may be useful. Examples of such medications are disulfiram, naltrexone, and acamprosate for alcohol use disorders and bupropion for nicotine dependence.

The ingestion of alcohol after disulfiram, an inhibitor of the enzyme aldehyde dehydrogenase, has been taken results in the accumulation of toxic levels of acetaldehyde accompanied by a host of unpleasant, potentially dangerous but rarely lethal signs and symptoms (148–151). The purpose of disulfiram is not to make the patient ill but to prevent the patient from drinking impulsively because he or she knows the symptoms that will result from drinking while taking disulfiram (see Sections IV.C.3.b and IX.B.3.b).

Naltrexone, described above as an antagonist therapy for the treatment of opiate dependence, is also effective in reducing alcohol craving and preventing alcohol-induced relapse (152–154), presumably because of the effect of mu opiate receptor antagonism in blocking the centrally mediated reinforcing effects of alcohol (155) (see Sections IV.C.3.a and IX.B.3.a).

Acamprosate (calcium bis-acetyl homotaurine) is a small, flexible molecule that resembles GABA and decreases glutamatergic neurotransmission, perhaps by acting as an N-methyl-d-aspartate antagonist (151, 156). It has been proposed that this medication helps sustain abstinence in detoxified alcohol-dependent individuals by reducing neuronal hyperexcitability during early recovery (156, 157) (see Sections IV.C.3.c and IX.B.3.c).

Treatment of nicotine dependence with the sustained-release formulation of the antidepressant bupropion has been associated with reductions in nicotine craving and smoking urges (158–160). The mechanism of action for bupropion in the treatment of nicotine dependence is unclear but is likely related to blockade of dopamine and norepinephrine reuptake (161) as well as antagonism of high-affinity nicotinic acetylcholine receptors (162) (see Sections III.E.2 and IX.A.1.b).

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6. Medications to treat co-occurring psychiatric conditions

The treatment of co-occurring psychiatric disorders may or may not improve treatment outcome for the substance use disorder, but if treatment of the co-occurring psychiatric disorder does not occur, it is less likely that the treatment of substance use disorder will be successful. The high prevalence of co-occurring psychiatric disorders in substance-dependent patients implies that many such patients will require specific pharmacotherapy for a co-occurring disorder. Examples include the use of mood stabilizers for substance-dependent patients with bipolar disorder, antipsychotics for patients with psychotic disorders, and antidepressants for patients with major depressive disorder (see also Section II.G.2.d).

Clinically significant issues for substance-dependent patients receiving pharmacotherapy for co-occurring psychiatric disorders include 1) synergy of prescribed medications and effects of the abused substance (e.g., benzodiazepines and alcohol), 2) drug-drug interactions that affect the efficacy of psychiatric treatment (e.g., antipsychotics and smoked tobacco), 3) nonadherence to treatment because of intoxication and withdrawal states as well as drug-seeking behaviors, and 4) intentional or unintentional overdose. Certain medications used to treat co-occurring psychiatric disorders may themselves be abused. For example, patients with a co-occurring anxiety disorder may abuse benzodiazepines, patients with attention deficit hyperactivity disorder (ADHD) may abuse prescribed stimulants, and patients with a co-occurring psychotic disorder who are treated with anticholinergics for antipsychotic adverse side effects may abuse the anticholinergic adjunct. Substance-dependent patients may also misuse prescribed medications in an attempt to ameliorate withdrawal syndromes, enhance the effect of other substances of abuse, or accelerate the action of the prescribed medication. Whenever possible, medications with low abuse potential and relative safety in overdose should be selected for the treatment of patients with a co-occurring substance use disorder.

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F. Psychosocial Treatments

Some type of psychosocial intervention is usually available in specialized substance use disorder treatment programs. These approaches are the mainstay of treatment for users of certain classes of substances (e.g., cocaine) for which there are no pharmacological treatments with established efficacy. The major psychotherapeutic treatments that have been studied in patients with substance use disorders are cognitive-behavioral, behavioral, psychodynamic/interpersonal, and recovery-oriented therapies. A growing body of efficacy data from controlled clinical trials suggests that psychotherapy is superior to control conditions as a treatment for patients with a substance use disorder. However, no particular type of psychotherapy has been found to be consistently superior when compared with other active psychotherapies for treating substance use disorders. Even comparatively brief psychotherapies appear to have durable effects among patients with a substance use disorder (123).

After a discussion of the role of psychotherapy in substance abuse treatment and the relation between psychotherapy and pharmacotherapy, this section reviews the major psychosocial treatment approaches, the principles underlying their use, and their application in the treatment of patients with substance use disorders.

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1. Role of psychosocial treatments

Psychosocial treatments for substance use disorders attempt to counteract compulsive substance use by bringing about changes in patients' behaviors, thought processes, affect regulation, and social functioning. Although the techniques and theories of therapeutic action vary widely across the different approaches reviewed below, they all address one or more of a set of common tasks: 1) enhancing motivation to stop or reduce substance use, 2) teaching coping skills, 3) changing reinforcement contingencies, 4) fostering management of painful affects, and 5) enhancing social supports and interpersonal functioning (163). A central challenge for clinicians treating individuals with substance use disorders is that the core symptom, compulsive substance use, at least initially results in euphoria or relief of dysphoria, with the aversive and painful effects of substance use occurring some time after the rewarding effects. This contrasts with the course of most other psychiatric disorders (e.g., mood or anxiety disorders), in which the primary symptoms are painful or aversive. In addition, substance use has come to serve an important function in the individual's life by the time treatment is sought. Sustained recovery from a substance use disorder entails both relinquishing a valued element of life and developing different behaviors, thought patterns, and relationships that serve the functions previously met by substance use (164).

Psychosocial treatments are often essential for many aspects of this recovery process: Sustained motivation is required to forgo the rewards of substance use, tolerate the discomforts of early and protracted withdrawal symptoms, and gather the energy to avoid relapse despite episodes of craving that can occur throughout a lifetime. Coping skills are required to manage and avoid situations that place the individual at high risk for relapse. Alternative sources of reward or symptom relief must be sought and used to fill the place of substance use. Dysphoric affects, such as anger, sadness, or anxiety, must be managed in ways that do not involve continued substance use. Social relationships that are supportive of recovery need to be developed or repaired.

Patients with substance use disorders vary widely in their need for attention to each of these aspects of recovery, and brief treatment or self-help methods may be sufficient for the recovery of highly motivated patients with good interpersonal functioning and social support. However, none of these processes can be assumed to occur simply as a result of detoxification or with the administration of medications. It is essential that these psychosocial aspects of recovery be evaluated during treatment planning to determine the need for behavioral treatments.

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2. Relation of psychosocial treatments to pharmacotherapy for substance use disorders

Research has demonstrated that the utility of pharmacotherapies for substance use disorders may be limited unless they are delivered with adjunctive psychotherapy. For example, naltrexone maintenance for opioid dependence is plagued by high rates of premature dropout (165, 166) that can be lessened by concurrent behavioral or family therapy (167). Without adjunctive psychotherapy, the utility of disulfiram may be limited, in part because of low rates of medication adherence (150); however, its effectiveness can be enhanced when it is delivered in the context of a contract with a family member or significant other (168). Methadone maintenance for opioid dependence is the most successful pharmacological treatment of a substance use disorder, with substantial evidence of its impact on treatment retention and associated reductions in opioid use and illegal activity (169). However, cross-program effectiveness varies widely in relation to the quality and amount of ancillary psychosocial services delivered (169). Moreover, McLellan et al. (170) have shown that methadone maintenance alone yields acceptable results for only a small fraction of patients and that outcome is enhanced in proportion to the intensity of concomitant psychosocial services. More recently, a meta-analysis confirmed that a combination of psychosocial treatment and methadone maintenance produced greater reductions in heroin use by opioid-dependent individuals than methadone maintenance alone (171). Similar results have been found with nicotine replacement treatments: rates of sustained abstinence are increased two- to fourfold when they are combined with behavioral therapies (172, 173).

These findings suggest that even the most efficacious pharmacotherapies for substance use disorders have limitations that need to be addressed with psychosocial interventions. First, medications frequently affect only part of the substance dependence syndrome while leaving other aspects untouched. For example, methadone is highly effective in relieving withdrawal symptoms and minimizing the impact of continued opioid use, but by itself it has limited impact on counteracting social impairments resulting from protracted substance use prior to a patient's entering treatment (169). Also, most medications have variable or partial effects on the target symptom. Second, side effects or delayed effects of medications may limit acceptability and adherence. Third, medications typically target only one class of substances, whereas abuse of multiple substances is the norm in treatment populations (174). Fourth, gains made while taking the medication tend to diminish when the treatment is discontinued, whereas vulnerability to relapse is lifelong. Psychosocial strategies for countering these limitations and enhancing effectiveness of pharmacotherapies include 1) increasing a patient's motivation to stop substance use by taking the prescribed medication, 2) providing guidance to the patient on using the medication and managing its side effects, 3) maintaining the patient's motivation to continue the medication after an initial period of abstinence is achieved, 4) providing the patient with a supportive therapeutic relationship aimed at preventing premature termination, and 5) helping the patient develop skills to adjust to a life without substance use.

The importance of psychosocial treatments is reinforced by the recognition that there are only a handful of effective pharmacotherapies for substance use disorders and that, for the most part, these therapies are limited to the treatment of opioid, alcohol, and nicotine dependence (175). Effective pharmacotherapies for dependence on cocaine and other stimulants, marijuana, hallucinogens, and sedative-hypnotics have yet to be developed. For individuals who abuse these latter substances, psychosocial therapies remain the principal treatments.

Although the foregoing discussion has emphasized the need for psychotherapy to enhance the effectiveness of pharmacotherapy, this section would not be complete without considering the role of pharmacotherapy in enhancing the efficacy of psychotherapy. These two treatments have different mechanisms of action and targeted effects that can counteract the weaknesses of either treatment alone. Psychotherapies effect change by psychological means in the psychosocial aspects of substance abuse, such as motivation, coping skills, dysfunctional thoughts, or social relationships. The weaknesses of these treatments include a limited effect on the physiological aspects of substance abuse or withdrawal. Also, the impact of behavioral treatments tends to be delayed, requiring practice, repeated sessions, and a "working through" process. In contrast, the relative strength of pharmacological treatments is their rapid action in reducing immediate or protracted withdrawal symptoms, craving, and the rewarding effects of continued substance use. In effect, pharmacotherapies for substance use disorders reduce the patients' immediate access to and preoccupation with the abused substance, freeing the patient to address other concerns such as long-term goals or interpersonal relationships. When medications are used in conjunction with psychotherapy, the dropout rate from therapy is reduced because the patient's urges to use and relapse to substance use are alleviated by the effects of the medication. In addition, a longer duration of abstinence can further enhance the efficacy of psychotherapy by preventing substance-related effects on attention and mental acuity, thereby maximizing the patient's ability for learning new behaviors in therapy.

Because of the complementary actions of psychotherapies and pharmacotherapies, combined treatment has a number of potential advantages. As is reviewed later, research evidence on combined treatment is sparse but generally supportive. Although factors such as patient acceptance can limit the use of combined approaches, it is important to note that for the treatment of substance use disorders, no studies have shown that combined treatments are less effective than either psychotherapy or pharmacotherapy alone.

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3. Cognitive-behavioral therapies

CBTs for the treatment of substance use disorders are based on social learning theories regarding the acquisition and maintenance of the disorder (176). 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 (177, 178) were derived from cognitive therapy for depression and anxiety by Beck and Emery (179) 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 (176, 180). 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 (181). 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 (182) and adolescents at risk for beginning substance abuse (183).

Relapse prevention is a treatment approach in which CBT techniques are used to help patients develop greater self-control to avoid relapse (184, 185). 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 (184, 186). In more recent clinical trials (43, 187), techniques drawn from cognitive therapy and relapse prevention have been combined with the aims of initiating abstinence and preventing relapse.

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4. 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. [6] and Miller and Rollnick [49]). 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.

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5. Behavioral therapies

Behavioral therapies are based on basic principles of learning theory (188), 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 (189) and 2) those that are based on operant conditioning and focus more on consequences such as community reinforcement therapy (190). Representative behavioral approaches are briefly described here.

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a) Contingency management

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 rules) (191–193). As an adjunctive treatment, contingency management has been used with a variety of substances of abuse, including cocaine (193–196), opiates (197–200), and marijuana (201). 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 (188). 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 (202) or work attendance (203). 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 (204, 205) and may reduce the total costs of contingency management approaches (206).

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 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 (207).

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b) Community reinforcement

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 (208). 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 (190). 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 (209, 210). CRA has been shown to be effective in treating alcohol dependence, with adjunctive disulfiram treatment increasing its effectiveness (211). CRA can be clinic or office based, but it is largely practiced in residential or partial hospitalization programs, therapeutic communities, and community residential facilities.

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c) Cue exposure and relaxation training

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 (212). Cue exposure can also be paired with relaxation techniques and drug-refusal training to facilitate the extinction of classically conditioned craving (213, 214). As an alternative, relaxation training has been used alone to provide a nonsubstance response to counteract dysphoric affects or anxiety.

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d) Aversion therapy

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.

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6. Psychodynamic and 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 (215) 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 (216). Systematic testing of the efficacy of psychodynamic treatments for substance use disorders has occurred only with supportive-expressive therapy (217), 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 (177, 218). 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 (219).

IPT for substance use disorders is based on the concept that dysfunctional social relationships either cause or prevent recovery from a substance use disorder (220). 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.

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7. Group therapy

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 (221–225).

Group therapies permit efficient use of therapist time (226). 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 (227, 228), 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 (229, 230). 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.

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8. Family therapies

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 (231). 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 (232–235). 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 (236). More recent studies have demonstrated the effectiveness of family involvement in substance use disorder treatment for both women and men (237, 238), 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 (239–242).

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 (120, 243, 244). 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 (245). The support for behavioral couples treatment is particularly strong (246).

Family intervention is indicated in circumstances in which a patient's abstinence upsets a previously well-established but maladaptive style of family interaction (233, 247) 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. (248), most attention has been paid to behavioral coping strategies, 12-step approaches, and confrontational interventions (249), 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 (250), than with more traditional interventions (248). 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 (251, 252).

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9. Self-help groups and 12-step-oriented approaches

The most widely available self-help groups (also called mutual help groups) are based on the 12-step approach, originally embodied in AA (253, 254), 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 (255), 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 (256). AA has been effective for both men and women and appears to be particularly useful for those with more severe alcohol dependence (257–259). Other recent research has suggested that 12-step groups may also benefit patients dependent on substances such as cocaine (256). 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 (260–266). Furthermore, several studies (43, 219, 265, 267) support the efficacy of professional treatment, including TSF therapy (268) and individual drug counseling (269), 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 (270). 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 (271), Secular Organizations for Sobriety (272), and Self-Management and Recovery Training (273) have been developed to address this problem and may be an option for some patients.

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10. Brief therapies

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, mental health clinic, EAP) (274, 275). More recent evidence suggests that brief interventions are also effective with other substance use disorders, including cannabis (276), opioid (277), and nicotine (278) dependence and in special populations such as adolescents (279), patients with co-occurring psychiatric and substance use disorders (280), and patients in the military (281).

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 (49). 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 (282, 283).

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11. Self-guided therapies

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 (284). These therapies are available as manual-guided self-help programs, manual-guided therapies with a clinician, and computer-guided programs (285, 286). 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.

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12. Hypnosis

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 (287).

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G. Clinical Features Influencing Treatment

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1. Use of multiple substances

Many patients entering treatment for a specific substance use disorder abuse more than one substance, and co-occurring nicotine dependence is particularly common. For some patients, there is a "drug of choice," with other substances serving as a substitute when the primary substance is unavailable. Others routinely use multiple substances simultaneously. An individual's concurrent use of two or more substances may be motivated by his or her wish to modify the effects of the primary drug of choice or to prevent or relieve withdrawal symptoms. In addition, many patients use multiple substances because of their availability. Frequent drug combinations include 1) cocaine and alcohol; 2) cocaine and heroin; 3) heroin and benzodiazepines; 4) alcohol, cocaine, and benzodiazepines; 5) nicotine and any other drug; 6) multiple "club drugs" (e.g., 3,4-methylenedioxymethamphetamine [MDMA], -hydroxybutyrate [GHB], ketamine); 7) "club drugs" with prescription medications (e.g., MDMA with sildenafil and/or fluoxetine); and 8) opioids, stimulants, sedatives, steroids, and other substances. The severity of abuse of each substance and the motivation to stop using each substance may vary widely in individuals who abuse multiple substances.

The treatment of patients using multiple substances may be complicated by 1) simultaneous intoxication or withdrawal from two or more drugs, 2) varying time frames for experiencing withdrawal symptoms, 3) the need to detoxify the patient from more than one drug, and 4) potential interactions between an abused substance and medications used to treat a comorbid substance use disorder (e.g., inadvertent precipitation of opioid withdrawal in patients treated with naltrexone for alcohol dependence).

Although the presence of multiple substance use disorders is the norm, there is limited research to guide clinicians on adapting the usual evidence-based clinical interventions to the treatment of individuals using more than one substance, including medication and psychosocial treatments. The best recommendation is for the clinician to do a comprehensive assessment of the patient and integrate the evidence-based treatment approaches, including pharmacological and psychosocial treatments, for each specific substance use disorder (288).

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2. Psychiatric factors

The presence of a substance use disorder will have an impact on psychiatric issues, such as the risk of suicide or other self-injurious behaviors and the risk of aggressive behaviors, including homicide. In addition, the presence of co-occurring psychiatric symptoms or disorders affects the patient's treatment adherence as well as the onset, course, and prognosis of the substance use disorder (170, 288–292). These factors need to be taken into consideration when arriving at a treatment plan for an individual patient.

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a) Risk of suicide

The frequency of suicide attempts and death by suicide is substantially higher among patients with a substance use disorder than in the general population. A systematic review of retrospective and prospective cohort studies of substance use disorders and suicide (293) demonstrated that individuals with alcohol use disorder, opioid dependence, or mixed drug use have a substantially greater likelihood of suicide compared with the general population, with a 9.8-, 13.5-, and 16.9-fold elevated risk, respectively. This review reported insufficient evidence to compare the suicide risk among patients with other drug use disorders (e.g., cocaine dependence). In terms of lifetime suicide mortality, a review of 83 studies demonstrated a lifetime suicide risk of 7% in individuals with an alcohol use disorder, which is comparable to that of individuals with a mood disorder (6%) or schizophrenia (4%) (294). These rates vary by country and may be slightly lower in the United States (295). In addition, significant rates of substance use disorders are found in psychological autopsy studies of individuals who have died by suicide (296–300), with a recent or impending interpersonal loss being a frequent apparent precipitant (301).

Rates of suicidal ideation and suicidal behaviors, including suicide attempts, are also increased in individuals with a substance use disorder. For example, in a recent prospective study, treatment-seeking individuals with alcohol dependence were found to have attempted suicide seven times more frequently than age-matched, non-alcohol-dependent comparison subjects during the 5-year follow-up period after the initial evaluation (302). The alcohol-dependent individuals who attempted suicide (4.5%) were more likely than the other individuals to have made prior attempts; other related factors were earlier onset of the substance disorder, more severe substance dependence, dependence on multiple substances, more panic symptoms, being separated or divorced, having had prior treatment, and having been diagnosed with a substance-induced psychiatric disorder (302). In addition, significant high rates of substance use disorders are seen among individuals who have attempted suicide (296, 303–305).

The risk of suicidal behaviors and death by suicide is further increased for individuals with a substance use disorder in the context of certain co-occurring psychiatric disorders, such as major depressive disorder, bipolar disorder, and cluster B personality disorders. The presence of major depressive disorder substantially increases impulsive suicidal behaviors and suicide risk (298, 303, 306–308). A recent review of the literature on co-occurring alcohol use disorders and major depressive disorder demonstrated that this comorbidity increases the risk of suicidal ideation, suicidal behaviors, and death by suicide (309). Among patients diagnosed with major depressive disorder and bipolar disorder, cigarette smoking has also been found to be an independent predictor of future suicidal behavior (310).

Prospective studies of patients with co-occurring bipolar and substance use disorders consistently report greater frequency of lifetime suicide attempts and suicidal ideation compared with bipolar disorder patients with no co-occurring substance use disorder (311–313). Bipolar patients with co-occurring anxiety symptoms or cluster B personality disorder features and a substance use disorder may be at the greatest risk for suicidal behaviors (314, 315).

Patients with co-occurring cluster B personality and substance use disorders also have a greater risk of suicidal ideation and death by suicide (316, 317). This population is also at greater risk for accidental death by injection drug overdose (318).

Despite this clear evidence for an increased risk of suicidal behaviors in individuals with a substance use disorder, few controlled studies are available to assist in guiding the treatment of such patients (319). As in the care of any patient with a psychiatric disorder, suicide risk should be assessed regularly and in a systematic manner. Assessment of suicide risk includes determining the presence or absence of current suicidal thoughts, intent, and plan; a history of suicide attempts (e.g., lethality of method, circumstances); a family history of suicide; a history of aggression (e.g., weapon use, circumstances); the intensity of current depressive and other mood symptoms; the current treatment regimen and response; recent life stressors (e.g., marital separation, job loss); substance use patterns; psychotic symptoms; and current living situation (e.g., social supports, availability of weapon). In substance-using individuals, suicidal ideation and suicide attempts may occur in the context of a major depressive episode or result from substance-induced sadness or dysphoria combined with increased impulsivity and poor judgment. However, individuals with a substance use disorder can also be at risk for suicide even in the apparent absence of depression. In terms of treatment implications, care should be used when prescribing potentially toxic medications to a suicidal patient. For additional recommendations on the assessment and treatment of suicidal patients with substance use disorders, the reader is referred to APA's Practice Guideline for the Assessment and Treatment of Patients With Suicidal Behaviors (301).

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b) Risk of aggressive behaviors, including homicide

Substance use disorders are associated with an increased risk for aggressive behaviors toward others, including physical assault, sexual aggression, domestic violence, child abuse, and homicide (320–322). Substance intoxication and withdrawal states may be associated with anxiety, irritability, agitation, impaired impulse control, disinhibition, decreased pain sensitivity, and impaired reality testing; these effects are hypothesized to account for the increased aggressive behaviors associated with substance use. In particular, intoxication with substances such as alcohol, cocaine, methamphetamine, PCP, anabolic steroids, and hallucinogens may be associated with aggression (138, 323–327), whereas withdrawal from substances such as alcohol, opioids, sedative-hypnotics, and cannabis can lead to withdrawal syndromes associated with a risk of aggressive behaviors (138, 320, 328). Intoxication with marijuana or hallucinogens may inadvertently lead individuals to perform aggressive acts because of a faulty perception of reality coupled with high levels of anxiety and paranoia (329–331). Substance use disorders are also indirectly associated with aggressive behaviors engaged in to obtain illicit or expensive substances. Although it is important to assess for and be aware of the potential for aggressive behaviors in individuals with a substance use disorder, it is also important to assess for substance use disorders in all individuals who present with a history of agitation or aggression. Because family and partners may be affected by substance-related domestic violence, systematic screening and referral for domestic violence treatment interventions may effectively reduce domestic violence. Some treatments such as abstinent partner therapy (e.g., coping skills training [332]) and couples therapy (e.g., behavioral couples therapy [333]) have been shown to reduce alcohol-related domestic violence in randomized, controlled trials.

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c) Sleep disturbances

Individuals with substance use disorders frequently report sleep disturbances, particularly after being detoxified. For some patients, managing sleep disturbances will be an important component of the treatment plan. Indeed, some studies have demonstrated that among detoxified alcohol-dependent individuals, insomnia is a strong predictor of relapse (334–336). Despite the recognition that sleep disturbances are a problem among individuals with substance use disorders, only a handful of studies have examined the treatment of sleep disturbances in these individuals, and these studies have focused only on individuals with alcohol dependence. For example, one small double-blind study found that trazodone was superior to placebo in improving sleep in alcohol-dependent individuals with insomnia (337). In an open-label study comparing trazodone and gabapentin for the treatment of insomnia in alcohol-dependent individuals, both medications were found to improve insomnia, but the gabapentin group showed greater improvements than the trazodone group (338). Given the open-label nature of this study, more research is needed to determine if gabapentin is an effective treatment for sleep disturbances related to alcohol dependence. In addition, more research is needed to determine if trazodone and gabapentin, as well as other sedating psychotropic medications, can effectively treat sleep disturbances not only in individuals with alcohol dependence but also in those with other substance use disorders.

In addition to the studies of pharmacological agents, there has been one randomized, controlled study that showed that CBT strategies helped improve sleep disturbances in alcohol-dependent individuals in recovery (339). As with the pharmacological treatments for sleep disturbances, more research is needed to determine if these strategies will help improve insomnia in individuals with other substance use disorders as well.

+
d) Co-occurring psychiatric and substance use disorders
+ (1) General principles

Co-occurring psychiatric and substance use disorders are common in all treatment settings (e.g., centers for the treatment of substance use disorders, mental health clinics, primary care settings, emergency departments) and in the general community. In fact, only a few differences (e.g., higher prevalence of schizophrenia and primary psychotic disorders in mental health care settings, more severe patterns of substance use in substance use treatment settings) are observable between patients with co-occurring psychiatric disorders receiving treatment in substance abuse treatment centers and patients with co-occurring substance use disorders receiving treatment in mental health treatment centers (340). In community population samples studied in the National Comorbidity Survey (341), individuals with alcohol dependence had high rates of clinically significant depression during their lifetime (men: 24% depression and 11% dysthymia; women: 49% depression and 21% dysthymia). Individuals with bipolar disorder had high rates of alcohol (61%) and other substance (41%) dependence (342). Treatment-seeking individuals have even higher rates of co-occurring disorders (343–345). For example, Penick et al. (346) studied a U.S. Department of Veterans Affairs (VA) hospital outpatient population with alcohol dependence or abuse and found that 56% reported co-occurring psychiatric disorders. In substance use disorder treatment settings, depression, anxiety, and personality disorders frequently occur. However, posttraumatic stress disorder (PTSD), adult ADHD, learning disabilities, social anxiety disorder, eating disorders, and pathological gambling are also common and are often underrecognized and undertreated (121, 288).

Individuals with nicotine dependence are more likely to have co-occurring psychiatric disorders than the general U.S. population (347). Furthermore, in mental health and substance use disorder treatment settings, nicotine dependence continues to be the most common co-occurring substance use disorder, with approximately 60%–95% of patients being nicotine dependent, although this varies by the type of psychiatric disorder and the treatment setting (348). One analysis of nicotine use as reported in the National Comorbidity Survey found that individuals with psychiatric disorders were about twice as likely to smoke as the general population and that about 44% of the cigarettes smoked in the United States were smoked by individuals with a psychiatric disorder (349).

Use of multiple substances and co-occurring psychiatric and substance use disorders are now so common in treatment settings that these combinations should be expected. Thus, all patients with a substance use disorder should be carefully assessed for the presence of co-occurring psychiatric disorders, including additional substance use disorders. Conversely, patients with identified psychiatric disorders should be routinely assessed for the presence of a co-occurring substance use disorder (350, 351).

Treating individuals with co-occurring psychiatric and substance use disorders in traditional inpatient and outpatient programs is challenging. Patients' motivation to change may vary according to the type of substance(s) they use and the severity of their psychiatric issues, and this needs to be taken into consideration in treatment planning. Recent research and consensus opinions by experts in the field support the notion that the integration of substance abuse and mental health treatment strategies, including integrated systems, programs, and clinical treatment, improves patient outcome (80, 121, 352, 353). There is growing evidence that patients in psychiatric or substance abuse treatment settings have better outcomes if they receive integrated treatment for their coexisting psychiatric and substance use disorders (121, 288, 354–356). Integrated treatment usually requires incorporating and modifying traditional psychiatric and substance abuse treatment methods so that the co-occurring disorders receive simultaneous treatment.

+ a. Integrated treatment

Recent research and clinical experience (80, 288) has also shed light on the question of treatment timing (e.g., if co-occurring disorders should be treated together in an integrated manner or in what circumstances one problem should be addressed before another). In general, the length of the observation period for a psychiatric or substance use disorder will be determined by balancing the following considerations: the degree of diagnostic certainty, the severity of the patient's condition, and the anticipated benefits and risks of the proposed treatment (288, 353).

The integrated treatment of co-occurring psychiatric and substance use disorders can include psychosocial and/or pharmacological interventions. Initial treatment efforts should include engaging the patient in treatment and assessing and managing the most severe symptoms of both types of disorders. This may include addressing symptoms of intoxication or withdrawal. Sometimes severe psychiatric symptoms (e.g., psychosis, suicidal ideation) can be managed while a patient is intoxicated or experiencing withdrawal; such patients may require immediate treatment in an emergency department or an inpatient psychiatric unit. Once a patient's acute psychiatric symptoms and intoxication or withdrawal states have been stabilized, the patient can be evaluated for treatment in an ongoing rehabilitative treatment program. When patients are being treated in a substance abuse treatment setting, their psychiatric symptoms should be monitored and addressed clinically through psychiatric medications, when appropriate, as well as through integrated psychosocial strategies (e.g., teaching patients mood management as part of relapse prevention therapy) and integrated treatment approaches for psychiatric disorders and substance use disorders (357).

In a psychiatric treatment setting, it would be incorrect to assume that successful treatment of a psychiatric disorder will resolve the substance use disorder. The substance use disorder will require specific treatment even when it arises in the context of another psychiatric disorder, a situation that is quite common and that presents an opportunity for the prevention of a secondary disorder (358).

Certain psychosocial and pharmacological treatments have been studied for specific combinations of psychiatric and substance use disorders (e.g., major depression and alcohol dependence, schizophrenia and cocaine dependence) (288, 353); the literature about these treatments is presented in the specific substance use disorder sections of this practice guideline. The reader is also advised to review other APA practice guidelines for the treatment of patients with specific psychiatric disorders for additional information.

+ b. Pharmacological management of psychiatric disorders

In most patients, the same medications are recommended for the treatment of a specific psychiatric disorder whether that disorder co-occurs with a substance use disorder or not. Clinical issues such as medication tolerability, safety, and abuse potential are important considerations in choosing a medication and will influence traditional psychopharmacological treatment algorithms. There is no evidence to suggest that the duration of pharmacotherapy for a psychiatric disorder in conjunction with a co-occurring substance use disorder would differ from that needed to treat the psychiatric condition alone, and there are no data to suggest that decisions about continuation and maintenance treatment should differ (288). An important clinical question in treating a co-occurring psychiatric disorder in a substance use disorder treatment setting is whether the prescribing clinician should initiate psychiatric medications during the acute treatment of the substance use disorder. For some psychiatric disorders (especially depression, generalized anxiety disorder [GAD], social anxiety disorder, and PTSD), there have been widely differing opinions about the amount of time a patient should be abstinent from a substance before a definitive diagnosis of a co-occurring psychiatric disorder versus a substance-induced psychiatric disorder can be made. If there is little overlap between the symptoms observed and the expected abstinence syndrome (such as bulimia nervosa in an opioid-dependent patient), then the psychiatric diagnosis can be immediately established. In circumstances when prominent mood or anxiety symptoms could be equally attributable to early abstinence or an independent co-occurring psychiatric disorder, a clinician may consider whether similar symptoms occurred before the substance use or during previous abstinence periods or whether the individual's family history suggests a vulnerability to a co-occurring mood or anxiety disorder. A common recommendation is to consider the severity of an individual's functional impairment when deciding whether or not to initiate pharmacotherapy, continue ongoing monitoring of symptoms, and initiate psychosocial treatment strategies for the management of anxiety and depression (288).

Medication nonadherence is common among individuals with co-occurring psychiatric and substance use disorders (359, 360). Nonadherence can be due to many factors, including cognitive impairment, the patient's fear of the interaction between prescribed medication and substances being abused, fear that the prescribed medication is itself harmful, change in motivation, and lack of support. Some patients attending 12-step meetings may feel pressure from some group members not to take psychiatric medications because they are "mood altering"; however, AA does support the appropriate use of needed medications (361, 362). AA brochures and other resources do state a reasonable concern about individuals' avoiding psychotropic medications with an abuse potential (e.g., sedative-hypnotics, anxiolytics, stimulants). When such medications are necessary, a clinician should prescribe them with caution and closely monitor their use (e.g., dispense in limited quantities, track prescription refills, monitor ongoing medical necessity for and the patient's response to the medication).

+ c. Medications to treat substance use disorders

Medications for treating substance use disorders, such as those for managing acute withdrawal and protracted withdrawal symptoms or reducing craving, have not been well studied in dually diagnosed populations but should be considered for these patients. The presence of a co-occurring mental illness may influence a clinician's decision to prescribe disulfiram for alcohol-dependent patients if, for example, the clinician is concerned about a patient's capacity to adhere to prescribing instructions due to acute psychiatric symptoms. However, a 12-week multicenter, randomized, controlled trial of disulfiram in patients with co-occurring alcohol dependence and psychiatric illness demonstrated the safety and effectiveness of this medication with this population (363). This same study also substantiated the safety and efficacy of naltrexone use in this population. However, no further benefit was achieved in this study by combining disulfiram and naltrexone.

+ d. Integrated psychosocial treatments

Psychosocial treatment is very important in the treatment of a substance use disorder both with and without a co-occurring psychiatric disorder. Integrated psychotherapy approaches represent some of the most recent advances in psychosocial treatments, and several have been developed for specific subtypes of co-occurring disorders. A common feature of these integrated therapies is their blending of traditional evidence-based psychotherapies with traditional evidence-based substance use disorder therapies such as MET, relapse prevention therapy/CBT, and TSF therapy. Examples of psychiatric disorders for which integrated treatments have been developed include PTSD (364–368), bipolar disorder (369), schizophrenia (80, 360, 370–372), and personality disorders (373, 374). The efficacy of these integrated psychotherapies is being actively investigated in individual as well as in family and group modalities (375–377).

+ (2) Treatment in the presence of specific co-occurring psychiatric disorders
+ a. Schizophrenia

A review of the literature examining nicotine dependence among individuals with schizophrenia demonstrated prevalence rates of 68%–88% among outpatients and 81%–88% among inpatients (378), suggesting that substance use vulnerability alone cannot account for the high smoking rates among patients with schizophrenia. Patterns of nicotine use among patients with schizophrenia are more severe than in patients with other psychiatric diagnoses (379), and these usage patterns are associated with increased morbidity and mortality due to tobacco-related medical diseases such as cancer and cardiovascular and respiratory diseases (359, 380–383). Apart from nicotine dependence, about 40%–60% of individuals with schizophrenia will have another co-occurring substance use disorder during their lifetime (353, 384, 385). Substance-abusing individuals with schizophrenia are more likely to be male, young, and less educated and have better social skills than those not abusing substances, but they have less peer support and poorer treatment outcomes in traditional substance abuse treatment settings because of the stress associated with the confrontational treatment approaches sometimes used in these programs (353, 386). Because substance abuse treatment staff typically have limited training in managing psychosis and because mental health clinicians are trained and able to provide both medications and psychosocial treatment for schizophrenia, this population most commonly receives integrated treatment for the co-occurring disorders within the mental health system.

Effective integrated treatment programs have used one clinical team to provide long-term, comprehensive care (i.e., medication and psychosocial treatment interventions) for both psychotic and substance use disorders (80, 353). Treatment is provided in the patient's natural environment, is matched to the patient's motivational state, provides comprehensive community services (e.g., stable housing, financial assistance through entitlements, vocational rehabilitation), and is not limited in duration (80, 387). Integrated treatment often begins by stabilizing a patient's psychotic symptoms, which may require psychiatric hospitalization. Integrated treatment programs can then initiate substance abuse treatment when the patient is sufficiently stable to participate in the psychosocial treatments for the psychiatric and substance use disorders. Thus, the acute stabilization phase may initially emphasize appropriate antipsychotic and psychosocial treatments that help stabilize the illnesses (353, 371).

+ 1) Pharmacotherapy

Existing studies and reports from expert consensus meetings on co-occurring disorders support the same first-line agents recommended in APA's Practice Guideline for the Treatment of Patients With Schizophrenia (388) for individuals with co-occurring schizophrenia and substance use disorders (80, 288). With the possible exception of clozapine for patients with treatment-resistant symptoms, antipsychotics generally have similar efficacy in treating the positive symptoms of schizophrenia (389), although there is emerging evidence and an ongoing debate regarding whether second-generation antipsychotics may have superior efficacy in treating global psychopathology and cognitive, negative, and mood symptoms (388). Various smaller studies have found better outcomes with clozapine (390–398), risperidone (394, 399–402), and olanzapine (403, 404) than with first-generation antipsychotics for patients with co-occurring schizophrenia and substance use disorders. However, most of these studies were retrospective, nonrandomized, or uncontrolled pilot studies. Furthermore, no evidence to date suggests that any one second-generation antipsychotic is more efficacious than another in this population, and no trials have been reported that compare these agents in the same clinical study. Some have thought that clozapine should be considered as a first-line agent in patients with schizophrenia co-occurring with a substance use disorder because of the number of studies supporting its use (394) and its ability to reduce the risk of suicidal behaviors (405). In addition, clozapine may have beneficial effects in decreasing smoking (406–408). However, most experts have continued to recommend clozapine as a second-line agent (288) because of the need for regular monitoring of the patient's white blood count to detect granulocytopenia or impending agranulocytosis, as well as other concerns about clozapine's side-effect profile (i.e., increased seizure risk and sedation). Because significant nonadherence to clozapine necessitates the retitration of the medication dose and because blood monitoring is an essential part of clozapine treatment, clozapine is generally used in more motivated patients and in well-integrated treatment programs.

In choosing an antipsychotic medication, a clinician should assess patient preferences and vulnerabilities regarding side effects, interactions with abused substances, and other safety considerations. It should be noted that individuals with schizophrenia who abuse alcohol and cocaine may have an increased risk for seizures or liver toxicity and may have cardiac abnormalities as a result of their substance use. Medications that may induce QT prolongation should be used with caution, with electrocardiographic monitoring as needed. Because most antipsychotic medications are hepatically metabolized and can lower seizure threshold to some degree, these factors should also be taken into consideration when choosing among antipsychotic medications. Patients with schizophrenia may also experience increased somnolence and orthostatic hypotension if they abuse alcohol or other sedating drugs while taking antipsychotic medications. Tobacco smoking substantially lowers blood levels of clozapine, olanzapine, and numerous first-generation antipsychotics (e.g., haloperidol, fluphenazine, chlorpromazine, thioridazine) by increasing cytochrome P450 (CYP) 1A2 enzyme hepatic metabolism, a moderate effect that may necessitate an increase in the medication dose. The metabolism of other second-generation antipsychotics is not significantly affected by changes in smoking status.

Another clinically important issue in this population is addressing poor adherence with both pharmacological and psychosocial interventions. The use of long-acting, injectable antipsychotic medications can help increase medication adherence. A long-acting, injectable form of the second-generation antipsychotic risperidone is available as are long-acting decanoate preparations of first-generation antipsychotics (i.e., haloperidol, fluphenazine); there have been no direct comparisons of these long-acting first- and second-generation antipsychotic agents in this population.

In general, medications targeting specific substance use disorders can be safely prescribed for patients with co-occurring schizophrenia and substance use disorders (288). However, careful assessment is indicated before initiating treatment with disulfiram. Given the cognitive difficulties associated with schizophrenia, disulfiram should be reserved for use in individuals whose judgment and memory are adequate and for whom impulsivity is not a significant concern. In addition, there may be some further concern about using high-dose disulfiram in this population because carbon disulfide, a metabolite of disulfiram, inhibits dopamine -hydroxylase, increases dopamine levels, and could potentially worsen psychosis (409, 410). Specific studies also support the use of naltrexone for alcohol dependence and methadone for opioid dependence in this population (411–413). The treatment of nicotine dependence with NRTs (i.e., nicotine patch, gum, spray, inhaler, or lozenge) and bupropion has helped improve treatment outcomes for tobacco smokers with schizophrenia (414, 415). There is a theoretical concern that bupropion may increase psychotic symptoms; however, this concern has not been borne out in studies to date (414). There are improved outcomes with combining NRT and bupropion with psychosocial treatments that are specific to nicotine dependence (348, 416).

+ 2) Psychosocial treatments

Integrated psychosocial treatments for individuals with co-occurring schizophrenia and substance use disorders most commonly occur in mental health settings and include unique psychotherapy approaches as well as modified treatment programs and systems (352). One key aspect of integrated treatment is that patients do better when clinicians are able to maintain an optimistic, empathic, and helpful approach (417). Integrated programs often provide comprehensive services, including active outreach and case management in the community setting, in an effort to better engage and retain patients and help them transition between different levels of care (370, 417). Model integrated treatment programs have been described and evaluated in the literature (417), including assertive community treatment teams and integrated stage-based motivational models; these models tend to emphasize a recovery-oriented perspective while combining medications, MET, relapse prevention therapy, social skills training, and specific dual recovery therapy approaches (80, 371, 386, 418, 419). Other helpful components to integrated treatment programs include contingency management and money management (360, 372). Money management helps patients prevent relapse, given that many receive Social Security disability or Supplemental Security Income payments and are most vulnerable to substance use and relapse soon after receiving these funds (372).

+ b. Depressive disorders

Major depressive and substance use disorders commonly co-occur in clinical populations and in the community (341, 343, 344, 420). Studies have demonstrated that individuals diagnosed with major depressive disorder have high lifetime co-occurrence rates of alcohol abuse (men 9% and women 30%) and alcohol dependence (men 24% and women 48.5%) (421). Among individuals with major depressive disorder, approximately 25% have a co-occurring substance use disorder (422). A large prospective, longitudinal study has demonstrated that alcohol and drug use disorders during adolescence predict later development of major depressive disorder in young adults (423).

Mood disturbance is one of the most common symptoms reported by individuals in substance use disorder treatment programs. In addition to the high rate of co-occurring major depressive and substance use disorders, patients in substance use disorder treatment settings frequently experience substance-induced mood disorders in which signs and symptoms of depression are related to acute substance intoxication or to acute or protracted withdrawal from substances; these symptoms remit with maintained abstinence (424). Because it is often difficult for a clinician to discern whether a cluster of symptoms is due to co-occurring major depressive disorder, substance intoxication, substance withdrawal, substance-induced mood disorder, or some combination thereof, guidelines have been established for diagnosing and treating mood symptoms in the context of a substance use disorder (425). When possible, it is advisable to delay antidepressant pharmacotherapy by 1–4 weeks, depending on the nature and severity of the mood symptoms, to allow the clinician to identify substance-induced mood symptoms that may remit without medication intervention.

In general, treatment of depressive symptoms of moderate to severe intensity should begin concurrently or soon after initiating treatment of the co-occurring substance use disorder, particularly if there is evidence of prior mood episodes. In individuals without prior episodes of depression or a family history of mood disorders, it may be appropriate to delay the treatment of mild to moderate depressive symptoms for the purpose of diagnostic clarification. Clinicians are advised to monitor symptoms, assess and reassess for suicidal ideation, provide education, encourage abstinence from substances, and observe changes in mental status during the substance-free period while actively considering whether antidepressant intervention is indicated (288, 426–429).

+ 1) Pharmacotherapy

Existing studies and expert consensus support the use of first-line agents recommended in APA's Practice Guideline for the Treatment of Patients With Major Depressive Disorder (430) and substance use disorder medications for detoxification, protracted withdrawal, and agonist maintenance treatment (288). Randomized, controlled trials supporting the efficacy of antidepressant pharmacotherapies for co-occurring major depressive disorder and specific substance use disorders exist for alcohol dependence, opioid dependence, cocaine use disorders, and nicotine dependence.

A meta-analysis of 14 well-designed placebo-controlled trials of antidepressant medication for co-occurring major depression and alcohol, opioid, or cocaine dependence (425) showed an overall beneficial effect of medication on mood outcome, similar in magnitude to the effect size observed in clinical trials involving depressed patients without substance problems. Studies showing the largest effects of medication on mood outcome also showed significant beneficial effects of medication on self-report measures of substance use, although rates of abstinence were low. The results across studies were inconsistent, with eight positive and six negative studies. The positive studies, those demonstrating a beneficial effect of antidepressant medication, had low placebo response rates and were more likely to have required at least a week of abstinence prior to diagnosing depression and starting medication. The evidence for medication effectiveness was more consistent among studies of patients with alcohol dependence than among studies of patients with drug dependence, in agreement with the conclusion of another recent meta-analysis (430a).

Of the selective serotonin reuptake inhibitors (SSRIs), fluoxetine (431) and sertraline (432–434) have been studied in the treatment of co-occurring major depressive disorder and alcohol dependence, and evidence is also available for the use of nefazodone (435, 436) and the tricyclic antidepressants (TCAs) imipramine (428, 437) and desipramine (438). These agents, however, have not been compared with each other nor has there been an adequate number of studies of other SSRIs to make recommendations for specific antidepressants as first-line agents in this population. A review of the literature indicates that antidepressant treatment is more effective in ameliorating mood symptoms than in improving drinking outcomes for this dually diagnosed population (439). Given the reported risks of hepatotoxicity and death with nefazodone use (440), this medication is not generally recommended unless other therapies have failed.

The evidence base for antidepressant pharmacotherapy in co-occurring opioid dependence and major depressive disorder is inconsistent and well studied only in methadone-maintained populations. Results of randomized, placebo-controlled trials of TCA treatment are mixed, with some showing no differences between antidepressant treatment and placebo (441–443) and others showing superior efficacy of TCAs compared with placebo (444–447). Evidence for SSRI efficacy in the same population is weaker (448), and many studies have failed to demonstrate beneficial effects of SSRIs on mood symptoms (413, 449, 450). Nevertheless, the relative safety of SSRIs as compared with TCAs in this population continues to influence the choice of SSRIs as first-line agents for patients with co-occurring opioid use disorder and major depressive disorder. Although the duration of antidepressant treatment in these studies was not >3 months, there are no available data to suggest that the duration of an antidepressant trial should be different than that used for treating major depressive disorder without a substance use disorder.

Treating mood symptoms in individuals with co-occurring cocaine use and major depressive disorders is complicated by the frequent occurrence of depressive symptoms during acute withdrawal from cocaine. Some randomized, controlled trials support the use of antidepressant intervention in these individuals (451, 452); this population also appears to have a more favorable mood response to TCAs than to SSRIs (453).

Nicotine dependence commonly co-occurs with major depressive disorder. In large well-designed, placebo-controlled trials, the antidepressant medications bupropion (158, 454) and nortriptyline (455, 456) have been found to improve smoking cessation rates and to prevent relapse after successful quit attempts. Smokers with a current major depression were excluded from these studies. The beneficial effects of both nortriptyline (456) and bupropion (454, 1587) have been shown not to depend on a past history of major depression—that is, the medications are equally effective for smokers with and without past depression. An analysis of mediators of treatment effect (456) suggested nortriptyline improves smoking cessation by reducing postquit dysphoria, with the effect, again, independent of past history of major depression. Serious depression sometimes emerges after a patient has successfully quit smoking (457, 457a, 763), suggesting the importance of monitoring mood during quit attempts. Studies are needed of the treatment of smokers with current depressive disorders. However, in such patients, most clinicians will prioritize stabilization of the depressive episode and then subsequently address treatment of nicotine dependence during the maintenance phase of depression treatment (348). Sustained-release bupropion for treating nicotine dependence may be safely added to other antidepressants (e.g., SSRIs, which do not alter smoking cessation rates) being used to treat major depressive disorder (458). NRTs are also recommended as a first-line option in treating nicotine dependence in depressed smokers. In addition, integrating standard tobacco dependence–related psychosocial treatment into ongoing psychosocial treatment for depression improves both tobacco dependence and depression outcomes among smokers with recurrent depression and heavy smoking (459).

Many patients with co-occurring major depressive and substance use disorders will report experiencing insomnia or anxiety symptoms. Such symptoms are optimally addressed using behavioral strategies (e.g., stress reduction, relaxation skills, adherence to sleep hygiene) and/or pharmacological interventions with medications that do not have a potential for abuse (e.g., buspirone) before medications with abuse potential (e.g., benzodiazepines, nonbenzodiazepine hypnotics such as zolpidem) are considered. Although not specifically studied in co-occurring major depressive and substance use disorders, the antidepressant trazodone may represent an additional option (see Section II.G.2.c).

In the context of continued substance use, inadequate symptom improvement should not lead the clinician to conclude that a medication regimen is a therapeutic failure. Patients with persistent depression and substance use may benefit from more frequent outpatient visits or referral to a higher level of care (e.g., intensive outpatient, partial or residential hospitalization, inpatient treatment).

+ 2) Psychosocial treatments

Integrated psychosocial therapies have been developed, and their efficacy is being tested in controlled trials for patients with co-occurring major depressive disorder and substance use disorders (456, 460, 461). These psychotherapy approaches combine traditional therapies for substance use disorders (e.g., MET, TSF, relapse prevention therapies, CBT, contingency management) with traditional therapies for depression (e.g., cognitive therapy, behavioral therapy, IPT, and brief psychodynamic therapy) (357, 462). These approaches commonly try to help patients identify and manage triggers for substance use, understand and manage feelings, deal with grief and anger, change thoughts and beliefs that worsen mood, improve relationships, and change behaviors and lifestyles (463).

+ c. Bipolar disorder

Individuals with bipolar disorder are at high risk for a co-occurring substance use disorder; community lifetime prevalence rates of co-occurrence are 50% (341, 420). Substance use disorders influence bipolar disorder by worsening each episode as well as worsening the overall course of the disorder by causing more mixed episodes, earlier onset, more frequent episodes, and slower symptom remission (464).

Few medication studies have been conducted with co-occurring bipolar and specific substance use disorders; however, the existing research (464–468) and expert consensus (469, 470) support use of the first-line agents recommended in APA's Practice Guideline for the Treatment of Patients With Bipolar Disorder (471) and the use of adjunctive medications that target specific substance use disorders. The few medication studies examining co-occurring bipolar and substance use disorders support the use of valproate (or valproic acid or divalproex) as a mood stabilizer because it shows some evidence of efficacy and appears to help overall treatment adherence (472). In addition, some evidence suggests that patients with these co-occurring disorders are more likely to respond to valproate or a combination of valproate plus lithium than to lithium alone (465–468, 472, 473). The relative lack of efficacy with lithium may be due to an increase in side effects or the difficulty that patients with co-occurring bipolar and substance use disorders have in achieving stable lithium blood levels. The use of carbamazepine in this population is supported by a few studies with positive outcomes (474). There is only one small pilot study to date evaluating the role of second-generation antipsychotics in patients with co-occurring substance use and bipolar disorders (475). Therefore, treatment recommendations follow those presented in APA's Practice Guideline for the Treatment of Patients With Bipolar Disorder (471), with first-line pharmacological treatment for more severe manic or mixed episodes with lithium or valproate plus an antipsychotic. For less ill patients, monotherapy with lithium, valproate, or an antipsychotic may be sufficient. Second-generation antipsychotics are generally preferred over first-generation antipsychotics because they appear less likely to cause tardive dyskinesia and extrapyramidal side effects; however, the possibility of weight gain, diabetes, and hyperlipidemia with these agents requires consideration. Second-generation antipsychotic agents with an FDA indication for use in treating acute manic or mixed episodes in bipolar disorder include olanzapine, risperidone, ziprasidone, and aripiprazole. Quetiapine has an FDA indication for the treatment of acute episodes of mania. In the acute setting of a manic episode, a benzodiazepine may be helpful. However, the general concern about using a medication with high abuse potential must be considered; therefore, caution should be exercised in using benzodiazepines beyond the time period of the acute manic episode. For mixed episodes, valproate may be somewhat more efficacious and thus may be preferred over lithium (465–468). Pharmacological alternatives to lithium and valproate include carbamazepine or oxcarbazepine. The possibility of pregnancy should be considered when prescribing valproate or carbamazepine for women of childbearing age, particularly given the increased risk of neural tube defects if the fetus is exposed to these medications in utero.

Because there are no specific studies of the treatment of bipolar depression in substance-abusing individuals, medication strategies should follow the recommendations for managing bipolar depression described in APA's Practice Guideline for the Treatment of Patients With Bipolar Disorder (471). The guideline recommends the initiation of lithium or lamotrigine as a first-line pharmacological treatment. Lamotrigine should be used cautiously in individuals with co-occurring bipolar and substance use disorders because active substance users may be unreliable in reporting rashes; gradual titration of lamotrigine is needed and may be problematic in individuals who may be inclined to take excess medication doses, and drug-drug interactions may alter lamotrigine levels and increase the risk of rash (476). Antidepressant monotherapy is not recommended due to concerns about precipitating a mixed or manic episode or contributing to the development of rapid cycling. As an alternative, especially for more severely impaired patients, some clinicians will initiate simultaneous treatment with lithium and an antidepressant. Also, IPT and CBT may help treat symptoms of bipolar depression when they are added to pharmacotherapy.

Integrated psychosocial treatments for bipolar and substance use disorders have been developed and demonstrated to be effective by Weiss et al. (369). The group therapy–based treatment approach in this study integrated cognitive-behavioral approaches that were effective in treating both disorders. The approach has been described in a clinical treatment manual for clinicians that includes educational, motivational, and coping strategies to enhance medication adherence and self-efficacy with cues and triggers for drug use (369).

Although nicotine dependence is common among individuals with bipolar disorder, there have been no reports on treating nicotine dependence in this population (348). Recommendations for treating co-occurring bipolar disorder and nicotine dependence are to integrate the standard somatic and psychosocial treatments for nicotine dependence (see Section III) into the context of the maintenance phase of treating bipolar disorder.

+ d. Anxiety disorders

Symptoms of anxiety and anxiety disorders commonly co-occur with substance use disorders (341). Based on a sample of individuals between ages 15 and 54 years, lifetime rates of anxiety disorders (including GAD, panic disorder, specific phobia, social phobia, obsessive-compulsive disorder, PTSD, and acute stress disorder) in the community are estimated to be about 19% in men and 31% in women (341). About 50% of individuals with a substance use disorder have an anxiety disorder (341, 420), with different rates for different anxiety disorders. For example, about 4.5% of patients with a substance use disorder have panic disorder, and 16% of panic disorder patients have a co-occurring substance use disorder (341). Despite the high prevalence rates, anxiety disorders are frequently underdiagnosed in substance abuse treatment settings (477). Because many substances cause state-dependent anxiety symptoms (i.e., during intoxication, acute withdrawal, or protracted withdrawal), the assessment of anxiety disorders in substance-using populations is challenging and requires careful assessment. The clinician should ask about symptoms that relate to specific anxiety disorders and use similar considerations during the assessment process to those recommended for depression symptoms and substance use disorders. Although nicotine dependence is also common among individuals with anxiety disorders, there are almost no treatment studies for this population, and treatment should follow the standard somatic and psychosocial treatment recommendations for nicotine dependence (see Section III).

Integrated treatment for co-occurring anxiety and substance use disorders may include medications and psychosocial treatments from both substance abuse and psychiatric treatment perspectives. Specific medications and CBTs for specific anxiety disorders have been developed and can be combined with the usual treatments for substance use disorders. Providing education about the anxiety and substance use disorders and the effects the disorders have on each other is also important.

The recommended medications for treating panic disorder with a co-occurring substance use disorder are SSRIs plus integrated psychosocial treatment (288, 478). If several SSRIs are tried and found to be ineffective, then a TCA may be considered; however, TCAs may be of concern when using them in the context of co-occurring substance use disorders because of the risk of cardiac toxicity and seizures and the potential for overdose in a suicide attempt. Although benzodiazepines are usually considered a first-line treatment for panic disorder in patients without an active substance use disorder, the risk of benzodiazepine abuse is a significant concern and precludes this class of medications from being first-line agents in treating panic disorder in the context of a coexisting substance use disorder. In rare cases, physicians have treated severe panic symptoms by using benzodiazepines on a time-limited basis, selecting patients without a history of misusing benzodiazepines but who have a family history of panic disorder, and fully informing the patient and sometimes the family of the risks of taking benzodiazepines. Physicians may also limit prescriptions, supervise medication administration, monitor medication adherence with pill counts, and request that patients come for more frequent office visits while patients are taking benzodiazepines. Two double-blind, placebo-controlled studies have demonstrated the efficacy of buspirone in patients with alcohol dependence and anxiety (479, 480).

Pharmacotherapy for social anxiety disorder in the context of co-occurring substance use disorder may include beta-blockers or SSRIs along with integrated psychosocial treatment. In a recent study in which simultaneous treatment of social anxiety disorder and co-occurring alcohol dependence was compared with treatment of alcohol dependence alone, both treatment conditions improved alcohol-related outcomes and social anxiety; however, treatment focused on alcohol only was associated with better alcohol use outcomes (481). Although more studies of concurrent treatments for social anxiety and substance use disorders are needed, these findings suggest that combination treatment of social anxiety and alcohol use disorders may not be effective for all patients.

The treatment of obsessive-compulsive disorder in the context of a co-occurring substance use disorder uses pharmacotherapy with SSRIs and integrated psychosocial treatment. TCAs, including clomipramine, may be of concern for use in patients with co-occurring substance use disorders because of the risk of seizures and the potential for overdose in a suicide attempt. Second-generation antipsychotics may be an option for some individuals (288).

GAD commonly co-occurs with other psychiatric and substance use disorders. CBT approaches can be particularly helpful for symptoms of preoccupation/rumination and exaggerated perceptions of danger. First-line agents for this population include buspirone and SSRIs. Although benzodiazepines may be used chronically in GAD patients with no substance use disorder, their use should be limited or applied in only the previously described circumstances in patients with a substance use disorder because of their abuse potential (288).

PTSD is common among individuals with a substance use disorder (about 20%), with women having about twice the rate of co-occurring PTSD as men (482); however, clinicians are advised not to overlook the possibility of PTSD in male patients, because in the general community, rates of PTSD are higher for men than for women (483). Rates of PTSD appear to be high in substance use disorder treatment settings, with one study reporting that 40% of 95 substance- abusing/dependent inpatients met criteria for current PTSD (484). Women with PTSD and a substance use disorder often experienced childhood physical and/or sexual abuse, whereas men typically experienced combat or were victims of crime (483). PTSD symptoms are a common trigger of substance use, and patients may perceive the substances as a way of coping with overwhelming emotional pain (485–488). Indeed, one study showed that individuals with PTSD and either cocaine or alcohol dependence experienced increased craving when exposed to both trauma and drug cues (489). As patients with co-occurring PTSD and a substance use disorder participate in treatment and become able to maintain continued abstinence, they may feel overwhelmed by a flood of memories and unprocessed feelings about the past traumas that have been masked by substance use (490). Simply because patients have become abstinent from substances does not mean that symptoms of PTSD have resolved, and these will need to be addressed in treatment (491, 492). Patients may carry a great burden of shame and guilt, as both PTSD and substance abuse may be associated with keeping secrets and denial. These individuals are sometimes perceived as "crazy," "lazy," or "bad" by others and by themselves, and these issues are similarly important to anticipate in psychotherapy (490).

Specific integrated psychotherapies for PTSD co-occurring with a substance use disorder have been developed and evaluated (365, 368, 490). These approaches have similar components in that they educate the patient about both disorders and how the two problems interact to worsen the course of either disorder alone. Treatment focuses on stabilizing the substance use disorder and developing coping skills to manage the PTSD symptoms and trauma memories as they occur during the early phase of abstinence as well as after prolonged periods of abstinence (490). Seeking Safety (490), an empirically tested group treatment for patients with PTSD and a coexisting substance use disorder, and integrated treatment approaches that combine the 12-step treatment model from substance use disorder treatment with traditional psychotherapeutic approaches to PTSD have been developed to treat this patient population (493, 494). One study of 107 women were randomly assigned to receive Seeking Safety treatment, a manual-guided relapse prevention therapy, or standard community treatment found that women receiving Seeking Safety or relapse prevention therapy had significant reductions in substance use, PTSD, and psychiatric symptoms over the 3-month treatment period, whereas the symptoms of women who received standard community treatment worsened (364); furthermore, the Seeking Safety and relapse prevention groups maintained the greater improvements in substance use and PTSD symptoms at the 6- and 9-month follow-ups. Outcomes did not differ between the Seeking Safety and relapse prevention groups.

Many integrated treatment approaches discourage having the patient describe or explore traumatic memories as might be done in exposure therapy. Only a few pilot studies have been published that evaluate trauma exploration therapies (e.g., exposure therapy) in substance-abusing patients (365, 368). In those few studies, positive results were generally reported. One recently published effectiveness trial of integrated exposure-based therapy for PTSD and psychosocial treatment of substance use disorders reported feasibility and clinical effectiveness within an inner-city mental health treatment setting serving dually diagnosed patients (366). Future research is needed to define which patients may benefit from this type of treatment. Other psychosocial treatments used to treat PTSD are being considered for adaptation to patients with PTSD and a co-occurring substance use disorder; these include mourning therapy (495), eye movement desensitization and reprocessing (496), and the counting method (497).

Medication recommendations for treating PTSD in the context of a co-occurring substance use disorder follow the general recommendations from APA's Practice Guideline for the Treatment of Patients With Acute Stress Disorder and Posttraumatic Stress Disorder (498). The SSRIs are considered first-line medication treatment for PTSD. Given the abuse potential of benzodiazepines, prescribing them to patients for the treatment of PTSD presents a risk for substance relapse and/or the development of a new substance use disorder.

+ e. Attention deficit hyperactivity disorder

Substance use disorders are common in adolescents and adults with ADHD, with about 33% of adult ADHD patients having a history of an alcohol use disorder and about 20% having a drug use disorder; even higher prevalence rates (50%–60%) of co-occurring nicotine dependence have been reported (341, 499). Among patients with alcohol, cocaine, or opioid dependence, 17%–50% have co-occurring ADHD (499). Establishing a diagnosis of ADHD can be complicated in the context of ongoing substance use, because attention problems are often caused by the acute and prolonged effects of specific substances of abuse, and these attention problems will often improve with prolonged abstinence. On the other hand, delaying adequate treatment of co-occurring ADHD may compromise a patient's capacity to fully participate in treatment for a substance use disorder (500, 501). Therefore, it is recommended that treating physicians attempt to gather evidence supporting a co-occurring ADHD diagnosis (e.g., childhood ADHD, evidence of symptoms during prolonged abstinence from substance use) during early assessment and treatment planning. Clinicians are also advised to assess patients with co-occurring ADHD and a substance use disorder for other commonly co-occurring psychiatric disorders (e.g., learning disorders, mood and anxiety disorders, conduct disorder/antisocial personality disorder) (499).

The occurrence of childhood ADHD contributes independently of other psychiatric disorders to the risk of developing an early-onset substance use disorder (502, 503). Early interventions for childhood ADHD (psychosocial and/or pharmacotherapy) may help to prevent new-onset substance use disorders in this population in adulthood.

Even though stimulants are commonly recommended for the treatment of childhood ADHD, concerns that childhood use of prescribed stimulants may predispose an individual to a future substance use disorder are unsubstantiated (504). In fact, a recent meta-analysis of the literature indicated that childhood stimulant therapy lowers the risk of developing a concurrent alcohol or drug use disorder during adolescence and adulthood (505, 506).

Stimulant pharmacotherapy is effective for adolescent and adult ADHD (507) and may be effective for patients with a co-occurring substance use disorder (508–510); however, clinicians must carefully assess symptom improvement with stimulant treatment against the risk for misuse or diversion of prescribed stimulants. Prescription monitoring (e.g., limited dispensing, medication logs) and the use of long-acting stimulant preparations and standardized clinical symptom assessments (511, 512) are recommended. When there is concern about the safety of stimulant treatment in patients with ADHD and a substance use disorder, alternative ADHD pharmacotherapies without an abuse potential may be considered, such as atomoxetine, bupropion, and desipramine (513).

ADHD symptoms often interfere with a patient's adherence to substance use treatment, and therefore integrated psychosocial and pharmacotherapy treatment is recommended for patients with ADHD and a substance use disorder (501, 514). Although integrated psychosocial interventions for this population are recommended, research to support their use is limited. Expert consensus recommends providing patients with education about both disorders, encouraging their active participation in support groups, and modifying psychosocial treatments to facilitate learning (e.g., using brief structured sessions with written handouts) (288, 499).

+ f. Eating disorders

Epidemiological studies indicate an association between bulimia nervosa and substance use disorders, but not between anorexia nervosa and substance use disorders (515). Bulimia nervosa is more common among individuals with a substance use disorder than in the general population (515). Inpatient substance abuse treatment studies report that about 15% of women and 1% of men have an eating disorder; this group is more likely to abuse stimulants and less likely to use opioids than individuals without an eating disorder (515). In clinical samples, substance use disorders have been found to be common among patients with bulimia (about 23%) (516) and less frequent among those with anorexia nervosa (about 15%) (515). The types of agents abused by individuals with an eating disorder include diet pills, stimulants, laxatives, diuretics, emetics, and many other substances (515, 517). With chronic use, tolerance to the effects of and withdrawal from these medications can occur. Tobacco use and dependence are also common among individuals with bulimia and anorexia nervosa and may be linked with attempts to lose weight. Individuals with co-occurring bulimia and substance use disorders are more likely to be younger when they seek treatment for their bulimia nervosa and have an earlier onset of problem drinking compared with those individuals with bulimia nervosa only (516).

Integrated treatment may occur within psychiatric or substance use disorder treatment programs, and can combine traditional psychosocial treatments for substance use disorders with treatments for bulimia, including relapse prevention or CBT strategies (e.g., identifying automatic thoughts, thought restructuring, identifying cues and triggers for bingeing/purging and substance use). Substance abuse treatment programs may need to add nutritional consultation and education for these patients, help them set goals for an acceptable weight range, and observe them at and between meals for bingeing and/or purging behaviors (515, 518). The 12-step recovery–oriented community groups for both disorders (such as AA and Overeaters Anonymous) can provide additional structure and support.

Medication strategies to treat bulimia or anorexia nervosa should follow the recommendations in APA's Practice Guideline for the Treatment of Patients With Eating Disorders (518). There are no controlled medication trials to guide treatment of bulimia nervosa co-occurring with a substance use disorder. Naltrexone may be worth considering for patients with co-occurring alcohol dependence and bulimia nervosa, given its clinical utility in bulimic patients (519, 520) and its established use with alcohol use disorders (see Sections IV.C.3.a and IX.B.3.a).

+ g. Personality disorders

Personality disorders and substance use disorders commonly co-occur, with an estimated 50%–60% of individuals with a substance use disorder having a co-occurring personality disorder (463, 521). Prevalence rates of borderline personality disorder (BPD) are approximately 30%–50% across inpatient, outpatient, and community samples of individuals with a substance use disorder (522). Antisocial personality disorder (ASPD) has a lifetime prevalence of 60% among injection drug users (523, 524), although there are recognized problems with the accuracy of an ASPD diagnosis in patients with a co-occurring substance use disorder due in part to drug-associated criminal behavior (525) and overlap with BPD (318). Establishing a personality disorder diagnosis in the context of a substance use disorder can be difficult and may be best done after a patient has achieved a prolonged period of abstinence from substance use. Because patients with a substance use disorder and BPD or ASPD have higher-risk behaviors and a higher suicide risk (303, 318, 526) as well as poorer treatment outcomes (527–532), improved instruments for assessing a co-occurring personality disorder in this context would help to identify high-risk patients who may require more intensive treatments.

Integrated treatments for this population initially focus on helping the therapist manage countertransference issues, develop a therapeutic alliance, and integrate existing behavioral therapy approaches for personality disorders into the substance use disorder treatment. Specific integrated psychosocial therapies that combine traditional substance use disorder treatment with the treatment of a personality disorder have been developed to address these co-occurring disorders (373, 374, 463). Although dialectical behavioral therapy has been shown to be effective for treating BPD with or without a co-occurring substance use disorder, it is not always effective in improving substance use outcomes (533), and there remains a need for improved integrated therapies for this high-risk population.

There have been few medication studies for co-occurring personality and substance use disorders. Medication recommendations in the APA's Practice Guideline for the Treatment of Patients With Borderline Personality Disorder (534) may be used to guide treatment. In some cases, medications for personality disorders are used episodically to treat specific symptoms. Benzodiazepines should be used with caution in patients with co-occurring personality and substance use disorders due to the risk of benzodiazepine abuse (535) and overdose and suicide attempts (536).

+ h. Pathological gambling

Individuals with a substance use disorder are vulnerable to other non-substance-related compulsive behaviors such as pathological gambling and compulsive sexual behaviors. Only pathological gambling is recognized as a DSM-IV-TR disorder. Individuals with a substance use disorder have about a four- to fivefold higher rate of pathological gambling when compared with the general population, and studies suggest that about 15% of substance abusers meet criteria for pathological gambling (537–539). The National Epidemiologic Survey on Alcohol and Related Conditions, a large nationally representative community study, reported that among adults with a lifetime history of pathological gambling, 73% have had a co-occurring alcohol use disorder, 38% have had a co-occurring drug use disorder, and 60% have had co-occurring nicotine dependence (540). It is likely that pathological gambling, though common, is underdiagnosed, because substance abuse or psychiatric treatment settings do not always screen for it (541). Individuals with pathological gambling and a substance use disorder are also at increased risk for engaging in unsafe sexual behaviors and having mood or anxiety problems, ADHD, ASPD, or legal problems (537, 539, 542, 543).

Integrated treatment programs rarely include pathological gambling treatment and generally do not provide Gamblers Anonymous meetings on-site (542, 544). However, integrated treatment could readily incorporate behavioral therapies for pathological gambling that are similar to traditional substance use disorder treatment, such as gambling relapse prevention strategies, social skills training, problem solving, and cognitive restructuring (544).

Medications that appear to help reduce the desire to gamble and gambling behaviors have not been examined in individuals with a co-occurring substance use disorder. Medications studied in pathological gambling alone include fluvoxamine (545–547) and naltrexone (548, 549). A large, multicenter, randomized, controlled trial of paroxetine plus psychosocial treatment failed to demonstrate a significant difference from placebo (550), and an open-label, flexible-dose study of sertraline also failed to demonstrate superiority to placebo (551). Lithium and valproate may be effective in the treatment of pathological gambling for those with bipolar disorder (552, 553). In general, medication trials for pathological gambling show a high early placebo rate; longer-duration studies may be needed to confirm the positive effects of medication.

+
3. Comorbid general medical disorders

Concurrent general medical conditions frequently complicate the treatment of substance use disorders. A full description of the medical problems associated with substance use disorders is beyond the scope of this practice guideline and has been provided elsewhere (554, 555).

Substance use causes a variety of health problems (Table 3), which vary depending on the substance used and its route of administration. These medical problems may be further complicated by the use of multiple substances and nutritional deficiencies that may accompany ongoing substance use. Many substance use disorder patients with a co-occurring medical disorder do not seek or receive adequate general medical care for a variety of reasons, including the chaotic and disorganized lifestyles often associated with substance abuse and these patients' lack of access to health care. Physicians may be reluctant to adequately treat the pain of individuals who have a painful medical condition but also a current or past substance use disorder (556). Thus, the substance abuse treatment encounter may be the first opportunity to address the general medical care needs of these patients.

+
Table Reference Number
Table 3. Medical Disorders Associated With Specific Substances

At present, the medical risks associated with marijuana use are not well understood. Because it is likely that marijuana contains many of the same carcinogens as cigarettes, it is possible that lung cancer may occur in marijuana smokers, although there is no evidence to support this (557).

Substance use–related conditions such as hepatitis and tuberculosis and associated events such as motor vehicle accidents, falls, suicide, and homicide contribute to an increased risk of death and disability in the substance-using population. Tobacco-related medical disorders are a greater cause of mortality than alcohol-related medical disorders among individuals dependent on alcohol or other nonnicotine substances (558). This finding highlights the importance of assessing substance-abusing patients for tobacco use and recommending psychosocial and/or pharmacological intervention that will help them quit. Among individuals who inject drugs, infectious diseases are the most common cause of general medical comorbidity. Approximately 30%-40% of inner-city intravenous drug users test positive for HIV (559, 560), and depending on the treatment setting, as many as 30%–75% of substance use disorder treatment patients have been diagnosed with hepatitis C. Indeed, intravenous drug use accounts for 60% of new cases of hepatitis C and 25% of new HIV infections per year (561). Regardless of treatment setting, the adoption of universal precautions against body contamination by infectious agents is a necessary part of protecting staff and patients against the spread of HIV (562).

The risks of contracting sexually transmitted diseases commonly differ between the sexes. Among individuals with severe psychiatric disorders, men with hepatitis C have increased lifetime rates of drug-related risk behaviors (e.g., needle use, needle sharing, crack cocaine use), whereas women have higher lifetime rates of sexual risk behaviors (e.g., unprotected sex in exchange for drugs, money, or gifts; unprotected vaginal or anal sex) (563). All substance-using patients should be counseled about safe sex practices and taught specific interpersonal skills (e.g., assertiveness, negotiation) for discussing and requiring the use of safe sex practices with their partners. Gender-specific group treatments using educational/skills building approaches have been developed and are being studied (e.g., in the National Institute on Drug Abuse [NIDA] Clinical Trials Network studies to reduce HIV-related and sexually transmitted disease–related risk behaviors in patients in substance abuse treatment). Needle exchange programs and effective treatment of the substance use disorder and HIV or hepatitis C also reduce the spread of HIV and hepatitis C infection (561, 564).

When treating HIV-seropositive, opioid-dependent individuals with antiretrovirals and methadone, the physician needs to be aware of the clinically significant interactions between these two medications that can decrease the efficacy of antiviral medications and/or require methadone dose adjustments (565). It is recommended that individuals with hepatitis C receiving treatment with interferon be assessed for lifetime or current major depressive disorder because of the frequent development and/or exacerbation of depressive symptoms during treatment with interferon (566). All patients receiving interferon should be monitored for the development of depression, and consideration should be given to initiating antidepressants and counseling. Guidelines for the psychiatric treatment of patients with HIV or AIDS are available in the APA's Practice Guideline for the Treatment of Patients With HIV/AIDS (567).

The rise of treatment-resistant tuberculosis among patients with a substance use disorder suggests the need to consider periodic tuberculosis screening for patients and staff who treat these patients, along with efforts to reduce the spread of tuberculosis in treatment environments. Supervised on-site chemoprophylaxis or treatment for tuberculosis within substance abuse treatment programs is also strongly recommended (568, 569).

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4. Pregnancy

The treatment of substance use disorders is crucial in the pregnant woman because ongoing substance use during pregnancy has the following multiple implications for both the mother and the developing fetus:

  1. The health of the pregnant woman. Pregnant women with a substance use disorder are at high risk for sexually transmitted diseases (e.g., HIV infection), hepatitis, anemia, tuberculosis, hypertension, and preeclampsia (570, 571). In addition, the presence of a substance use disorder may affect a woman's ability to maintain a healthy lifestyle, including proper nutrition and prenatal care.

  2. The course of the pregnancy. Women with certain substance use disorders may be at greater-than-average risk for spontaneous abortions, preeclampsia, abruptio placentae, and early and prolonged labor (572–574), in addition to complications of other general medical conditions that may be attributable to the substance use (e.g., hypertension in cocaine users) (575).

  3. Fetal development. Some abused substances, including nicotine, opioids, cocaine, and alcohol, are known to pass through the placenta and directly affect fetal metabolism and development (576–578). This may happen at any stage of development but is particularly likely during the third trimester, when maternal fetal blood flow and rates of placental transport are increased. Fetal concentrations of abused substances average 50%–100% of maternal blood levels and may be higher than maternal blood levels (579). The circulation of active metabolites is another source of fetal exposure to potentially toxic substances. The fetus may be at higher-than-average risk for birth defects, cardiovascular problems, impaired growth and development, prematurity, low birth weight, and stillbirth (573, 580–585). After delivery, the neonate may experience withdrawal from the substance, which may be difficult to recognize, particularly if the pediatrician is unaware of the mother's substance use disorder.

  4. Child development. Some substances (e.g., alcohol) are associated with long-term negative effects on physical and cognitive development, as is seen in fetal alcohol spectrum disorders (586–588).

  5. Parenting behavior. In addition to ongoing treatment for the disorder itself, mothers with a substance use disorder are frequently in need of education and training in parenting skills, social services, nutritional counseling, assistance in obtaining health and welfare entitlements, and other interventions aimed at reducing the likelihood of child abuse or neglect (589, 590). This is particularly true of women with co-occurring substance use and psychiatric disorders.

Goals for the treatment of pregnant, substance-using women include 1) providing appropriate treatment for the substance use disorder (e.g., methadone maintenance for opioid dependence and abstinence from other substances, including alcohol, cocaine, marijuana, and nicotine), 2) treating co-occurring medical or psychiatric disorders, 3) monitoring the safety of patient behaviors during pregnancy as well as during the postpartum period, 4) facilitating competent parenting behaviors, and 5) motivating the patient to remain abstinent after childbirth.

The optimal therapeutic approach is nonpunitive and maintains patient confidentiality. Education and counseling to help women make an informed decision about continuing or terminating a pregnancy should be provided. Women likely to return to a substance-abusing milieu should be counseled about long-term treatment options available in the community.

+
5. Gender-related factors

Information on the natural history, clinical presentation, physiology, and treatment of substance use disorders in women is limited. Although women are estimated to comprise 34% of all individuals with a substance use disorder other than nicotine dependence in the United States (591), psychosocial and financial barriers (e.g., lack of child care, lack of health insurance) prevent many women from seeking treatment (592). Another explanation for women's low utilization of substance use disorder treatment services may be women's perception of greater social stigma associated with their substance abuse (593–595). Once in treatment, women have been found to have a higher prevalence than men of primary co-occurring mood and anxiety disorders that require psychiatric care (593, 596). Many women with a substance use disorder have a history of physical and/or sexual abuse (both as children and as adults), which may also influence treatment planning, participation, and outcomes (597, 598). Female patients, particularly single mothers, may have more family responsibilities and may require more help with family-related problems. There is some evidence that tailoring the goals of treatment to meet the needs of women improves treatment outcomes for substance-using women (599, 600).

In terms of nicotine dependence, there is some evidence to suggest that women may smoke less for nicotine reinforcement and more for nonnicotine factors such as other sensory effects of smoke inhalation, conditioned responses to smoke stimuli, and secondary social reinforcement (601). It has also been suggested that women have more difficulties with smoking cessation than men, although recent studies have suggested that cessation rates are similar between the two sexes. There is some evidence that NRT is less effective in female smokers, but the evidence for this is not strong; any initial failures with NRT could be followed by nonnicotine therapies such as bupropion and clonidine (602). Two recent studies showed that women have improved rates of smoking cessation when treated with naltrexone in combination with either smoking cessation therapy alone (603) or NRT and psychosocial therapy (604). Naltrexone as an adjunctive treatment to NRT and/or smoking cessation therapy may also be a treatment option for women who have had initial failures with NRT, although more research is needed to support this. Factors that may lead to poorer outcomes in women include depressive symptoms, negative affect, and reduced social supports. Women also frequently cite the fear of weight gain or actual weight gain after smoking cessation as a reason for relapsing to smoking. Therefore, smoking cessation therapies for women should emphasize weight-management strategies.

Women may also experience more adverse physical outcomes from tobacco use. Women may be more sensitive to secondhand smoke than men (605), and studies indicate that women smokers are at increased risk for lung cancer of all histological types, even after controlling for the number of cigarettes smoked (606). Estrogen effects on carcinogenesis in the lung may account for this difference in women.

The prevalence of smokeless tobacco use in young men over the last several years has dramatically increased (607). This is particularly alarming given the high rates of oral cancer associated with smokeless tobacco use. Smokeless tobacco use should be taken into consideration in addition to cigarette, cigar, and pipe use during the assessment and treatment planning processes.

With regard to alcohol use, female-to-male ratios for alcohol abuse are highest in the younger age groups, suggesting more alcohol use among young women and a closure of the original gap in usage rates between the sexes (596, 608). Of notable concern is the poorer prognosis for medical sequelae of alcohol abuse and dependence in women. Alcohol-dependent women consume less alcohol than men yet progress to late stages of alcohol-related illness more rapidly (609) and have a shorter time course to the initial development of alcohol-related medical morbidity than do men. Prevalence rates of alcohol-related cirrhosis of the liver and cardiomyopathy in women are twice that in men with alcohol abuse or dependence. Breast cancer and mortality are increased in women consuming more than two standard unit drinks per day (610). Alcohol-abusing women are also at higher risk for death when compared with same-sex, sober control populations (reviewed in Greenfield and O'Leary [611]).

One study of individuals with a substance use disorder in three outpatient treatment settings (methadone maintenance clinic, intensive outpatient program for cocaine dependence, and general outpatient substance abuse treatment clinic) showed that women with a substance use disorder reported significantly more cardiovascular, mood, nose/throat, CNS, skin, and gastrointestinal symptoms related to substance use than did men (612). This occurred despite the lack of differences between men and women in this sample in their preference for cocaine, alcohol, or opioid drugs. Women frequently initiate cocaine and opioid use in the context of a substance-using partner and tend to initiate use at a younger age than men (593, 613).

+
6. Age
+
a) Children and adolescents

An in-depth review of the evaluation and treatment of substance use disorders in children and adolescents is beyond the scope of this practice guideline. However, because an adult psychiatrist may be called on to evaluate children or adolescents with a substance use disorder, some general information and treatment principles are reviewed here. For more detailed information, the reader is referred to the American Academy of Child and Adolescent Psychiatry's Practice Parameter for the Assessment and Treatment of Children and Adolescents With Substance Use Disorders (614) and the Substance Abuse and Mental Health Services Administration (SAMHSA) recommendations for screening and assessing adolescents for substance use disorders (615–617).

Alcohol and other psychoactive substance use, abuse, and dependence in children and adolescents continue to present a serious public health problem in the United States. Alcohol and other substance use are among the leading causes of morbidity and mortality from motor vehicle accidents, suicidal behavior, violence, drowning, and unprotected sexual activity in this population (618).

Regional studies reveal that 7%-10% of adolescents are in need of treatment for substance use disorders (619). Children and adolescents are generally more likely to have abuse rather than dependence disorders and are less likely to appreciate the need for entering and remaining in treatment. Abuse is not necessarily a prodrome to dependence, and it may be developmentally limited in many adolescents. In addition, Pollock and Martin (620) demonstrated the importance of a new nosological entry in youth diagnoses entitled "orphan diagnoses" that includes subthreshold symptomatology of alcohol dependence (i.e., one or two symptoms only) but no abuse symptoms. A 3-year follow-up study demonstrated that this entity has a unique trajectory dissimilar to that of abuse and dependence.

Assessment and treatment of children and adolescents with a substance use disorder must take into account their psychosocial developmental levels and the possible role of their substance use disorder in impeding the successful attainment of developmental milestones, including a sense of autonomy, the ability to form interpersonal relationships, and general integration into society. The assessment should be multidimensional and address problems in several life domains, including psychiatric comorbidity, school or employment performance, family functioning, peer social relationships, legal status, and recreational activities (621).

Children reared in family environments in which other family members abuse or are dependent on alcohol or other substances are at higher risk for physical and sexual abuse, particularly when family members exhibit antisocial behaviors; these children may exhibit psychological and behavioral sequelae (including substance abuse) as a result (622, 623).

Most adolescents with substance use disorders also have one or more co-occurring psychiatric disorders, most often conduct disorder and/or major depression, although ADHD, anxiety disorders (including social phobia and PTSD), bipolar disorder, eating disorders, learning disabilities, and other axis II disorders are also common (624–626). Many adolescents with substance use disorders also have preexisting and concurrent impulsive, oppositional, self-injurious, and suicidal symptoms or syndromes (627). Treatment should also address these problems, with treatment of the substance use disorder(s) and coexisting psychiatric symptoms occurring simultaneously.

In general, the range of treatment modalities used with adults can be used with adolescents as well. These modalities include brief interventions, motivational enhancement strategies, cognitive-behavioral approaches, psychodynamic/interpersonal approaches (individual, group, and family), self-help groups (628), and medications when needed (629). Most adolescents are treated in outpatient settings, and treatment is often delivered in a group therapy format. Although research data establishing the efficacy of specific treatment modalities for adolescent substance use disorders are sparse, program outcomes for adolescents appear to be enhanced by the availability of treatment that is developmentally appropriate and peer oriented and includes educational, vocational, and recreational services. Corrective experiences in family interaction should be part of the treatment plan (628). Family therapy also appears to have benefit (241, 242, 630). Residential facilities are very effective in reducing substance use, but gains are lost when aftercare is not well coordinated (56).

The prevention of substance use and abuse is considered the primary intervention for schools and clinicians (631–633). At-risk children and adolescents include those with a substance-abusing parent and those living under deprived conditions (i.e., neglect and/or abuse). Educational programs describe the negative consequences of substance use and teach drug refusal and harm-reduction behavioral strategies. Life skills training is a substance use prevention curriculum (634) that focuses on teaching youths the skills necessary to avoid social pressures to experiment with smoking, drinking, and drug use. In addition to showing efficacy in white middle-class youth (634, 635), the effects of the life skills training approach has also been demonstrated to be beneficial in African American and Hispanic youth (636). Masterman and Kelly (637) noted that the empirical literature suggests that universal prevention programs may delay the onset of drinking among low-risk baseline abstainers (i.e., individuals who are not drinking at the baseline assessment and who would be predicted to be at low risk of developing an alcohol use disorder on the basis of multiple risk factors); however, not enough studies support the utility of such programs for at-risk adolescents. Furthermore, they argue that motivational interviewing within a harm-reduction framework is well suited to adolescents.

Interventions aimed at preventing smoking are similarly crucial, given that smoking rates among adolescents continue to rise, despite reductions in other age groups (638). Smoking in adolescents is often a marker of psychiatric problems such as another substance use disorder or depression. In adolescents who smoke, the motivation to quit is often low; many of these adolescents are nicotine dependent and will have difficulties stopping smoking without behavioral and pharmacological support. There have been relatively few studies of smoking cessation in adolescent smokers, and success rates with interventions such as brief motivational enhancement, nicotine patch, and bupropion appear to be very low, at approximately 20% by the end of treatment (639–641).

Two common assumptions concerning adolescent substance use that are unfounded should be mentioned. Supporting the findings of a recent meta-analysis (506), a 16-year prospective, controlled trial showed that the use of stimulant medication (e.g., methylphenidate) in adolescence to treat ADHD does not lead to increased substance use in adulthood (642). Furthermore, contrary to the common perception, cannabis withdrawal is highly prevalent in adolescents (643).

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b) Elderly individuals

Substance use disorders in elderly individuals are often undiagnosed and undertreated (644, 645). Abuse of and dependence on prescribed medications, particularly benzodiazepines, sedative-hypnotic medications, and opioids, can contribute to excessive confusion and sedation in elderly patients, poor adherence with prescribed treatment regimens, and inadvertent overdose, particularly when these drugs are combined with alcohol (646–648). In addition, alcohol use disorders, whether an extension of a long-standing disorder or of later onset, are a major problem among elderly individuals, particularly those living alone (649–651). Alcohol-related cognitive impairment, co-occurring depressive disorder, dementia, poststroke syndromes, and other conditions are also common among elderly individuals and may impair their ability to obtain or adhere to treatment for a substance use disorder or other general medical or psychiatric disorder (652).

Although rates of smoking decline with age (by 15%–20%), elderly patients who do smoke should be encouraged to quit. Even in older smokers, smoking cessation can lead to health improvements, including improved quality and length of life. There are few published studies of smoking cessation in the elderly; however, clinical experience suggests that the use of NRT is a safe and effective option. However, caution should be used when prescribing bupropion to elderly individuals because of its potential hypertensive effects (653, 654). This agent should be considered as a second-line agent, as controlled studies have not been conducted in this population.

There is a paucity of empirical data on the treatment of substance use disorders in the elderly population; it is generally accepted that empirically supported treatments of adult substance use disorders can be effectively applied to the treatment of elderly patients. Some modifications, such as slowing the pace of therapy, placing follow-up outreach calls, and providing patients with written information, improve the effectiveness of some therapies. In a recent study of 250 elderly men screened for substance abuse from a VA outpatient population, predictors of patient engagement in substance abuse treatment included severity of substance use, co-occurrence of depression, healthy cognitive status, and higher educational achievement (655). A large multisite study (PRISM-E) has also shown that primary care patients screening positive for a substance use disorder prefer to be treated within the medical system, with integrated psychiatric and substance abuse services, rather than to have facilitated referral to outside treatment (31).

Studies of individuals with alcohol use disorders also suggest that the needs of older adults may be different from those of younger patients. Kofoed et al. (656) reported that VA patients age 54 years or older who received specialized services for elderly patients as part of a treatment program were four times more likely to complete the program and remained in treatment longer than those who received conventional services, although posttreatment relapse rates were comparable in the two groups.

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7. Racial, ethnic, and cultural factors

Current research suggests poorer prognoses for ethnic and racial minorities in conventional treatment programs, although this may be accounted for by socioeconomic group differences (657–659). Although there is a paucity of research on the efficacy of culturally specific programming, treatment services that are culturally sensitive and address the special concerns of ethnic minority groups may improve acceptance of, adherence to, and, ultimately, the outcome of treatment. The training of staff to be sensitive to and incorporate culture-specific beliefs about healing and recovery should be part of a comprehensive treatment program that serves different minority and ethnic groups (660). For example, Native Americans and Alaskans may have a greater acceptance of treatment that incorporates the use of the Medicine Wheel (661, 662). Still, clinical judgment in determining what cultural-based modifications to treatment are appropriate is advised, because some ethnic groups have large heterogeneity (e.g., Latino/ Latina [663]); specialized cultural approaches (664) can be considered with a patient to determine whether or not the approach would be perceived as useful.

In terms of nicotine dependence, African Americans and Hispanics appear to be less likely to initiate smoking, tend to smoke in lower amounts, and have increased cotinine levels (due to slower metabolism of nicotine). When compared with whites, they appear less likely to become dependent but have less success in smoking cessation efforts (665–668). Recent studies suggest that the nicotine patch (669) and bupropion (670) are safe and effective treatments for African American smokers, but further study is needed.

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8. Gay/lesbian/bisexual/transgender issues

Controversies in the literature exist about whether or not substance use rates are elevated in homosexual and bisexual populations. For example, earlier reports that lesbians are at higher risk than heterosexual women for alcohol-related disorders (671) have not been consistently replicated (672). Nonetheless, multiple studies do indicate increased rates of drug use among gay and bisexual sexually active men and lesbian women as compared with exclusively heterosexual men and women, with a prominence of cannabis and nicotine dependence for both homosexual men and lesbian women (673–675). In one undergraduate college student population, a higher incidence of drug use and smoking was found among gay and bisexual men and lesbian women as compared with heterosexual men and women (676). Among older gay, lesbian, and bisexual populations (ages 60–91 years), the incidence of alcohol abuse is greater for men than for women (677). Methodological issues of population sampling may confound interpretation of these findings. For example, in one community with a high concentration of gay and bisexual men, few differences were observed in drug use patterns among gay, bisexual, and heterosexual men (678). Furthermore, demographic variables other than sexual orientation influence the presence of substance abuse (679).

Because of concerns about increased risk and prevalence of substance use disorders in gay, lesbian, and bisexual populations, substance use disorder treatment programs frequently inquire about an individual's sexual orientation and whether or not the individual believes that his or her sexual orientation contributes in any way to the substance use. Special therapeutic strategies have been developed that target known regional associations between sexual orientation and substance abuse, such as a Los Angeles program for the treatment of male methamphetamine abusers who have sex with other men (680, 681). The rationale for this program was the discovery that this population has a high rate of HIV transmission. A similar concern over the higher prevalence of smoking among adolescent and adult gay, lesbian, and bisexual individuals has triggered the development of prevention and cessation programs for these populations (682, 683). SAMHSA published a statement in 2001 concerning the need to address substance abuse issues among gay, lesbian, bisexual, and transgender populations (684).

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9. Family characteristics

Substance use disorders exact an enormous toll on family members. High levels of interpersonal conflict, domestic violence, inadequate parenting, child abuse and neglect, separation and divorce, financial and legal difficulties, and substance-related general medical problems (e.g., AIDS, tuberculosis), if present, can add to the family burden. In addition, children reared in family environments in which other family members abuse or are dependent on alcohol or other substances are also at increased risk of physical or sexual abuse (685).

Families who have one or more members with a substance use disorder often display a multigenerational pattern of transmission of both a substance use disorder and other frequently associated psychiatric disorders (e.g., ASPD, pathological gambling) (686, 687). The impact of maternal substance use on fetal development and childhood cognitive and emotional adjustment, coupled with the influence of genetically inherited risk factors (e.g., high genetic loading for alcoholism in the male population) and negative role models, plays a role in the development of substance use disorders across generational lines (688).

The substantial burden that having one or more members with a substance use disorder imposes on families and the impact of family interactions in perpetuating or ameliorating these problems affect the initiation of, perpetuation of, and patient's recovery from the substance use disorder; the patient's motivation and ability to adhere to treatment; and the patient's clinical course and outcome. These relationships, combined with the high prevalence of substance use disorders, co-occurring general medical and psychiatric disorders, psychosocial disability, and family burden make family screening and interventions extremely important (232, 236, 689, 690).

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10. Social milieu and living environment

The patient's overall social milieu has an important impact on the development of and recovery from a substance use disorder. The social milieu shapes attitudes about the appropriate context for substance use (e.g., the difference between social drinking on family occasions and recreational drinking to achieve intoxication). Role models among one's family or peers influence the social and psychological context for substance use, the choice of substance, and the degree of control exerted over substance-using behaviors.

Once a pattern of dependence or abuse has developed, an individual's motivation and ability to adhere to treatment are influenced by the degree of support within his or her immediate peer group and social environment. Poor outcome is predicted by continued involvement with substance-using peer groups or family members as well as by residence in an environment in which substances are readily available. Addressing these issues is an important component of any treatment plan. Patients with high levels of psychosocial and environmental stressors need correspondingly high levels of community-based support or, in some cases, temporary relief from these stressors through treatment in a residential setting until the patient is able to develop specific relapse prevention strategies that can be applied in a community setting. Sexually active individuals should be educated about the prevalence and prevention of HIV infection and other sexually transmitted diseases (691).

Socioeconomic status may also play a role in the initiation and cessation of substance use. For example, smokers with lower education level, wages, and socioeconomic status are more likely to initiate smoking and less likely to quit; this may be due to less support for attempts to quit and less access to smoking cessation services. (692, 693).

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H. Legal and Confidentiality Issues

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1. Effect of legal pressure on treatment participation and outcome

Many patients with substance use disorders seek treatment in response to pressure from family members, employers, legal authorities, or other sources. Although being internally motivated for treatment is often regarded as a good prognostic sign, outcome studies of patients in therapeutic communities have shown that individuals who enter treatment under legal compulsion (e.g., as a condition of probation, to avoid incarceration) stay longer and do as well as comparable patients who enter treatment voluntarily (694, 695). The use of the opiate antagonist naltrexone has produced higher rates of adherence to court-mandated treatment by patients and physicians or other professionals who are at risk of losing their professional licenses should they fail to comply. Similar findings have been reported for professionals being treated for substance use disorders by means of contingency contracting approaches in which the contingency for nonadherence with treatment is being reported to a professional board of registration (696).

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2. Confidentiality and reporting of treatment information

To protect patients' privacy and encourage their entry into treatment, federal law and regulations 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). Disclosure of information from treatment records is prohibited unless the patient has given written consent, the disclosure is in response to a medical emergency, or there is a court order authorizing disclosure. Other times when patient confidentiality may be attenuated include disclosure needed 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, reporting of suspected child abuse or neglect, or, depending on the requirements of the local jurisdiction, reporting of suspected abuse of elderly individuals. Consequently, psychiatrists should be familiar with local and state reporting laws concerning the possible abuse and neglect of children, other dependents, or elderly individuals who may be at risk in the families of substance users.

Federal law generally does not make specific reference to the confidentiality of information pertaining to the HIV/AIDS status of a patient in substance abuse treatment, but there are many different state laws restricting disclosure of such status. The federal Health Insurance Portability and Accountability Act of 1996 has been particularly prominent in protecting the privacy of patients with a psychiatric disorder (697). Psychiatric disorders commonly co-occur with substance use disorders, and these patients are "doubly protected" by law.

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3. Legal requirements for pharmacotherapy with opioids

Federal and state regulations govern the use of methadone, LAAM, and buprenorphine, the three opioids approved by the FDA for the treatment of opioid dependence. Programs that use these agents to treat opioid-dependent patients are registered with and accredited by the Center for Substance Abuse Treatment. The center holds opioid agonist treatment programs to a variety of accreditation standards that regulate issues such as admissions, record keeping, and the frequency of drug testing. In addition, individual states may also impose stricter licensing criteria for these programs.

In an effort to expand access beyond the highly regulated opioid agonist treatment programs, Congress passed the Drug Addiction Treatment Act of 2000, which allows "qualified physicians" in office-based practices to prescribe FDA-approved schedule III, IV, and V medications for the detoxification and maintenance of opioid dependence. Currently, sublingual buprenorphine and sublingual buprenorphine/naloxone are the only agents approved by the FDA for this purpose. Most physicians qualify by completing 8 hours of formal training and obtaining a special U.S. Drug Enforcement Agency number ("x" number). To obtain this number, physicians must have the capacity to refer patients for appropriate counseling and other ancillary services. Once qualified, physicians may treat patients in an individual or group practice with sublingual buprenorphine or sublingual buprenorphine/naloxone. As with all opioid agonist therapies, strict documentation of informed consent, qualification of the patient as being dependent on opioids with a history of relapse or medical risk, ongoing monitoring of efficacy, and evidence of abstinence or substance use through urine toxicology testing are required for safe prescribing. Physicians should also document the protection of children from accidental access to medication.

Table Reference Number
Table 1. DSM-IV-TR Criteria for Substance Abuse
Table Reference Number
Table 2. DSM-IV-TR Criteria for Substance Dependence
Table Reference Number
Table 3. Medical Disorders Associated With Specific Substances

References

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