Assessment and Treatment of Addictive Behaviors Carl W. Lejuez, PhD - PowerPoint PPT Presentation


Title: Assessment and Treatment of Addictive Behaviors Carl W. Lejuez, PhD


1
Assessment and Treatment of Addictive
BehaviorsCarl W. Lejuez, PhD
  • Lecture 9
  • Drug Treatment

2
Drug Treatment Cost Effective?
  • Yes!
  • Less expensive than alternatives, such as not
    treating addicts or simply incarcerating addicts
  • 1 year of methadone maintenance is about 4,700
    per patient
  • 1 full year of imprisonment costs about 18,400
    per person
  • Every 1 invested in addiction treatment programs
    yields a return of between 4 and 7 in reduced
    drug-related crime, criminal justice costs, and
    theft alone
  • Costs reduced due to drops in health care
    expenses, interpersonal conflicts, improvements
    in workplace productivity, and reductions in
    drug-related accidents

3
Initial Considerations
  • Due to heterogeneity of drug problems, detailed
    initial assessment is crucial
  • Should assess how they made it to treatment are
    they self-referred or by the will of others
    including court mandate
  • Multidimensional Outcomes
  • Abstinence doesnt guarantee improvement in
    social, occupational, etc functioning
  • Relapse often a part of long-term success
  • Relapse rate on 1st attempt seeking treatment 25
  • Common treatments often have little empirical
    support

4
Basics of Treatment
  • In addition to stopping drug use, the goal of
    treatment is to return the individual to
    productive functioning in the family, workplace,
    and community
  • Measures of effectiveness
  • criminal behavior
  • family functioning
  • Employability
  • medical condition
  • Overall, treatment of addiction is as successful
    as treatment of other chronic diseases, such as
    diabetes, hypertension, and asthma

5
Basics of Treatment
  • Treatment reduces drug use by 40 60
    significantly decreases criminal activity during
    after treatment
  • For example, a study of therapeutic community
    treatment for drug offenders demonstrated that
    arrests for violent and nonviolent criminal acts
    were reduced by 40 percent or more
  • Methadone treatment has been shown to decrease
    criminal behavior by as much as 50 percent.
  • Research shows that drug addiction treatment
    reduces the risk of HIV infection and that
    interventions to prevent HIV are much less costly
    than treating HIV-related illnesses.

6
Basics of Treatment
  • Important Considerations
  • No single treatment is appropriate for all
    individuals
  • An individual's treatment and services plan must
    be assessed continually and modified as necessary
    to ensure that the plan meets the person's
    changing needs
  • Counseling and other behavioral therapies are
    critical components of effective treatment for
    addiction
  • Medications are an important element of treatment
    for many patients
  • Medical detoxification is an important first step
    to most drug addiction treatments

7
Basics of Treatment
  • Medical Detoxification
  • Detoxification alone is rarely sufficient to help
    addicts achieve long-term abstinence
  • Medical detoxification safely manages the acute
    physical symptoms of withdrawal associated with
    stopping drug use.
  • Strongly indicated precursor to effective drug
    addiction treatment

8
Types of Treatment
  • Pharmacological Treatment
  • Medication can be used to accomplish a number of
    goals
  • Prevention of overdose
  • Suppression of withdrawal
  • Reduction of cravings
  • Reduction of psychiatric symptoms
  • Heroin Methadone, LAAM, Naltrexone,
    Buprenorphine
  • Alcohol Disulfiram (Antabuse), Benzodiazepines
  • No FDA approved medications for treatment for the
    following
  • Cocaine
  • LSD
  • PCP
  • Marijuana
  • Methamphetamine and other stimulants
  • Inhalants
  • Anabolic steroids

9
Types of Treatment
  • Behavioral Treatment
  • Assumption Drug Taking is a special case of
    operant behavior maintained by the reinforcing
    effects of the drugs.
  • EvidenceHuman and animal self-administration
    studies repeatedly demonstrate that various
    psychoactive drugs serve as positive
    reinforcers.Variables that control other
    operant behaviorssuch as reinforcer magnitude,
    response requirement, and the availability of
    alternative reinforcersalso control drug
    taking.Numerous treatment studies have
    demonstrated that contingency management
    procedures can effectively reduce drug use
  • Examples
  • Contingency Management Interventions
  • Behavioral Activation

10
Types of Treatment
  • Multisystemic and Social Support Treatments
  • These treatment programs attend to abstinence as
    well as other aspects of the individuals needs
    based on the theory that sobriety can not be
    maintained in a vacuum
  • Areas Addressed include medical attention,
    occupational training, educational training
    (GED), housing, family relationships, exposure to
    community resources, social support, etc.
  • Examples
  • Out-patient treatment Programs
  • Residential Programs
  • Therapeutic Communities
  • NA/AA/Narconon

11
Types of Treatment
  • Psychotherapy
  • Useful for providing patients with individualized
    therapy
  • Provides more privacy than group setting
  • Enables patient to address problems that may be
    only peripherally related to drug use
  • Enables patient to address other mental health
    issues
  • Examples
  • Individualized Drug Counseling
  • Motivational Enhancement Therapy
  • Relapse Prevention

12
Treatment Duration
  • Individuals progress through drug addiction
    treatment at various speeds, but Good outcomes
    are contingent on adequate lengths of treatment.
  • residential or outpatient treatment,
    participation for less than 90 days is of limited
    or no effectiveness, and treatments lasting
    significantly longer often are indicated.
  • For methadone maintenance, 12 months of treatment
    is the minimum, and some opiate-addicted
    individuals will continue to benefit from
    methadone maintenance treatment over a period of
    years.
  • Successful outcomes may require multiple
    treatment experience. Many addicted individuals
    have multiple episodes of treatment, often with a
    cumulative impact.

13
Pharmacological Treatments
14
Agonist Maintenance Treatment
  • For opiate addicts usually is conducted in
    outpatient settings, often called methadone
    treatment programs
  • These programs use a long-acting orally
    administered synthetic opiate medication
  • usually methadone or LAAM
  • sustained period at a dosage sufficient to
    prevent opiate withdrawal, block the effects of
    illicit opiate use, and decrease opiate craving
  • Patients stabilized on opiate agonists can engage
    more readily in counseling and other behavioral
    interventions
  • Most effective opiate agonist maintenance
    programs include individual and/or group
    counseling, as well as provision/referral to
    other needed medical, psychological, social
    services.

15
Agonist Maintenance Treatment
  • As used in maintenance treatment, methadone and
    LAAM are not heroin substitutes
  • Pharmacological effects are markedly different
    from those of heroin.
  • Far more gradual onsets of action than heroin
  • No rush
  • Wears off much more slowly than heroin
  • No sudden crash
  • Euphoric effects of heroin are significantly
    blocked
  • No marked fluctuations experienced by brain and
    body
  • Reduced craving for heroin

16
Narcotic Antagonist Treatment Using Naltrexone
  • For opiate addicts, usually conducted in
    outpatient settings although initiation of the
    medication often begins after medical
    detoxification in a residential setting
  • Naltrexone is a long-acting synthetic opiate
    antagonist with few side effects that is taken
    orally either daily or three times a week for a
    sustained period of time
  • Individuals must be medically detoxified and
    opiate-free for several days before naltrexone
    can be taken to prevent precipitating an opiate
    abstinence syndrome. When used this way, all the
    effects of self-administered opiates, including
    euphoria, are completely blocked.

17
Narcotic Antagonist Treatment Using Naltrexone
  • Theory repeated lack of the desired opiate
    effects, as well as the perceived futility of
    using the opiate, will gradually result in
    breaking the habit of opiate addiction
  • Naltrexone itself has no subjective effects or
    potential for abuse and is not addicting.
  • Patient noncompliance is a common problem.
  • Most useful for highly motivated, recently
    detoxified patients who desire total abstinence
    because of external circumstances, including
    impaired professionals, parolees, probationers,
    and work-release prisoners

18
Other Medications for Heroin Dependence
  • Buprenorphine has recently been approved for
    maintenance treatment.
  • Does not require daily administration, an
    advantage over methadone.
  • Like methadone and LAAM, Buprenorphine suppress
    withdrawal, reduce cravings, and prevent users
    from getting high from heroin
  • Another potential answer prescription Heroin
  • Why prescribe heroin?
  • Methadone does not work for everyone
  • Might bring more people into treatment
  • Reduce some of the harm associated with heroin
  • Undermine the black market

19
Cocaine Vaccine
  • TA-CD is a combination of the cocaine molecule
    and a large protein
  • Triggers the generation of antibodies.
  • If cocaine is taken
  • Antibodies combine with cocaine molecules to form
    a complex that is too big to cross the
    blood-brain barrier.
  • Initial trails have indicated TA-CD is safe and
    effective in reducing cocaine intake in rats
  • A single human study has shown that the drug was
    well tolerated (low side effects) and safe in
    humans.
  • Awaiting FDA approval for use as a treatment of
    cocaine dependence

20
Behavioral Treatment
21
Contingency Management Programs
  • Based on idea that in any particular instance,
    benefits of drug use often are immediate
    certain, whereas negatives often are delayed
    often uncertain
  • Also focuses on fact that benefits for nonuse
    often are delayed and uncertain
  • Basic Procedures
  • Drug use and abstinence are readily detected
  • Drug abstinence is readily reinforced
  • Drug use results in a loss of reinforcement
  • Reinforcement derived from non-drug sources is
    increased to compete with the reinforcing effects
    of drug use(Higgins et al., 1991)

22
Voucher-Based Reinforcement Therapy in Methadone
Maintenance Treatment
  • Provision of a voucher for each drug-free urine
    sample
  • Voucher has monetary value and can be exchanged
    for goods and services consistent with treatment
    goals
  • Initially, voucher values are low, but value
    increases with the number of consecutive
    drug-free urine specimens
  • Cocaine- or heroin-positive urine specimens reset
    the value
  • Escalating contingency to reinforce sustained
    drug abstinence.
  • Patients receiving vouchers for drug-free urine
    achieved significantly longer abstinence than
    patients who were given vouchers independent of
    urinalysis results.

23
Community Reinforcement Approach (CRA) Plus
Vouchers
  • Intensive 24-week outpatient therapy for
    treatment of cocaine
  • To achieve cocaine abstinence long enough for
    patients to learn new life skills that will help
    sustain abstinence
  • To reduce alcohol consumption for patients whose
    drinking is associated with cocaine use.
  • Patients attend one or two individual counseling
    sessions per week, where they focus on improving
    family relations, learning a variety of skills to
    minimize drug use, receiving vocational
    counseling, and developing new recreational
    activities and social networks.

24
CRA Plus Vouchers
  • Those who also abuse alcohol receive
    clinic-monitored disulfiram (Antabuse) therapy
  • Patients submit urine samples two or three times
    each week receive vouchers for cocaine-negative
    samples
  • The value of the vouchers increases with
    consecutive clean samples. Exchange vouchers for
    retail goods
  • Facilitates patients' engagement in treatment and
    aids in gaining substantial periods of cocaine
    abstinence.
  • Tested in urban and rural areas and used
    successfully in outpatient detoxification of
    opiate-addicted adults and with inner-city
    methadone maintenance patients who have high
    rates of intravenous cocaine abuse.

25
Multisystemic and Social Support Treatments
26
Outpatient Treatment
  • Outpatient Drug-Free Treatment
  • Varies in the types and intensity of services
    offered.
  • Costs less than residential or inpatient
    treatment
  • Most suitable for individuals who are employed or
    who have extensive social supports.
  • Low-intensity programs focus is on drug
    education and admonition.
  • Intensive day treatment comparable to
    residential programs in services and
    effectiveness
  • Group counseling is emphasized
  • Medical or mental health problems may also be
    treated

27
Long-Term Residential
  • Provides care 24 hours per day, generally in
    nonhospital settings
  • The best-known residential treatment model is the
    therapeutic community (TC), but residential
    treatment may also employ other models, such as
    cognitive-behavioral therapy

28
Therapeutic Communities
  • Residential programs with planned stays of 6-12
    months
  • TCs focus on the "resocialization" of the
    individual and use the program's entire
    "community,"
  • including other residents, staff, and the social
    context, as active components of treatment
  • Addiction is viewed in the context of an
    individual's social and psychological deficits
  • treatment focuses on developing personal
    accountability and responsibility and socially
    productive lives.
  • Highly structured and at times be confrontational
  • activities designed to help residents examine
    damaging beliefs, self-concepts, and patterns of
    behavior and to adopt new, more harmonious and
    constructive ways to interact with others

29
Therapeutic Communities
  • Many TCs are quite comprehensive and can include
    employment training and other support services on
    site.
  • Compared with patients in other forms of drug
    treatment, the typical TC resident has more
    severe problems, with more co-occurring mental
    health problems and more criminal involvement.
  • Research shows that TCs can be modified to treat
    individuals with special needs, including
    adolescents, women, those with severe mental
    disorders, and individuals in the criminal
    justice system

30
Narcotics Anonymous
  • Begin in 1953, based on AA
  • NA's earliest self-titled pamphlet, known among
    members as "the White Booklet," describes
    Narcotics Anonymous as
  • "a nonprofit fellowship or society of men and
    women for whom drugs had become a major problem .
    . . who meet regularly to help each other stay
    clean We are not interested in what or how much
    you usedbut only in what you want to do about
    your problem and how we can help.
  • Membership is open to any drug addict
  • regardless of the particular drug or combination
    of drugs used.
  • When adapting AA's First Step, the word
    "addiction" was substituted for "alcohol,
  • Removed drug-specific language
  • Continued focus on disease concept of addiction

31
Demographics of NA
  • Male/female ratio 58 male, 42 female
  • Ages from 16 to 69 years, with an average of 37
    years
  • Ethnicity 56 Caucasian, 28 African-American,
    4 Hispanic, 11 other
  • Employment status 76 employed full-time, 9
    part-time, 5 homemakers, 4 disabled, 1
    retired, and 5 unemployed
  • Continuous abstinence/recovery ranged from less
    than one year to 35 years, with a mean average of
    5.5 years

32
Narconon
  • The Narconon Treatment Residential Treatment
    Program
  • The Narconon program is designed to get drug or
    alcohol abusers off drugs and back in control of
    their lives.
  • Narconon was founded in the Arizona State Prison
    by an inmate and former heroin addict, William
    Benitez.
  • The original group of ten inmates expanded to
    over one hundred within the first year
  • In 1972 the program was made available to the
    public with the opening of the first street
    program in Los Angeles.
  • Today there are Narconon centers throughout the
    Western world, in Canada, France, Germany, the
    Netherlands, Italy, Spain, Denmark, Sweden,
    Switzerland and Australia, as well as across the
    United States.

33
Narconon
  • PHASE I
  • Drug-Free Withdrawal
  • Narconon provides a safe, 24-hour care procedure
    for a drug free withdrawal. An individual in
    withdrawal is under the careful supervision of a
    Withdrawal Specialist 24 hours a day until the
    physical and mental discomfort associated with
    drug and alcohol withdrawal is no longer present.
  • PHASE II
  • Learning Improvement Course
  • This course provides the student with the
    ability to study and retain knowledge along with
    the ability to recognize and overcome
    obstructions in the study and learning process.
  • The Communications and Perception Course
  • This course utilizes exact procedures, which
    focus the students attention onto the present,
    as opposed to being stuck in past experiences. It
    improves the students perception of his
    environment, and gets the student into better
    communication with others.

34
Narconon
  • PHASE III
  • Ups and Downs in Life Course
  • In this course, students learn the
    characteristics of social and anti-social
    personalities in order to evaluate objectively
    and choose those people in their lives who need
    to be avoided
  • Personal Values and Integrity Course
  • This course restores to the clients his basic
    sense of right and wrong, and the ability to live
    honestly again. Values and purposes are recovered
    and strengthened. Students often experience a
    strong feeling of relief, and a newfound feeling
    of freedom and self-respect because of this
    course.
  • PHASE IV
  • The Changing Conditions in Life Course
  • This course gives the student the exact formulas
    to use to evaluate objectively and improve
    conditions having to do with himself, his family,
    the groups he belongs to, and other areas of
    life.
  • The Way to Happiness Course
  • This course introduces the student to a common
    sense moral code that he can use in living a new
    drug and alcohol-free life.

35
Narconon
  • Final Program Review
  • A comprehensive review to ensure the student has
    thoroughly completed all phases of the program.
  • Additional course work is assigned based on
    specific student needs to prepare the student to
    deal with life situations after graduation from
    the program.

36
Narconon
  • Follow-up Program
  • A comprehensive long-term follow-up program is
    designed and implemented to assist the student
    through the first year of recovery. This is
    accomplished through regular contact with the
    student and family members.
  • The entire Narconon program takes between 3-5
    months to complete. The difference in time
    depends on each individual and what is required
    for them.

37
Psychotherapy Treatments
38
Individualized Drug Counseling
  • Focuses directly on reducing or stopping the
    addict's illicit drug use
  • Addresses related areas of impaired
    functioningsuch as employment status, illegal
    activity, family/social relations
  • Emphasis on short-term behavioral goals
  • Development and application of coping strategies
    and tools for maintaining abstinence
  • The addiction counselor
  • Encourages 12-step participation
  • Makes referrals for needed supplemental medical,
    psychiatric, employment, and other services
  • Individuals are encouraged to attend sessions one
    or two times per week

39
Motivational Enhancement Therapy
  • Client-centered counseling approach for
    initiating behavior change by helping clients to
    resolve ambivalence about engaging in treatment
    and stopping drug use.
  • Employs strategies to evoke rapid and internally
    motivated change in the client, rather than
    guiding the client stepwise through the recovery
    process.
  • Consists of an initial assessment battery
    session, followed by two to four individual
    treatment sessions with a therapist.
  • The first treatment session provides feedback
    generated from assessment battery to stimulate
    discussion regarding personal substance use and
    to elicit self-motivational statements.
  • Motivational interviewing principles are used to
    strengthen motivation and build a plan for
    change.
  • Coping strategies for high-risk situations are
    suggested and discussed with the client.
  • This approach has been used successfully with
    alcoholics and with marijuana-dependent
    individuals.

40
Confrontation vs. Motivation Enhancement
41
Other Techniques
  • Application of Marlatts Relapse Prevention for
    alcohol
  • Cue Exposure
  • Extinction
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Title: Assessment and Treatment of Addictive Behaviors Carl W. Lejuez, PhD


1
Assessment and Treatment of Addictive
BehaviorsCarl W. Lejuez, PhD
  • Lecture 9
  • Drug Treatment

2
Drug Treatment Cost Effective?
  • Yes!
  • Less expensive than alternatives, such as not
    treating addicts or simply incarcerating addicts
  • 1 year of methadone maintenance is about 4,700
    per patient
  • 1 full year of imprisonment costs about 18,400
    per person
  • Every 1 invested in addiction treatment programs
    yields a return of between 4 and 7 in reduced
    drug-related crime, criminal justice costs, and
    theft alone
  • Costs reduced due to drops in health care
    expenses, interpersonal conflicts, improvements
    in workplace productivity, and reductions in
    drug-related accidents

3
Initial Considerations
  • Due to heterogeneity of drug problems, detailed
    initial assessment is crucial
  • Should assess how they made it to treatment are
    they self-referred or by the will of others
    including court mandate
  • Multidimensional Outcomes
  • Abstinence doesnt guarantee improvement in
    social, occupational, etc functioning
  • Relapse often a part of long-term success
  • Relapse rate on 1st attempt seeking treatment 25
  • Common treatments often have little empirical
    support

4
Basics of Treatment
  • In addition to stopping drug use, the goal of
    treatment is to return the individual to
    productive functioning in the family, workplace,
    and community
  • Measures of effectiveness
  • criminal behavior
  • family functioning
  • Employability
  • medical condition
  • Overall, treatment of addiction is as successful
    as treatment of other chronic diseases, such as
    diabetes, hypertension, and asthma

5
Basics of Treatment
  • Treatment reduces drug use by 40 60
    significantly decreases criminal activity during
    after treatment
  • For example, a study of therapeutic community
    treatment for drug offenders demonstrated that
    arrests for violent and nonviolent criminal acts
    were reduced by 40 percent or more
  • Methadone treatment has been shown to decrease
    criminal behavior by as much as 50 percent.
  • Research shows that drug addiction treatment
    reduces the risk of HIV infection and that
    interventions to prevent HIV are much less costly
    than treating HIV-related illnesses.

6
Basics of Treatment
  • Important Considerations
  • No single treatment is appropriate for all
    individuals
  • An individual's treatment and services plan must
    be assessed continually and modified as necessary
    to ensure that the plan meets the person's
    changing needs
  • Counseling and other behavioral therapies are
    critical components of effective treatment for
    addiction
  • Medications are an important element of treatment
    for many patients
  • Medical detoxification is an important first step
    to most drug addiction treatments

7
Basics of Treatment
  • Medical Detoxification
  • Detoxification alone is rarely sufficient to help
    addicts achieve long-term abstinence
  • Medical detoxification safely manages the acute
    physical symptoms of withdrawal associated with
    stopping drug use.
  • Strongly indicated precursor to effective drug
    addiction treatment

8
Types of Treatment
  • Pharmacological Treatment
  • Medication can be used to accomplish a number of
    goals
  • Prevention of overdose
  • Suppression of withdrawal
  • Reduction of cravings
  • Reduction of psychiatric symptoms
  • Heroin Methadone, LAAM, Naltrexone,
    Buprenorphine
  • Alcohol Disulfiram (Antabuse), Benzodiazepines
  • No FDA approved medications for treatment for the
    following
  • Cocaine
  • LSD
  • PCP
  • Marijuana
  • Methamphetamine and other stimulants
  • Inhalants
  • Anabolic steroids

9
Types of Treatment
  • Behavioral Treatment
  • Assumption Drug Taking is a special case of
    operant behavior maintained by the reinforcing
    effects of the drugs.
  • EvidenceHuman and animal self-administration
    studies repeatedly demonstrate that various
    psychoactive drugs serve as positive
    reinforcers.Variables that control other
    operant behaviorssuch as reinforcer magnitude,
    response requirement, and the availability of
    alternative reinforcersalso control drug
    taking.Numerous treatment studies have
    demonstrated that contingency management
    procedures can effectively reduce drug use
  • Examples
  • Contingency Management Interventions
  • Behavioral Activation

10
Types of Treatment
  • Multisystemic and Social Support Treatments
  • These treatment programs attend to abstinence as
    well as other aspects of the individuals needs
    based on the theory that sobriety can not be
    maintained in a vacuum
  • Areas Addressed include medical attention,
    occupational training, educational training
    (GED), housing, family relationships, exposure to
    community resources, social support, etc.
  • Examples
  • Out-patient treatment Programs
  • Residential Programs
  • Therapeutic Communities
  • NA/AA/Narconon

11
Types of Treatment
  • Psychotherapy
  • Useful for providing patients with individualized
    therapy
  • Provides more privacy than group setting
  • Enables patient to address problems that may be
    only peripherally related to drug use
  • Enables patient to address other mental health
    issues
  • Examples
  • Individualized Drug Counseling
  • Motivational Enhancement Therapy
  • Relapse Prevention

12
Treatment Duration
  • Individuals progress through drug addiction
    treatment at various speeds, but Good outcomes
    are contingent on adequate lengths of treatment.
  • residential or outpatient treatment,
    participation for less than 90 days is of limited
    or no effectiveness, and treatments lasting
    significantly longer often are indicated.
  • For methadone maintenance, 12 months of treatment
    is the minimum, and some opiate-addicted
    individuals will continue to benefit from
    methadone maintenance treatment over a period of
    years.
  • Successful outcomes may require multiple
    treatment experience. Many addicted individuals
    have multiple episodes of treatment, often with a
    cumulative impact.

13
Pharmacological Treatments
14
Agonist Maintenance Treatment
  • For opiate addicts usually is conducted in
    outpatient settings, often called methadone
    treatment programs
  • These programs use a long-acting orally
    administered synthetic opiate medication
  • usually methadone or LAAM
  • sustained period at a dosage sufficient to
    prevent opiate withdrawal, block the effects of
    illicit opiate use, and decrease opiate craving
  • Patients stabilized on opiate agonists can engage
    more readily in counseling and other behavioral
    interventions
  • Most effective opiate agonist maintenance
    programs include individual and/or group
    counseling, as well as provision/referral to
    other needed medical, psychological, social
    services.

15
Agonist Maintenance Treatment
  • As used in maintenance treatment, methadone and
    LAAM are not heroin substitutes
  • Pharmacological effects are markedly different
    from those of heroin.
  • Far more gradual onsets of action than heroin
  • No rush
  • Wears off much more slowly than heroin
  • No sudden crash
  • Euphoric effects of heroin are significantly
    blocked
  • No marked fluctuations experienced by brain and
    body
  • Reduced craving for heroin

16
Narcotic Antagonist Treatment Using Naltrexone
  • For opiate addicts, usually conducted in
    outpatient settings although initiation of the
    medication often begins after medical
    detoxification in a residential setting
  • Naltrexone is a long-acting synthetic opiate
    antagonist with few side effects that is taken
    orally either daily or three times a week for a
    sustained period of time
  • Individuals must be medically detoxified and
    opiate-free for several days before naltrexone
    can be taken to prevent precipitating an opiate
    abstinence syndrome. When used this way, all the
    effects of self-administered opiates, including
    euphoria, are completely blocked.

17
Narcotic Antagonist Treatment Using Naltrexone
  • Theory repeated lack of the desired opiate
    effects, as well as the perceived futility of
    using the opiate, will gradually result in
    breaking the habit of opiate addiction
  • Naltrexone itself has no subjective effects or
    potential for abuse and is not addicting.
  • Patient noncompliance is a common problem.
  • Most useful for highly motivated, recently
    detoxified patients who desire total abstinence
    because of external circumstances, including
    impaired professionals, parolees, probationers,
    and work-release prisoners

18
Other Medications for Heroin Dependence
  • Buprenorphine has recently been approved for
    maintenance treatment.
  • Does not require daily administration, an
    advantage over methadone.
  • Like methadone and LAAM, Buprenorphine suppress
    withdrawal, reduce cravings, and prevent users
    from getting high from heroin
  • Another potential answer prescription Heroin
  • Why prescribe heroin?
  • Methadone does not work for everyone
  • Might bring more people into treatment
  • Reduce some of the harm associated with heroin
  • Undermine the black market

19
Cocaine Vaccine
  • TA-CD is a combination of the cocaine molecule
    and a large protein
  • Triggers the generation of antibodies.
  • If cocaine is taken
  • Antibodies combine with cocaine molecules to form
    a complex that is too big to cross the
    blood-brain barrier.
  • Initial trails have indicated TA-CD is safe and
    effective in reducing cocaine intake in rats
  • A single human study has shown that the drug was
    well tolerated (low side effects) and safe in
    humans.
  • Awaiting FDA approval for use as a treatment of
    cocaine dependence

20
Behavioral Treatment
21
Contingency Management Programs
  • Based on idea that in any particular instance,
    benefits of drug use often are immediate
    certain, whereas negatives often are delayed
    often uncertain
  • Also focuses on fact that benefits for nonuse
    often are delayed and uncertain
  • Basic Procedures
  • Drug use and abstinence are readily detected
  • Drug abstinence is readily reinforced
  • Drug use results in a loss of reinforcement
  • Reinforcement derived from non-drug sources is
    increased to compete with the reinforcing effects
    of drug use(Higgins et al., 1991)

22
Voucher-Based Reinforcement Therapy in Methadone
Maintenance Treatment
  • Provision of a voucher for each drug-free urine
    sample
  • Voucher has monetary value and can be exchanged
    for goods and services consistent with treatment
    goals
  • Initially, voucher values are low, but value
    increases with the number of consecutive
    drug-free urine specimens
  • Cocaine- or heroin-positive urine specimens reset
    the value
  • Escalating contingency to reinforce sustained
    drug abstinence.
  • Patients receiving vouchers for drug-free urine
    achieved significantly longer abstinence than
    patients who were given vouchers independent of
    urinalysis results.

23
Community Reinforcement Approach (CRA) Plus
Vouchers
  • Intensive 24-week outpatient therapy for
    treatment of cocaine
  • To achieve cocaine abstinence long enough for
    patients to learn new life skills that will help
    sustain abstinence
  • To reduce alcohol consumption for patients whose
    drinking is associated with cocaine use.
  • Patients attend one or two individual counseling
    sessions per week, where they focus on improving
    family relations, learning a variety of skills to
    minimize drug use, receiving vocational
    counseling, and developing new recreational
    activities and social networks.

24
CRA Plus Vouchers
  • Those who also abuse alcohol receive
    clinic-monitored disulfiram (Antabuse) therapy
  • Patients submit urine samples two or three times
    each week receive vouchers for cocaine-negative
    samples
  • The value of the vouchers increases with
    consecutive clean samples. Exchange vouchers for
    retail goods
  • Facilitates patients' engagement in treatment and
    aids in gaining substantial periods of cocaine
    abstinence.
  • Tested in urban and rural areas and used
    successfully in outpatient detoxification of
    opiate-addicted adults and with inner-city
    methadone maintenance patients who have high
    rates of intravenous cocaine abuse.

25
Multisystemic and Social Support Treatments
26
Outpatient Treatment
  • Outpatient Drug-Free Treatment
  • Varies in the types and intensity of services
    offered.
  • Costs less than residential or inpatient
    treatment
  • Most suitable for individuals who are employed or
    who have extensive social supports.
  • Low-intensity programs focus is on drug
    education and admonition.
  • Intensive day treatment comparable to
    residential programs in services and
    effectiveness
  • Group counseling is emphasized
  • Medical or mental health problems may also be
    treated

27
Long-Term Residential
  • Provides care 24 hours per day, generally in
    nonhospital settings
  • The best-known residential treatment model is the
    therapeutic community (TC), but residential
    treatment may also employ other models, such as
    cognitive-behavioral therapy

28
Therapeutic Communities
  • Residential programs with planned stays of 6-12
    months
  • TCs focus on the "resocialization" of the
    individual and use the program's entire
    "community,"
  • including other residents, staff, and the social
    context, as active components of treatment
  • Addiction is viewed in the context of an
    individual's social and psychological deficits
  • treatment focuses on developing personal
    accountability and responsibility and socially
    productive lives.
  • Highly structured and at times be confrontational
  • activities designed to help residents examine
    damaging beliefs, self-concepts, and patterns of
    behavior and to adopt new, more harmonious and
    constructive ways to interact with others

29
Therapeutic Communities
  • Many TCs are quite comprehensive and can include
    employment training and other support services on
    site.
  • Compared with patients in other forms of drug
    treatment, the typical TC resident has more
    severe problems, with more co-occurring mental
    health problems and more criminal involvement.
  • Research shows that TCs can be modified to treat
    individuals with special needs, including
    adolescents, women, those with severe mental
    disorders, and individuals in the criminal
    justice system

30
Narcotics Anonymous
  • Begin in 1953, based on AA
  • NA's earliest self-titled pamphlet, known among
    members as "the White Booklet," describes
    Narcotics Anonymous as
  • "a nonprofit fellowship or society of men and
    women for whom drugs had become a major problem .
    . . who meet regularly to help each other stay
    clean We are not interested in what or how much
    you usedbut only in what you want to do about
    your problem and how we can help.
  • Membership is open to any drug addict
  • regardless of the particular drug or combination
    of drugs used.
  • When adapting AA's First Step, the word
    "addiction" was substituted for "alcohol,
  • Removed drug-specific language
  • Continued focus on disease concept of addiction

31
Demographics of NA
  • Male/female ratio 58 male, 42 female
  • Ages from 16 to 69 years, with an average of 37
    years
  • Ethnicity 56 Caucasian, 28 African-American,
    4 Hispanic, 11 other
  • Employment status 76 employed full-time, 9
    part-time, 5 homemakers, 4 disabled, 1
    retired, and 5 unemployed
  • Continuous abstinence/recovery ranged from less
    than one year to 35 years, with a mean average of
    5.5 years

32
Narconon
  • The Narconon Treatment Residential Treatment
    Program
  • The Narconon program is designed to get drug or
    alcohol abusers off drugs and back in control of
    their lives.
  • Narconon was founded in the Arizona State Prison
    by an inmate and former heroin addict, William
    Benitez.
  • The original group of ten inmates expanded to
    over one hundred within the first year
  • In 1972 the program was made available to the
    public with the opening of the first street
    program in Los Angeles.
  • Today there are Narconon centers throughout the
    Western world, in Canada, France, Germany, the
    Netherlands, Italy, Spain, Denmark, Sweden,
    Switzerland and Australia, as well as across the
    United States.

33
Narconon
  • PHASE I
  • Drug-Free Withdrawal
  • Narconon provides a safe, 24-hour care procedure
    for a drug free withdrawal. An individual in
    withdrawal is under the careful supervision of a
    Withdrawal Specialist 24 hours a day until the
    physical and mental discomfort associated with
    drug and alcohol withdrawal is no longer present.
  • PHASE II
  • Learning Improvement Course
  • This course provides the student with the
    ability to study and retain knowledge along with
    the ability to recognize and overcome
    obstructions in the study and learning process.
  • The Communications and Perception Course
  • This course utilizes exact procedures, which
    focus the students attention onto the present,
    as opposed to being stuck in past experiences. It
    improves the students perception of his
    environment, and gets the student into better
    communication with others.

34
Narconon
  • PHASE III
  • Ups and Downs in Life Course
  • In this course, students learn the
    characteristics of social and anti-social
    personalities in order to evaluate objectively
    and choose those people in their lives who need
    to be avoided
  • Personal Values and Integrity Course
  • This course restores to the clients his basic
    sense of right and wrong, and the ability to live
    honestly again. Values and purposes are recovered
    and strengthened. Students often experience a
    strong feeling of relief, and a newfound feeling
    of freedom and self-respect because of this
    course.
  • PHASE IV
  • The Changing Conditions in Life Course
  • This course gives the student the exact formulas
    to use to evaluate objectively and improve
    conditions having to do with himself, his family,
    the groups he belongs to, and other areas of
    life.
  • The Way to Happiness Course
  • This course introduces the student to a common
    sense moral code that he can use in living a new
    drug and alcohol-free life.

35
Narconon
  • Final Program Review
  • A comprehensive review to ensure the student has
    thoroughly completed all phases of the program.
  • Additional course work is assigned based on
    specific student needs to prepare the student to
    deal with life situations after graduation from
    the program.

36
Narconon
  • Follow-up Program
  • A comprehensive long-term follow-up program is
    designed and implemented to assist the student
    through the first year of recovery. This is
    accomplished through regular contact with the
    student and family members.
  • The entire Narconon program takes between 3-5
    months to complete. The difference in time
    depends on each individual and what is required
    for them.

37
Psychotherapy Treatments
38
Individualized Drug Counseling
  • Focuses directly on reducing or stopping the
    addict's illicit drug use
  • Addresses related areas of impaired
    functioningsuch as employment status, illegal
    activity, family/social relations
  • Emphasis on short-term behavioral goals
  • Development and application of coping strategies
    and tools for maintaining abstinence
  • The addiction counselor
  • Encourages 12-step participation
  • Makes referrals for needed supplemental medical,
    psychiatric, employment, and other services
  • Individuals are encouraged to attend sessions one
    or two times per week

39
Motivational Enhancement Therapy
  • Client-centered counseling approach for
    initiating behavior change by helping clients to
    resolve ambivalence about engaging in treatment
    and stopping drug use.
  • Employs strategies to evoke rapid and internally
    motivated change in the client, rather than
    guiding the client stepwise through the recovery
    process.
  • Consists of an initial assessment battery
    session, followed by two to four individual
    treatment sessions with a therapist.
  • The first treatment session provides feedback
    generated from assessment battery to stimulate
    discussion regarding personal substance use and
    to elicit self-motivational statements.
  • Motivational interviewing principles are used to
    strengthen motivation and build a plan for
    change.
  • Coping strategies for high-risk situations are
    suggested and discussed with the client.
  • This approach has been used successfully with
    alcoholics and with marijuana-dependent
    individuals.

40
Confrontation vs. Motivation Enhancement
41
Other Techniques
  • Application of Marlatts Relapse Prevention for
    alcohol
  • Cue Exposure
  • Extinction
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