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

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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 7
  • Drugs, Alcohol, and Smoking 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 lt
    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
Counseling Strategy Confrontational Motivation Enhancement
Labeling Y N
Locus of control Provider Patient
Evidence for change Presented and interpreted by provider Presented provider Interpreted patient
Problem solving provider Driven by patient with help from provider
Interpret resistance Denial by patient Need new provider strategy
Treatment goals Set by provider Negotiated
Change strategies Set by provider Negotiated
41
Other Techniques
  • Application of Marlatts Relapse Prevention for
    alcohol
  • Cue Exposure
  • Extinction

42
  • Alcohol Treatment

43
Factors that affect treatment success
  • Current level of dependence
  • Medical Problems
  • Treatment History
  • Previous Quit Attempts
  • Social Support Systems
  • Personal resources
  • Other psychological problems
  • Attitudes about treatment

44
Detoxification
  • Sx begin 5-12 hrs after drinking stopped and may
    last up to 72 hrs
  • 4 detox alternatives
  • Inpatient medical
  • Partial hospital medical
  • Inpatient nonmedical
  • Outpatient medical

45
Treatment Modalities
  • Self-help groups
  • Individual treatment
  • Group therapy
  • Couples therapy
  • Family therapy
  • In most cases, can occur as inpatient or
    outpatient

46
Treatment Approaches
47
Marlatts Relapse Prevention Model
  • Coping Skills Training
  • Drinking conceptualized in terms of deficits in
    interpersonal and coping skills
  • Condition more adaptive responses to drinking
    cues
  • Focus on new coping skills
  • Functional analysis, relapse prevention, cue
    exposure, refusal skills

48
Relapse Prevention
  • Cognitive-behavioral therapy
  • Developed for the treatment of problem drinking
    by Marlatt
  • Adapted for cocaine and other drugs more recently
  • Based on the theory that learning processes play
    a critical role in the development of maladaptive
    behavioral patterns
  • Individuals learn to identify and correct
    problematic behaviors
  • Includes several cognitive-behavioral strategies
    that facilitate abstinence and provide help for
    people who experience relapse
  • Techniques include
  • Exploring the positive and negative consequences
    of continued drinking
  • Self-monitoring to recognize cravings early on
    and to identify high-risk situations for use
  • Avoiding high-risk situations
  • Developing strategies for coping with avoidable
    high-risk situations

49
Community Reinforcement Approach
  • Based in Cognitive/Behavioral theory
  • Sobriety through use of support systems
  • Examine interaction of environment drinking
  • Uses skills training
  • Functional analysis
  • Mood monitoring
  • Vocational counseling
  • Drink refusal training
  • Compliance monitoring
  • Buddy systems
  • Can be limited by high cost of implementation,
    including time, , and participation of others

50
Motivational Enhancement
  • Developed by Miller
  • Brief intervention tradition
  • Nonconfrontational
  • Client-centered
  • Focus on motivation/readiness to change
  • Techniques include
  • Feedback of risk/impairment
  • Responsibility for change
  • Advice to change
  • Menu of alternative change options
  • Therapist empathy
  • Facilitation of client self-efficacy

51
Cue Exposure
  • Based in classical conditioning
  • Expose individual to alcohol-related stimuli such
    as people, places and things that they have
    experienced with alcohol in the past and that now
    cue alcohol urges
  • Do not let the individual consume alcohol in the
    presence of the cue to begin to break down the
    association of the cue and alcohol consumption ?
    should reduce power of cue to produce urge over
    time
  • Patients often taught drink refusal and other
    coping skills in the presence of the cue to help
    them deal with exposure to the cue in the future

52
Pharmacological (1)
  • Disulfiram/Antabuse
  • In pill form by prescription only
  • Inhibits adelhyde dehydrogenase (ALDH)
  • Body cant break down alcohol
  • When in system (lasts up to 3 days), alcohol use
    produces strong aversive physical reaction
  • Must be taken daily
  • Compliance is major drawback

53
Pharmacological (2)
  • Naltrexone
  • In pill form by prescription only
  • Blocks opioid receptors in the brain
  • 2 main effects
  • Decreases rewarding experience of alcohol
  • Reduces craving
  • Must be taken daily
  • Compliane is major drawback

54
12 Step Groups AA, NA, GA etc
  • Most common form of tx across addictions
  • AA established 1935
  • Alcoholics Anonymous is a fellowship of men and
    women who share their experience, strength and
    hope with each other that they may solve their
    common problem and help others to recover from
    alcoholism. The only requirement for membership
    is a desire to stop drinking. There are no dues
    or fees for A.A. membership we are
    self-supporting through our own contributions.
    A.A. is not allied with any sect, denomination,
    politics, organization or institution does not
    wish to engage in any controversy neither
    endorses nor opposes any causes. Our primary
    purpose is to stay sober and help other
    alcoholics to achieve sobriety. All available
    medical testimony indicates that alcoholism is a
    progressive illness, that it cannot be cured in
    the ordinary sense of the term, but that it can
    be arrested through total abstinence from alcohol
    in any form.

55
Alcoholics Anonymous
  • Estimated A.A. Membership and Group
    InformationGroups in U.S. 51,735
    Members in U.S. 1,162,112 Groups in Canada
    5,104 Members in Canada
    98,816 Groups Overseas 41,423 Members
    Overseas 832,994 Internationalists
    106 Groups in Correctional
    Facilities (U.S./Canada) 2,504 Lone
    Members 313 Total 2,160,013
    Members 100,766 Groups
  • Estimates provided by the A.A. General Office,
    January 1, 2001

56
12 Step Groups Keys to success
  • Acceptance of powerlessness vs. addiction
  • Recovery cant occur alone
  • External motivation (from god?)
  • Recognition of own character defects
  • Fellowship in a group
  • Completion of steps
  • 90 meetings in 90 days

57
12 Steps of AA
  1. We admitted we were powerless over alcohol - that
    our lives had become unmanageable.
  2. Came to believe that a Power greater than
    ourselves could restore us to sanity.
  3. Made a decision to turn our will and our lives
    over to the care of God as we understood Him.
  4. Made a searching and fearless moral inventory of
    ourselves.
  5. Admitted to God, to ourselves and to another
    human being the exact nature of our wrongs.
  6. Were entirely ready to have God remove all these
    defects of character.
  7. Humbly asked Him to remove our shortcomings.
  8. Made a list of all persons we had harmed, and
    became willing to make amends to them all.
  9. Made direct amends to such people wherever
    possible, except when to do so would injure them
    or others.
  10. Continued to take personal inventory and when we
    were wrong promptly admitted it.

58
Success rates of AA
  • Why are success rates unclear?
  • Only minimal amount of empirical evidence to
    support claims of high success rates
  • A.A. and 2-step treatment are associated with
    significant reductions in substance abuse and
    psychiatric problems.
  • Also associated with reduced health care costs
    over time in naturalistic, quasi-experimental,
    and experimental studies.
  • Humphreys, 2003

59
Rational Recovery 1
  • Differs from AA
  • Greater emphasis on rational thought, viewing
    drinking problems as problems in living for which
    people need to learn cognitive/behavior skills
  • Grounded in Rational Emotive Therapy (RET Ellis)
  • Views use of psychoactive substances as
    irrational choice.
  • Believes that persons can learn to use their
    rational mind, rather than spirituality, to
    empower themselves not to drink.
  • RR suggests abstinence as the safest route but
    emphasizes rational decision making, and
    acknowledges that some members may make a
    rational decision to drink moderately rather than
    to abstain.

60
Rational Recovery 2
  • All groups have a professional therapist as an
    advisor.
  • Attend meetings for 6-12 months, then move on
    with life
  • Not a lifelong program of recovery requiring
    regular attendance at meetings.
  • One study analyzed the Big Book and the Little
    Book (of RR) and found that the Big Book 8th-
    9th grade reading level was required, for RR
    book, needed college educ for adequate
    comprehension.
  • VERY FEW STUDIES (MAYBE ONLY 1 2) OF RR.
    THEREFORE, EFFICACY IS UNKNOWN.

61
Rational Recovery 13 ideas
  • I have considerable voluntary control over my
    extremities and facial muscles.
  • I accept that, in order to get better, I had
    better refrain from any use of alcohol or drugs,
    because any use will very likely lead to more,
    and then a return to my previous addiction.
  • I accept that I will likely benefit from
    residential care, because I have been
    unsuccessful in previous attempts to resist my
    desire to drink or use drugs.
  • Although I may have serious personal problems, I
    still have the capacity to learn about myself,
    about new ideas, and how to achieve a satisfying,
    rational sobriety.
  • The idea that I must depend on something greater
    than myself in order to stay sober is only
    another dependency idea, and dependency is my
    original problem.
  • I am willing to reject ideas of perfection for
    myself and for others, and my first goal is to
    learn to accept myself as I am a fallible, yet
    worthwhile, human being.
  • I place high value on principles of rationality,
    learning, objectivity, self-forgiveness, my own
    self interest
  • I recognize that, even though I am chemically
    dependent, I am responsible for my
    emotions/behavior.
  • Over time, I may learn that refraining from
    mind-altering drugs is easier than trying to
    control them
  • I will eventually complete my recovery and live a
    normal life.

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What works across approaches
  • Address Motivational/reinforcing effects
  • Use a nonconfrontational approach
  • Teach specific skills
  • Promote active coping and goal setting
  • Target social/environmental factors
  • Decrease cues for drinking
  • Support for not drinking
  • Relationship change
  • Increase access to social support

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Nonspecific factors that affect treatment
  • Therapist empathy
  • Therapist active interest
  • Patient adherence

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  • Nicotine treatment

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"All Truth passes through Three Stages First, it
is Ridiculed...Second, it is Violently
Opposed...Third, it is Accepted as being
Self-Evident." - Arthur Schopenhauer (1778-1860)
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Treatment Success
  • About 25 of Americans currently smoke
  • 42 in 1960 with annual reduction of about .5 up
    until 25 in 1990s currently leveling off
  • About equal number of men and women
  • Due to increase in females smokers from about
    1960
  • 1/3 of smokers attempt to quit each year
  • Between 1 and 5 are successful
  • Most attempt to quit on their own
  • Smoking cessation NOT associated with worse
    outcomes for abstinence from other substances

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Nicotine Withdrawal
  • Physical Up to 2 weeks of the following
  • Depressed mood
  • Insomnia
  • Irritability/frustration/anger
  • Anxiety
  • Difficulty concentrating
  • Restlessness
  • Decreased heart rate
  • Increased appetite
  • Psychological the possibilities are limitless!

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Pharmacotherapy
  • Nicotine Replacement
  • It may seem counter-intuitive to put nicotine in
    your body when trying to quit, but its somewhat
    effective
  • Basic idea behind NRT is to slowly taper smoker
    off the nicotine in cigarettes by replacing it
    with another, controlled source
  • Patch (often fewest problems with compliance, low
    side-effects)
  • Gum (control dosing)
  • Inhaler (some behavioral components of smoking,
    due to puffing)
  • May be used for longer time(3 months) because it
    may address psychological factors as well as
    physical
  • Limitation used for 15-20 at a time
  • Nasal Spray (fastest acting, control dosing, high
    side-effects)
  • May be best for highly dependent smokers who miss
    rush from smoking
  • Lozenge

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The patch
  • Never use while smoking (max of 5 per day across
    several days)
  • Use highest dose (about 22mg for 24-hr and 16mg
    for 16hr) from quit unless smoking less than
    10/day or weigh under 100
  • Continue for 4 weeks
  • Reduce dose for weeks 5-6 and reduce again for
    weeks 7-8
  • Benefits are minor after 8 weeks

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Zyban
  • Chemical name is Buproprion
  • Renamed version of the low level anti-depressant
    Wellbutrin
  • Prescription-only medication to help reduce
    smoking urges and withdrawal symptoms
  • Exact course of action unknown, but the drug has
    anti-depressant qualities
  • Evidence suggests that it can be effective
  • especially when used with psychosocial treatment

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Zyban
  • Begin taking about 2 weeks prior to quit attempt
  • unlike NRT, can be used while still smoking
  • Taken for about 10 weeks
  • Doses 8 hours apart
  • Helps limit the following withdrawal symptoms
    from smoking
  • Mood changes, anxiety, irritability, decreased
    concentration, restlessness, unusual hunger,
    trouble sleeping, constipation
  • Side-effects of Zyban
  • Dry mouth, sleeplessness, shakiness,
    constipation, nausea, headache, appetite loss,
    blurred vision, heart palpations

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Standard TreatmentBased on Marlatts Relapse
Prevention Model
  • Triggers identification management
  • Relaxation
  • Why quit smoking personalize pros and cons
  • Social support for not smoking
  • Non smoking game plan
  • Lifestyle change
  • Coping w/ high risk situations
  • Feeling badly if you slip
  • Preparing for the quit
  • fading

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Triggers
  • People, places, things etc
  • Identify cigarettes that would be most difficult
    to give up
  • Use wrap sheets to identify triggers

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Relaxation Breathing
  • Benson 1975
  • Getting ready
  • Choose quite undisturbed time and space, in a
    comfortable position and relax
  • Relaxing
  • Sit quietly in comfortable position
  • Close eyes
  • Relax muscles full and deep
  • Become aware of breathing, with each breath out
    repeat word or phrase associated with relaxation
  • 10-20 minutes and cool down before standing

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Relaxation Muscle Relaxation
  • Similar to breathing, but
  • Start with one muscle group
  • Tense for 5 sec and then relax
  • Work way through muscle groups, tensing new group
    and keeping old group relaxed
  • Relax, but do not fall asleep must learn to
    associate relaxation with wakeful activivty

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Coping with high risk situations
  • Based in Marlatts relapse prevention theory
  • Identify behavior chain associated with smoking
    and use functional analysis
  • Emotion vs. problem focused coping
  • Use cognitive restructuring and behavioral
    experiments

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Fading
  • Brand fading
  • Movement to cigarettes with less nicotine
  • Week 1 30 reduction
  • similar reductions until 90 less nicotine
  • Makes smoking less preferable
  • Rate fading
  • Reduce number of cigarettes gradually
  • Not a good idea to go under 10 or so
  • Might make few cigarettes seem really good
  • One alternative is to smoke in unusual
    situations
  • Both decrease future withdrawal
  • Money in the bank

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Other Techniques
  • Rapid Paced Aversive Smoking
  • Create aversive reaction to smoking through
    overuse
  • Mixed evidence regarding effectiveness and safety
  • Motivational Interviewing
  • Cognitive-Behavioral Treatment
  • Similar to standard treatmentbut
  • Focus on addictive beliefs
  • I need a cigarette
  • I cant cope without a cigarette
  • Smoking as a learned habit
  • Hypnosis
  • Some effects, but no better than other strategies
  • Acupuncture

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Positives of Quitting
  • 20 minutes
  • Drop in BP and HR, Increase in temp
  • 8 hours
  • CO normal increase in blood oxygen levels
  • 24 hours
  • Chances of heart attach drop
  • 48 hours
  • Regain shaprness of taste and smell
  • 2-3 weeks
  • Circulation improves
  • 1-9 months
  • Breath easier, increased energy
  • 1 year
  • Risk of coronary heart disease cut in half
  • 5-15 years and beyond
  • Risk of stroke and cancer reduced significantly

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Web Site for Hypnosis
  • Better described as Relaxology
  • Safe/natural and is completely drug free and non
    addictive
  • It is self induced assisted by the suggestions of
    the hypnotist
  • It involves a  state of deep mental and physical
    relaxation and concentration, bringing with it, a
    state of heightened awareness.
  • Here are some FACTS
  • The client remains conscious at all times
  • The client is not asleep.
  • The client is unlikely to "feel" hypnotized
  • The client remains in complete control at all
    times
  • The client is not manipulated to do anything they
    do not wish to do
  • The client cannot get "stuck" in hypnosis
  • The client will suffer no unpleasant side effects
  • Once is a state of Hypnosis, the conscious mind
    can be almost "shut-down" allowing positive
    ideas, strategies and concepts to accepted and
    acted upon by the sub-conscious
  • At this same time the subconscious can be
    encouraged to release that pent up anxiety
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