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Treatment of Addictions

The following treatment guidelines are meant as a reference tool, but are not intended as treatment advice or to replace the clinical decision-making process of psychiatrists or other health professionals who administer these treatments. In clinical practice there are often good reasons why treatment approaches differ from what is described here.

 

When individuals with Substance Abuse or Dependence are offered treatment, they can be at different stages of accepting or denying that they have a substance use problem. Identifying the stage at which the person is in is very important in order to determine where and how to start treatment. (However, in cases where an individual's immediate safety is in question due to substance intoxication, withdrawal, or other medical emergencies, they may need to be hospitalized, even against their will.)

The five stages of change that have been described are as follows [ref]:

Precontemplation is when the individual is still unwilling or unable to consider changing their substance use behaviors

Contemplation is when the person begins to acknowledge concerns regarding their substance misuse and the possibility of change, though they remain ambivalent about this.

Preparation is when the individual has decided that they need to change their behaviors, but they are still deciding how to go about this.

Action is when the individual is taking active steps to reduce and discontinue their substance use.

Maintenance is when the person has achieved abstinence and now must work to prevent any relapses.

These stages are not necessarily sequential, as individuals may cycle back and forth between them.

Precontemplation and Contemplation

In these stages, before the individual is ready to reduce their substance use, the two goals are harm-reduction and motivational-enhancement. These goals can be met with the help of any treating personnel, be it a physician, psychologist, nurse, social worker, or lay addictions worker.

The goal of harm-reduction is to minimize the various behaviors associated with the substance use that pose dangers to the individual's health and safety. This includes directing intravenous drug users to needle exchange programs so as to minimize their chances of contracting viruses like hepatitis and HIV, and counseling alcoholics on proper diet and nutrition. Contraception should be discussed so as to minimize the chances of fetuses being exposed to substances. For individuals in the contemplation phase, it can be helpful to educate them on the various heath risks posed by their substance use.

Motivational-enhancement refers to the use of Motivational Interviewing to encourage individuals to move from the precontemplation and contemplation phases into the preparation and action phases. The principles of Motivational Interviewing are easily learned and can be administered by any treating personnel. The most basic but important element of this approach is to keep the individual engaged in the treatment process regardless of what stage they are at. This requires a non-judgmental attitude and good interpersonal skills on the part of the treating personnel [ref].

Preparation and Action

Once the individual is ready to begin the work of reducing and ceasing their substance use, deciding on the appropriate treatment setting is important.

Hospitalization is indicated mainly for those people who are at risk of having medical complications from the withdrawal from the substance(s) they use. This can include those who want to withdraw from several substances at once, those with alcohol dependence who experienced delirium tremens in the past, or those who have pre-existing medical conditions.

Residential treatment takes place in residences often removed from urban centers, where people with substance use disorders come to live for periods of several months. Many of these residences are considered therapeutic communities, where many of the treating personnel are individuals who themselves suffered from substance use disorders in the past, and where all the residents actively participate in the day-to-day running of the residence. Residential treatment is indicated for people whose substance use has become a central and all-consuming focus of their lives and daily routine, and who lack the ability to remain abstinent in an ambulatory setting.

Day hospital programs, also known as partial hospitalization or intensive outpatient programs, are geared for individuals who are able to live on their own, but whose lives have been significantly impacted by their substance use problems, who may not be able to hold a job or be in school at the moment, and who require the structure and support of a full-day treatment program.

Standard outpatient treatment, where the individual comes for regular appointments, is reserved for those people who are functioning reasonably well on their own, have good social supports, and are working, in school, or have some other stable and productive daily routine. Nicotine and cannabis dependence are often treated in these settings

In all of these treatment settings, psychotherapy and counseling, either in individual or group format, is the main form of intervention offered, though medications are also used. The choice of treatments is made based on what is available in a given treatment program and the individual's particular needs and preferences. There is no evidence that any one form of therapy is superior to any others [ref].

Cognitive Behavioral Therapy, Behavioral Therapy, Psychodynamic Psychotherapy and Interpersonal Therapy, in individual and group formats, are all acceptable options, with the most supporting evidence available for Cognitive Behavioral Therapy [ref].

For individuals still living with or in close contact with their families, Family Therapy can also be considered, especially when family members have fallen into a pattern of unintentionally enabling or supporting an individual's substance use [ref].

Twelve-step programs - Alcoholics Anonymous being the most well known - are also commonly used and effective treatment programs [ref].

For information on the use of medications for treating substance use disorders, and for additional information on specific treatments for particular substances, please refer to the PsychVisit sections on the individual substances.

Also, the American Society for Addiction Medicine (ASAM) has developed guidelines for choosing appropriate treatments and levels of care for individuals with Substance Use Disorders. These guidelines are under copyright and can be purchased here.

Maintenance

Once an individual has achieved abstinence, maintaining this state and preventing relapse remains an important focus of treatment that can continue for many years. The same treatments as listed above are used for this purpose. Individuals who participate in a twelve-step program can remain invested in these programs for the rest of their lives.

 

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