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Center for Substance Abuse Treatment. A Guide to Substance Abuse Services for Primary Care Clinicians. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 1997. (Treatment Improvement Protocol (TIP) Series, No. 24.)

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A Guide to Substance Abuse Services for Primary Care Clinicians.

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Chapter 5—Specialized Substance Abuse Treatment Programs

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Primary care clinicians need to be familiar with available treatment resources for their patients who have diagnosed substance abuse or dependence disorders. The clinician's responsibility to the patient does not end with the patient's entry into formal treatment; rather, the physician may become a collaborative part of the treatment team, or, minimally, continue to treat the patient's medical conditions during the specialized treatment, encourage continuing participation in the program, and schedule followup visits after treatment termination to monitor progress and help prevent relapse.

Understanding the specialized substance abuse treatment system, however, can be a challenging task. No single definition of treatment exists, and no standard terminology describes different dimensions and elements of treatment. Describing a facility as providing inpatient care or ambulatory services characterizes only one aspect (albeit an important one): the setting. Moreover, the specialized substance abuse treatment system differs around the country, with each State or city having its own peculiarities and specialties. Minnesota, for example, is well known for its array of public and private alcoholism facilities, mostly modeled on the fixed-length inpatient rehabilitation programs initially established by the Hazelden Foundation and the Johnson Institute, which subscribe to a strong Alcoholics Anonymous (AA) orientation and have varying intensities of aftercare services. California also offers a number of community-based social model public sector programs that emphasize a 12-Step, self-help approach as a foundation for life-long recovery. In this chapter, the term treatment will be limited to describing the formal programs that serve patients with more serious alcohol and other drug problems who do not respond to brief interventions or other office-based management strategies. It is also assumed that an in-depth assessment has been conducted to establish a diagnosis and to determine the most suitable resource for the individual's particular needs (see Chapter 4).

Directories of Local Substance Abuse Treatment Systems

The first step in understanding local resources is to collect information about the specialized drug and alcohol treatment currently available in the community. In most communities, a public or private agency regularly compiles a directory of substance abuse treatment facilities that provides useful information about program services (e.g., type, location, hours, and accessibility to public transportation), eligibility criteria, cost, and staff complement and qualifications, including language proficiency. This directory may be produced by the local health department, a council on alcoholism and drug abuse, a social services organization, or volunteers in recovery. Additionally, every State has a single State-level alcohol and other drug authority that usually has the licensing and program review authority for all treatment programs in the State and often publishes a statewide directory of all alcohol and drug treatment programs licensed in the State. Another resource is the National Council on Alcohol and Drug Dependence, which provides both assessment or referral for a sliding scale fee and distributes free information on treatment facilities nationally. Also, the Substance Abuse and Mental Health Services Administration distributes a National Directory of Drug Abuse and Alcoholism Treatment and Prevention Programs (1-800-729-6686).

Knowing the resources and a contact person within each will facilitate access to the system. One useful referral tool is a list of agencies organized across different characteristics, such as services tailored to meet the needs of special populations (e.g., women, adolescents, people who are HIV-positive, and minorities). Resources also should include self-help groups in the area.

Goals and Effectiveness of Treatment

While each individual in treatment will have specific long- and short-term goals, all specialized substance abuse treatment programs have three similar generalized goals (Schuckit, 1994; American Psychiatric Association, 1995):

  • Reducing substance abuse or achieving a substance-free life
  • Maximizing multiple aspects of life functioning
  • Preventing or reducing the frequency and severity of relapse

For most patients, the primary goal of treatment is attainment and maintenance of abstinence (with the exception of methadone-maintained patients), but this may take numerous attempts and failures at "controlled" use before sufficient motivation is mobilized. Until the patient accepts that abstinence is necessary, the treatment program usually tries to minimize the effects of continuing use and abuse through education, counseling, and self-help groups that stress reducing risky behavior, building new relationships with drug-free friends, changing recreational activities and lifestyle patterns, substituting substances used with less risky ones, and reducing the amount and frequency of consumption, with a goal of convincing the patient of her individual responsibility for becoming abstinent (American Psychiatric Association, 1995). Total abstinence is strongly associated with a positive long-term prognosis.

Becoming alcohol- or drug-free, however, is only a beginning. Most patients in substance abuse treatment have multiple and complex problems in many aspects of living, including medical and mental illnesses, disrupted relationships, underdeveloped or deteriorated social and vocational skills, impaired performance at work or in school, and legal or financial troubles. These conditions may have contributed to the initial development of a substance use problem or resulted from the disorder. Substantial efforts must be made by treatment programs to assist patients in ameliorating these problems so that they can assume appropriate and responsible roles in society. This entails maximizing physical health, treating independent psychiatric disorders, improving psychological functioning, addressing marital or other family and relationship issues, resolving financial and legal problems, and improving or developing necessary educational and vocational skills. Many programs also help participants explore spiritual issues and find appropriate recreational activities.

Increasingly, treatment programs are also preparing patients for the possibility of relapse and helping them understand and avoid dangerous "triggers" of resumed drinking or drug use. Patients are taught how to recognize cues, how to handle craving, how to develop contingency plans for handling stressful situations, and what to do if there is a "slip." Relapse prevention is particularly important as a treatment goal in an era of shortened formal, intensive intervention and more emphasis on aftercare following discharge.

While the effectiveness of treatment for specific individuals is not always predictable, and different programs and approaches have variable rates of success, evaluations of substance abuse treatment efforts are encouraging. All the long-term studies find that "treatment works" -- the majority of substance-dependent patients eventually stop compulsive use and have less frequent and severe relapse episodes (American Psychiatric Association, 1995; Landry, 1996). The most positive effects generally happen while the patient is actively participating in treatment, but prolonged abstinence following treatment is a good predictor of continuing success. Almost 90 percent of those who remain abstinent for 2 years are also drug- and alcohol-free at 10 years (American Psychiatric Association, 1995). Patients who remain in treatment for longer periods of time are also likely to achieve maximum benefits -- duration of the treatment episode for 3 months or longer is often a predictor of a successful outcome (Gerstein and Harwood, 1990). Furthermore, individuals who have lower levels of premorbid psychopathology and other serious social, vocational, and legal problems are most likely to benefit from treatment. Continuing participation in aftercare or self-help groups following treatment also appears to be associated with success (American Psychiatric Association, 1995).

An increasing number of randomized clinical trials and other outcome studies have been undertaken in recent years to examine the effectiveness of alcohol and various forms of drug abuse treatment. It is beyond the scope of this chapter to report the conclusions in any depth. However, a few summary statements from an Institute of Medicine report on alcohol studies are relevant:

  • No single treatment approach is effective for all persons with alcohol problems, and there is no overall advantage for residential or inpatient treatment over outpatient care.
  • Treatment of other life problems associated with drinking improves outcomes.
  • Therapist and patient (and problem) characteristics, treatment process, posttreatment adjustment factors, and the interactions among these variables also determine outcomes.
  • Patients who significantly reduce alcohol consumption or become totally abstinent usually improve their functioning in other areas (Institute of Medicine, 1990).

A recent comparison of treatment compliance and relapse rates for patients in treatment for opiate, cocaine, and nicotine dependence with outcomes for three common and chronic medical conditions (i.e., hypertension, asthma, and diabetes) found similar response rates across the addictive and chronic medical disorders (National Institute on Drug Abuse, 1996). All of these conditions require behavioral change and medication compliance for successful treatment. The conclusion is that treatment of drug addiction has a similar success rate as treatment of other chronic medical conditions (National Institute on Drug Abuse, 1996).

Treatment Dimensions

The terminology describing the different elements of treatment care for people with substance use disorders has evolved as specialized systems have developed and as treatment has adapted to changes in the health care system and financing arrangements. Important differences in language persist between public and private sector programs and, to a lesser extent, in treatment efforts originally developed and targeted to persons with alcohol- as opposed to illicit drug-related problems. Programs are increasingly trying to meet individual needs and to tailor the program to the patients rather than having a single standard format with a fixed length of stay or sequence of specified services.

A recent publication of the Substance Abuse and Mental Health Services Administration, Overview of Addiction Treatment Effectiveness (Landry, 1996), divides substance abuse treatment along three dimensions: (1) treatment approach -- the underlying philosophical principles that guide the type of care offered and that influence admission and discharge policies as well as expected outcomes, attitudes toward patient behavior, and the types of personnel who deliver services; (2) treatment setting -- the physical environment in which care is delivered; and (3) treatment components -- the specific clinical interventions and services offered to meet individual needs. These services can be offered for varying lengths of time and delivered at differing intensities. Another important dimension is treatment stage, because different resources may be targeted at different phases along a continuum of recovery. Programs also have been developed to serve special populations -- by age, gender, racial and ethnic orientation, drug of choice, and functional level or medical condition. Some of these offer the most appropriate environment and services for special populations.

Treatment Models and Approaches

Historically, treatment programs were developed to reflect the philosophical orientations of founders and their beliefs regarding the etiology of alcoholism and drug dependence. Although most programs now integrate the following three approaches, a brief review of earlier distinctions will help primary care clinicians understand what precursors may survive or dominate among programs. The three historical orientations that still underlie different treatment models are

  1. A medical model, emphasizing biological and genetic or physiological causes of addiction that require treatment by a physician and utilize pharmacotherapy to relieve symptoms or change behavior (e.g., disulfiram, methadone, and medical management of withdrawal).
  2. A psychological model, focusing on an individual's maladaptive motivational learning or emotional dysfunction as the primary cause of substance abuse. This approach includes psychotherapy or behavioral therapy directed by a mental health professional.
  3. A sociocultural model, stressing deficiencies in the social and cultural milieu or socialization process that can be ameliorated by changing the physical and social environment, particularly through involvement in self-help fellowships or spiritual activities and supportive social networks. Treatment authority is often vested in persons who are in recovery themselves and whose experiential knowledge is valued.

These three models have been woven into a biopsychosocial approach in most contemporary programs. The four major treatment approaches now prevalent in public and private programs are

  1. The Minnesota model of residential chemical dependency treatment incorporates a biopsychosocial disease model of addiction that focuses on abstinence as the primary treatment goal and uses the AA 12-Step program as a major tool for recovery and relapse prevention. Although this approach, which has evolved from earlier precursors (i.e., Willmar State Hospital, Hazelden Foundation, and Johnson Institute efforts), initially required 28 to 30 days of inpatient treatment followed by extensive community-based aftercare, more recent models have shortened inpatient stays considerably and substituted intensive outpatient treatment followed by less intensive continuing care. The new hybrid, used extensively by public and private sector programs, blends 12-Step concepts with professional medical practices. Skilled chemical dependency counselors, often people in recovery as well as mental health and social work professionals, use a variety of behavioral and reality-oriented approaches. Psychosocial evaluations and psychological testing are conducted; medical and psychiatric support is provided for identified conditions; and the inpatient program utilizes therapeutic community concepts. Although a disease model of etiology is stressed, the individual patient has ultimate responsibility for making behavioral changes. Pharmacological interventions may be used, particularly for detoxification; extensive education about chemical dependency is provided through lectures, reading, and writing; and individual and group therapy are stressed, as is the involvement of the family in treatment planning and aftercare (Institute of Medicine, 1990; Gerstein and Harwood, 1990; Landry, 1996).
  2. Drug-free outpatient treatment uses a variety of counseling and therapeutic techniques, skills training, and educational supports and little or no pharmacotherapy to address the specific needs of individuals moving from active substance abuse to abstinence. This is the least standardized treatment approach and varies considerably in both intensity, duration of care, and staffing patterns. Most of these programs see patients only once or twice weekly and use some combination of counseling strategies, social work, and 12-Step or self-help meetings. Some programs now offer prescribed medications to ameliorate prolonged withdrawal symptoms; others stress case management and referral of patients to available community resources for medical, mental health, or family treatment; educational, vocational, or financial counseling; and legal or social services. Optimally, a comprehensive continuum of direct and supportive services is offered through a combination of onsite and referral services. High rates of attrition are often a problem for drug-free outpatient programs; legal, family, or employer pressure may be used to encourage patients to remain in treatment (Landry, 1996; American Psychiatric Association, 1995; Gerstein and Harwood, 1990).
  3. Methadone maintenance -- or opioid substitution -- treatment specifically targets chronic heroin or opioid addicts who have not benefited from other treatment approaches. Such treatment includes replacement of licit or illicit morphine derivatives with longer-acting, medically safe, stabilizing substitutes of known potency and purity that are ingested orally on a regular basis. The methadone or other long-acting opioid, when administered in adequate doses, reduces drug craving, blocks euphoric effects from continued use of heroin or other illegal opioids, and eliminates the rapid mood swings associated with short-acting and usually injected heroin. The approach, which allows patients to function normally, does not focus on abstinence as a goal, but rather on rehabilitation and the development of a productive lifestyle. A major emphasis in recent years has been on reducing HIV infection transmission rates among patients who remain in treatment and stop injection drug use. Individual and group counseling in addition to pharmacotherapy and urine testing are the mainstay of most programs, but more comprehensive and successful programs also offer psychological and medical services, social work assistance, family therapy, and vocational training. Methadone maintenance treatment, which is more controversial and extensively evaluated than any other treatment approach, has consistently been found to be effective in reducing the use of illicit opioids and criminal activity as well as in improving health, social functioning, and employment (Gerstein and Harwood, 1990; Landry, 1996; National Institute on Drug Abuse, 1996).
  4. Therapeutic community residential treatment is best suited to patients with a substance dependence diagnosis who also have serious psychosocial adjustment problems and require resocialization in a highly structured setting. Treatment generally focuses on negative patterns of thinking and behavior that can be changed through reality-oriented individual and group therapy, intensive encounter sessions with peers, and participation in a therapeutic milieu with hierarchical roles, privileges, and responsibilities. Strict and explicit behavioral norms are emphasized and reinforced with specified rewards and punishments directed toward developing self-control and social responsibility. Tutorials, remedial and formal education, and daily work assignments in the communal setting or conventional jobs (for residents in the final stages before graduation) are usually required. Enrollment is relatively long-term and intensive, entailing a minimum of 3 to 9 months of residential living and gradual reentry into the community setting. While patients who stay in therapeutic communities for at least a third to half the planned course of treatment usually have markedly improved functioning in terms of reduced criminal activity and drug consumption and improved rates of employment or schooling (and graduates do even better), the biggest drawback to therapeutic communities is the large percentage of enrollees (75 percent or more) who never complete treatment (Gerstein and Harwood, 1990; Landry, 1996).

Treatment Settings

Substance abuse treatment is delivered in two basic settings or environments: inpatient and outpatient. Although the two types of settings vary widely by cost, recent evaluation studies have not found that treatment setting correlates strongly with a successful outcome. In fact, research has not found a clear relationship between treatment setting and the amounts or types of services offered, although there is a correlation between the services provided and posttreatment outcomes. Essentially, most patients can benefit from treatment delivered in either in- or outpatient settings, although specific subgroups seem to respond optimally to particular environments (Landry, 1996).

Initially, however, it is important to match the patient's needs to a treatment setting. The goal is to place patients in the least restrictive environment that is still safe and effective and then move them along a continuum of care as they demonstrate the capacity and motivation to cooperate with treatment and no longer need a more structured setting or the types of services offered only in that environment (i.e., medical or nursing supervision and room and board). Movement, however, is not always in the direction of less intensive care as relapse or failure to respond to one setting may require moving a patient to a more restrictive environment (American Psychiatric Association, 1995; Landry, 1996).

The continuum of treatment settings, from most intensive to least, includes inpatient hospitalization, residential treatment, intensive outpatient treatment, and outpatient treatment.

Inpatient hospitalization includes around-the-clock treatment and supervision by a multidisciplinary staff that emphasizes medical management of detoxification or other medical and psychiatric crises, usually for a short period of time. Currently, hospital care is usually restricted to patients with (1) severe overdoses and serious respiratory depression or coma; (2) severe withdrawal syndromes complicated by multiple drugs or a history of delirium tremens; (3) acute or chronic general medical conditions that could complicate withdrawal; (4) marked psychiatric comorbidity who are a danger to themselves or others; and (5) acute substance dependence and a history of nonresponse to other less intensive forms of treatment (American Psychiatric Association, 1995).

Residential treatment in a live-in facility with 24-hour supervision is best for patients with overwhelming substance use problems who lack sufficient motivation or social supports to stay abstinent on their own but do not meet clinical criteria for hospitalization. Many residential facilities offer medical monitoring of detoxification and are appropriate for individuals who need that level of care but do not need management of other medical or psychiatric problems. These facilities range in intensity and duration of care from long-term and self-contained therapeutic communities to less supervised halfway and quarterway houses from which the residents are transitioning back into the community. Specialized residential programs are specifically tailored to the needs of adolescents, pregnant or postpartum women and their dependent children, those under supervision by the criminal justice system, or public inebriates for whom extensive treatment has not worked (American Psychiatric Association, 1995; Landry, 1996).

Intensive outpatient treatment requires a minimum of 9 hours of weekly attendance, usually in increments of 3 to 8 hours a day for 5 to 7 days a week. This setting is also known as partial hospitalization in some States and is often recommended for patients in the early stages of treatment or those transitioning from residential or hospital settings. This environment is suitable for patients who do not need full-time supervision and have some available supports but need more structure than is usually available in less intensive outpatient settings. This treatment encompasses day care programs and evening or weekend programs that may offer a full range of services. The frequency and length of sessions is usually tapered as patients demonstrate progress, less risk of relapse, and a stronger reliance on drug-free community supports (American Psychiatric Association, 1995).

Least intensive is outpatient treatment with scheduled attendance of less than 9 hours per week, usually including once- or twice-weekly individual, group, or family counseling as well as other services. As already noted, these programs can vary from ambulatory methadone maintenance treatment to drug-free approaches. Patients attending outpatient programs should have some appropriate support systems in place, adequate living arrangements, transportation to the services, and considerable motivation to attend consistently and benefit from these least intensive efforts. Ambulatory care is used by both public programs and private practitioners for primary intervention efforts as well as extended aftercare and followup (Institute of Medicine, 1990).

Treatment Techniques

Within each treatment approach, a variety of specialized treatment techniques (also known as elements, modalities, components, or services) are offered to achieve specified goals. Each patient is likely to receive more than one service in various combinations as treatment proceeds. The emphasis may change, for example, from pharmacological interventions to relieve withdrawal discomforts in the initial stage of treatment to behavioral therapy, self-help support, and relapse prevention efforts during the primary care and stabilization phase and continuing AA participation after discharge from formal treatment. A patient in methadone maintenance treatment will receive pharmacotherapy throughout all phases of care, in addition to other psychological, social, or legal services that are selected as appropriate for achieving specified individual treatment goals. Again, the categorization of these techniques is not standardized and the terminology differs among programs. However, the principal elements are

  • Pharmacotherapies, which discourage continuing alcohol or other drug use, suppress withdrawal symptoms, block or diminish euphoric effects or cravings, replace an illicit drug with a prescribed medication, or treat coexisting psychiatric problems (see Appendix A for more information on specific pharmacotherapies)
  • Psychosocial or psychological interventions, which modify destructive interpersonal feelings, attitudes, and behaviors through individual, group, marital, or family therapy
  • Behavioral therapies, which ameliorate or extinguish undesirable behaviors and encourage desired ones
  • Self-help groups for mutual support and encouragement to become or remain abstinent before, during, and after formal treatment

Pharmacotherapy

Medications to manage withdrawal take advantage of cross-tolerance to replace the abused drug with another and safer drug in the same class. The latter can then be gradually tapered until physiologic homeostasis is restored. Benzodiazepines are frequently used to alleviate alcohol withdrawal symptoms, and methadone to manage opioid withdrawal, although buprenorphine and clonidine are also used. Numerous drugs such as buprenorphine and amantadine and desipramine hydrochloride have been tried with cocaine abusers experiencing withdrawal, but their efficacy is not established. Acute opioid intoxication with marked respiratory depression or coma can be fatal and requires prompt reversal, using naloxone. However, if a patient is physically dependent on opioids, naloxone will precipitate withdrawal symptoms (American Psychiatric Association, 1995; Institute of Medicine, 1990; Gerstein and Harwood, 1990). (See Appendix A.)

Medications to discourage substance use precipitate an unpleasant reaction or diminish the euphoric effects of alcohol and other drugs. Disulfiram (Antabuse), the best known of these agents, inhibits the activity of the enzyme that metabolizes a major metabolite of alcohol, resulting in the accumulation of toxic levels of acetaldehyde and numerous highly unpleasant side effects such as flushing, nausea, vomiting, hypotension, and anxiety. More recently, the narcotic antagonist, naltrexone, has also been found to be effective in reducing relapse to alcohol use, apparently by blocking the subjective effects of the first drink. Naltrexone also is used with well-motivated, drug-free opioid addicts to block the effects of usual street doses of heroin or morphine derivatives. Naltrexone keeps opioids from occupying receptor sites, thereby inhibiting their euphoric effects. These antidipsotropic agents, such as disulfiram, and blocking agents, such as naltrexone, are only useful as an adjunct to other treatment, particularly as motivators for relapse prevention (American Psychiatric Association, 1995; Landry, 1996). (See Appendix A.)

Agonist substitution therapy replaces an illicit drug with a prescribed medication. Opioid maintenance treatment, currently the only type of this therapy available, both prevents withdrawal symptoms from emerging and reduces craving among opioid-dependent patients. The leading substitution therapies are methadone and the even longer acting levo-alpha-acetyl-methadol (LAAM). Patients using LAAM only need to ingest the drug three times a week, while methadone is taken daily. Buprenorphine, a mixed opioid agonist-antagonist, is also being used to suppress withdrawal, reduce drug craving, and block euphoric and reinforcing effects (American Psychiatric Association, 1995; Landry, 1996).

Medications to treat comorbid psychiatric conditions are an essential adjunct to substance abuse treatment for patients diagnosed with both a substance use disorder and a psychiatric disorder. Prescribing medication for these patients requires extreme caution, partly due to difficulties in making an accurate differential diagnosis and partly due to the dangers of intentional or unintentional overdose if the patient combines medications with abused substances or takes higher than prescribed doses of psychotropic medications. Since there is a high prevalence of comorbid psychiatric disorders among people with substance dependence, pharmacotherapy directed at these conditions is often indicated (e.g., lithium or other mood stabilizers for patients with confirmed bipolar disorder, neuroleptics for patients with schizophrenia, and antidepressants for patients with major or atypical depressive disorder). Many psychiatrists agree that diagnoses for comorbid psychiatric conditions cannot be made until patients have been detoxified from abused substances and observed in a drug-free condition for 3 to 4 weeks since many withdrawal symptoms mimic those of psychiatric disorders. Absent a confirmed psychiatric diagnosis, it is unwise for primary care clinicians and other physicians in substance abuse treatment programs to prescribe medications for insomnia, anxiety, or depression (especially benzodiazepines with a high abuse potential) to patients who have alcohol or other drug disorders. Even with a confirmed psychiatric diagnosis, patients with substance use disorders should be prescribed drugs with a low potential for (1) lethality in overdose situations, (2) exacerbation of the effects of the abused substance, and (3) abuse itself. Selective serotonin reuptake inhibitors (SSRIs) for patients with depressive disorders and buspirone for patients with anxiety disorders are examples of psychoactive drugs with low abuse potential. These medications should also be dispensed in limited amounts and be closely monitored (Institute of Medicine, 1990; Schuckit, 1994; American Psychiatric Association, 1995; Landry, 1996).

Because prescribing psychotropic medications for patients with dual diagnoses is clinically complex, a conservative and sequential three-stage approach is recommended. For a person with both an anxiety disorder and alcohol dependence, for example, nonpsychoactive alternatives such as exercise, biofeedback, or stress reduction techniques should be tried first. If these are not effective, nonpsychoactive drugs such as buspirone (or SSRIs for depression) should be administered. Only if these do not alleviate symptoms and complaints should psychoactive medications be provided. Proper prescribing practices for these dually diagnosed patients encompass the following six "Ds" (Landry et al., 1991a):

  1. Diagnosis is essential and should be confirmed by a careful history, thorough examination, and appropriate tests before prescribing psychotropic medications. Patients with substance use disorders should be evaluated for anxiety disorders and, conversely, those with anxiety disorders evaluated for substance abuse or dependence rather than just treating presenting symptoms.
  2. Dosage must be appropriate for the diagnosis and the severity of the problem, without over- or undermedicating. If high doses are needed, these should be administered daily in the office to ensure compliance with the prescribed amount.
  3. Duration should not be longer than recommended in the package insert or the Physician's Desk Reference so that additional dependence can be avoided.
  4. Discontinuation must be considered if there are complications (e.g., toxicity or dependence), at the expiration of the planned trial, if the original crisis abates, or when the patient learns and accepts alternative coping strategies.
  5. Dependence development must be continuously monitored. The clinician also should warn the patient of this possibility and the need to make decisions regarding whether the condition warrants toleration of dependence.
  6. Documentation is critical to ensure a record of the presenting complaints, the diagnosis, the course of treatment, and all prescriptions that are filled or refused as well as any consultations and their recommendations.

Psychosocial Interventions

Individual therapy uses psychodynamic principles with such modifications as limit-setting and explicit advice or suggestions to help patients address difficulties in interpersonal functioning. One approach that has been tested with cocaine- and alcohol-dependent persons is supportive-expressive therapy, which attempts to create a safe and supportive therapeutic alliance that encourages the patient to address negative patterns in other relationships (American Psychiatric Association, 1995; National Institute on Drug Abuse, unpublished). This technique is usually used in conjunction with more comprehensive treatment efforts and focuses on current life problems, not developmental issues. Some research studies indicate that individual psychotherapy is most beneficial for opiate-dependent patients with moderate levels of psychopathology who can form a therapeutic alliance (National Institute on Drug Abuse, unpublished). Drug counseling provided by paraprofessionals focuses on specific strategies for reducing drug use or pragmatic issues related to treatment retention or participation (e.g., urine testing results, attendance, and referral for special services). This differs from psychotherapy by trained mental health professionals (American Psychiatric Association, 1995).

Group therapy is one of the most frequently used techniques during primary and extended care phases of substance abuse treatment programs. Many different approaches are used, and there is little agreement on session length, meeting frequency, optimal size, open or closed enrollment, duration of group participation, number or training of the involved therapists, or style of group interaction. Most controversial is whether confrontation or support should be emphasized.

Group therapy offers the experience of closeness, sharing of painful experiences, communication of feelings, and helping others who are struggling with control over substance abuse. The principles of group dynamics often extend beyond therapy in substance abuse treatment, in educational presentations and discussions about abused substances, their effects on the body and psychosocial functioning, prevention of HIV infection and infection through sexual contact and injection drug use, and numerous other substance abuse-related topics (Institute of Medicine, 1990; American Psychiatric Association, 1995).

Marital therapy and family therapy focus on the substance abuse behaviors of the identified patient and also on maladaptive patterns of family interaction and communication. Many different schools of family therapy have been used in treatment programs, including structural, strategic, behavioral, and psychodynamic orientations. The goals of family therapy also vary, as does the phase of treatment when this technique is used and the type of family participating (e.g., nuclear family, married couple, multigenerational family, remarried family, cohabitating same or different sex couples, and adults still suffering the consequences of their parents' substance abuse or dependence). Family intervention, a structured and guided attempt to move a resistant and active substance abuser into treatment, can be a helpful motivator for program entry. Involved family members can help ensure medication compliance and attendance, plan treatment strategies, and monitor abstinence, while therapy focused on ameliorating dysfunctional family dynamics and restructuring poor communication patterns can help establish a more appropriate environment and support system for the person in recovery. Several well-designed research studies support the effectiveness of behavioral relationship therapy in improving the healthy functioning of families and couples and improving treatment outcomes for individuals (Landry, 1996; Institute of Medicine, 1990; American Psychiatric Association, 1995). Preliminary studies of Multidimensional Family Therapy (MFT), a multicomponent family intervention for parents and substance-abusing adolescents, have found improvement in parenting skills and associated abstinence in adolescents for as long as a year after the intervention (National Institute on Drug Abuse, 1996).

Behavioral Therapies

Cognitive behavioral therapy attempts to alter the cognitive processes that lead to maladaptive behavior, intervene in the chain of events that lead to substance abuse, and then promote and reinforce necessary skills and behaviors for achieving and maintaining abstinence. Research studies consistently demonstrate that such techniques improve self-control and social skills and thus help reduce drinking (American Psychiatric Association, 1995). Some of the strategies used are self-monitoring, goal setting, rewards for goal attainment, and learning new coping skills. Stress management training -- using biofeedback, progressive relaxation techniques, meditation, or exercise -- has become very popular in substance abuse treatment efforts. Social skills training to improve the general functioning of persons who are deficient in ordinary communications and interpersonal interactions has also been demonstrated to be an effective treatment technique in promoting sobriety and reducing relapse. Training sessions focus on how to express and react to specific feelings, how to handle criticism, or how to initiate social encounters (Institute of Medicine, 1990; American Psychiatric Association, 1995; Landry, 1996).

Behavioral contracting or contingency management uses a set of predetermined rewards and punishments established by the therapist and patient (and significant others) to reinforce desired behaviors. Effective use of this technique requires that the rewards and punishments, or contingencies, be meaningful, that the contract be mutually developed, and that the contingencies be applied as specified. Some studies suggest that positive contingencies are more effective than negative ones (National Institute on Drug Abuse, unpublished). Care must be taken that negative contingencies are not unethical or counterproductive (e.g., reducing methadone doses if urine results indicate continuing illicit drug use). Contingency management is only effective within the context of a comprehensive treatment program (National Institute on Drug Abuse, unpublished; Institute of Medicine, 1990; Landry, 1996).

Relapse prevention helps patients first recognize potentially high-risk situations or emotional "triggers" that have led to substance abuse, and then learn a repertoire of substitute responses to cravings. Patients also develop new coping strategies for handling external stressors and learn both to accept lapses into substance abuse as part of the recovery process and to interrupt them before adverse consequences ensue. Controlled studies have found relapse prevention to be as effective as other psychosocial treatments, especially for patients with comorbid sociopathy or psychiatric symptoms (American Psychiatric Association, 1995). Cognitive-behavioral strategies, the improvement of self-efficacy, self-control training, and cue exposure and extinction have all been used as components of relapse prevention. In recent years, relapse prevention has become a vital part of most treatment efforts, learned during the intensive stage of treatment and practiced during aftercare (Institute of Medicine, 1990; American Psychiatric Association, 1995; Landry, 1996).

Self-Help Groups

Mutual support, 12-Step groups such as Alcoholics Anonymous, Narcotics Anonymous, Cocaine Anonymous or more recent alternatives (e.g., Rational Recovery and Women for Sobriety) are the backbone of many treatment efforts as well as a major form of continuing care. While AA and related groups are widely used, the success of this technique has not been rigorously evaluated. Nevertheless, these fellowships apparently help persons at any point in the recovery process to change old behavior patterns, react responsibly to drug cravings, maintain hope and determination to become and remain abstinent. Self-help groups can also help people build a new social network in a community of understanding peers, find satisfactory drug-free activities and recreational skills, establish healthy intimate relationships, and avoid stressful social situations and environments.

The process of working through the 12 steps under the tutelage of a sponsor encourages group members to reassess past life experiences and take more responsibility for their substance use disorders. Attendance may vary from daily to much less frequent, with more intensive involvement available whenever the recovering person feels this need.

Patients who do not accept the spiritual focus and abstinence orientation of AA may benefit from Rational Recovery groups or the Recovery Training and Self-Help (RTSH) programs in some communities. Patients who are prescribed psychotropic medications for comorbid psychiatric disorders (e.g., antidepressants or neuroleptics) or are maintained on methadone or LAAM must attend fellowships or groups where pharmacotherapy is accepted as appropriate treatment. Young persons, persons of color, and gays and lesbians often find more acceptance in groups where at least some members have similar characteristics. Friends and relatives of persons in recovery and of those who refuse treatment can benefit from Al-Anon, Alateen, Nar-Anon, and similar groups that offer support and education about the disease of alcoholism or other forms of substance abuse and teach participants to curb their own "enabling" behaviors. Improvements in substance-abusing behavior among meeting participants are associated with frequent attendance, obtaining a sponsor, "working" the 12 steps, and leading meetings (National Institute on Drug Abuse, 1993; American Psychiatric Association, 1995; Landry, 1996).

Other Primary and Ancillary Services

Patients in treatment may need other primary and adjunctive services as well: social services, vocational training, education, legal assistance, financial counseling, health and dental care, and mental health treatment. These may be provided onsite or through referral to community resources. Adjunctive services to encourage patients to enter and remain in treatment may include child care, transportation arrangements, financial assistance or welfare support, supported housing, and other supplemental help. The types of additional services supplied or arranged through a treatment program will obviously depend heavily on the characteristics of the population served. For example, persons with heroin, cocaine, or methamphetamine dependence disorders who inject these drugs will require many specialized education, identification, counseling, and health care services for HIV infection and AIDS that are not likely to be needed by programs for people with alcohol dependence.

The Treatment Process

All the components, approaches, techniques, and settings discussed above must be monitored and adjusted as treatment progresses. Primary care clinicians should understand the following aspects of appropriate care.

  • Repeating assessments to evaluate a patient's changing medical, psychological, social, vocational, educational, and recreational needs, especially as more basic and acute deficits or crises are resolved and new problems emerge or become amenable to treatment. For example, homelessness or acute withdrawal symptoms will need to be treated before family interactions can be identified or resolved. Suicidal thoughts or actions will need prompt attention whenever they emerge.
  • Developing a comprehensive treatment plan that clearly reflects all identified problems, has explicit goals and strategies for their attainment, and specifies techniques and services to be provided by designated specialists at particular frequencies or intensities.
  • Monitoring progress and clinical status through written notes or reports that describe responses to treatment approaches and outcomes of services provided, including counseling sessions, group meetings, urine or other biological testing, physical examinations, administered medications, and referrals for other care. Each patient should have an individual treatment record that includes all appropriate materials yet maintains the patient's privacy.
  • Establishing a therapeutic alliance with an empathic primary therapist or counselor who can gain the confidence and trust of the patient and significant others or family members and take responsibility for continuity of care. This is particularly important in the early stages of treatment to prevent dropout and encourage participation.
  • Providing education to help the patient and designated others understand the diagnosis, the etiology and prognosis for the disorder, and the benefits and risks of anticipated treatment(s). Patients with special problems will need more extensive information. As with other medical treatments, informed consent to potentially risky procedures should always be obtained (American Psychiatric Association, 1995).

Treatment Programs for Special Populations

A variety of substance abuse treatment programs have been developed to meet the particular needs of special populations, including women, pregnant and postpartum mothers, adolescents, elderly persons, members of various minority groups, public inebriates or homeless persons, drinking drivers, and children of alcoholics. These special programs are found in the public and private sectors and include both residential and ambulatory care settings using therapeutic community, Minnesota model, outpatient drug-free, and methadone maintenance approaches. Researchers have not confirmed that these separate programs for special populations are superior to mainstream efforts with respect to outcomes, and experts question their cost-effectiveness and applicability to heterogeneous groups with overlapping characteristics that complicate placement of a particular patient in one group over another. Clinicians must be wary of defining any patient in relation only to age, gender, racial group membership, or functional characteristics, especially since other patient-related variables have been found to have greater implications for successful outcomes (e.g., addiction severity, employment stability, criminal involvement, educational level, and socioeconomic status). Nonetheless, clinical observations do indicate that treatment of special populations may be enhanced if their particular needs are considered and met. Notable components of these separate programs for special populations are as follows (Institute of Medicine, 1990; American Psychiatric Association, 1995; Landry, 1996).

Women are more likely than men to have comorbid depressive and anxiety disorders, including posttraumatic stress disorders as a result of past or current physical or sexual abuse. Although women tended in the past to become involved with different substances than men (e.g., prescription drugs), their drug use patterns have become more similar to males' in recent years. Treatment components can address women's special issues and needs for child care, parenting skills, building healthy relationships, avoiding sexual exploitation or domestic violence, preventing HIV infection and other sexually transmitted diseases, and enhanced self-esteem. A high ratio of female staff and same-sex groups are also thought to improve treatment retention.

Pregnant and postpartum women and their dependent children have numerous special needs, including prenatal and obstetrical care, pediatric care, knowledge of child development, parenting skills, economic security, and safe, affordable housing. Pregnant women -- and those in their childbearing years -- need to know about birth control as well as the risks to pregnancy and fetal development of continuing substance use (e.g., spontaneous abortion, abruptio placentae, preeclampsia, early and prolonged labor, birth defects, impaired fetal growth, low birth weight, stillbirth, and neonatal withdrawal syndrome). Methadone maintenance throughout pregnancy and the postpartum period is often the treatment of choice for opioid-dependent women with seriously compromised lifestyles who are not likely to remain abstinent. However, many other medications used in the treatment of addiction, including disulfiram and naltrexone, should not be prescribed for pregnant substance abusers. See Appendix A and *TIP 2, Pregnant, Substance-Using Women (CSAT, 1993a).

Adolescents need treatment that is developmentally appropriate and peer-oriented. Educational needs are particularly important as well as involvement of family members in treatment planning and therapy for dysfunctional aspects. Substance abuse among adolescents is frequently correlated with depression, eating disorders, and a history of sexual abuse (American Psychiatric Association, 1995). A history of familial substance abuse and dependence is predictive of serious adolescent involvement. More information on specialized treatment of adolescents can be found in TIP 4, Guidelines for the Treatment of Alcohol- and Other Drug-Abusing Adolescents *(CSAT, 1993c).

Elderly persons may have unrecognized and undertreated substance dependence on alcohol or prescribed benzodiazepines and sedative hypnotics that can contribute to unexplained falls and injuries, confusion, and inadvertent overdose because age decreases the body's ability to metabolize many medications. Other coexisting medical and psychiatric conditions can also complicate treatment and compromise elderly patients' ability to comply with recommended regimens.

Minority group members may identify with particular cultural norms and institutions that increase feelings of social acceptance. While early phases of treatment that focus on achieving abstinence are not likely to be affected by minority group differences, the development of appropriate, drug-free social supports and new lifestyles during more extended treatment and aftercare stages may be enhanced by support groups with similar ethnic identification and cultural patterns. For some African-American patients, involving the church and treatment that incorporates a spiritual element may improve outcomes. Treatment programs for Native American tribes often incorporate their traditions, and a family focus as well as bilingual staff and translated written materials are important ingredients of many treatment programs for Hispanics. However, the Consensus Panel believes that culturally sensitive treatment may not be as important to individuals who do not strongly identify with an ethnic or cultural group and of less concern than socioeconomic differences, for example, in treatment retention.

Confidentiality

One important aspect of working with or making a referral for substance abuse treatment is the legal requirement to comply with Federal regulations governing the confidentiality of information about a patient's substance use or abuse. Laws protecting the confidentiality of alcohol and drug abuse patient records were instituted to encourage patients to enter treatment without fear of stigmatization or discrimination as a result of information disclosure without the patient's express permission (42 C.F.R. Part 2). Clarifying amendments passed in 1987 make it clear that patient records generated in general medical settings and hospitals are not covered unless the treating clinician or unit has a primary interest in substance abuse treatment *(CSAT, 1995b, p. 64). Nonetheless, records containing information about substance use disorders should always be handled with discretion.

If referral is made by the primary care clinician for a substance abuse assessment or to a specialized treatment program, written permission of the patient is required before any information or records can be disclosed or redisclosed in which the patient's identity is revealed, except in cases of medical emergency or reporting suspected child abuse to the proper authorities. Often, treatment programs will want to coordinate a patient's treatment with the primary care provider -- such collaboration is essential for certain patients, such as chemically involved pregnant women. See Appendix B for a detailed discussion of confidentiality. Confidentiality issues are also discussed in TIPs 4 (Guidelines for the Treatment of Alcohol- and Other Drug-Abusing Adolescents) (CSAT, 1993c), 8 (Intensive Outpatient Treatment for Alcohol and Other Drug Abuse) (CSAT, 1994a), 11 (Simple Screening Instruments for Outreach for Alcohol and Other Drug Abuse and Infectious Diseases) (CSAT, 1994c), 13 (The Role and Current Status of Patient Placement Criteria in the Treatment of Substance Use Disorders) (CSAT, 1995a), 16 (Alcohol and Other Drug Screening of Hospitalized Trauma Patients) (CSAT, 1995b), and 19 (Detoxification from Alcohol and Other Drugs) (CSAT, 1995c).

The Role of the Primary Care Clinician Throughout Treatment

As already noted, all primary care clinicians have important roles to play in identifying, screening, and referring patients with substance use disorders for in-depth assessment or treatment and in delivering brief interventions to patients with milder substance-related problems. In addition, the clinician has an array of options, depending on time and resources available, for offering ongoing support and encouragement to patients who do enter the formal treatment system. These options include

  • Learning about treatment resources in the community that offer appropriate services
  • Keeping in touch with the specific treatment program where the patient is enrolled to ascertain its quality and understand the approach and services offered
  • Requesting formal reports regarding the treatment plan and progress indicators from the program on a periodic basis (with the patient's explicit permission)
  • Clarifying the clinician's role in the continued care of the patient (e.g., treating specified medical conditions, writing prescriptions, and monitoring compliance through urine or other biological testing)
  • Reinforcing the importance of continuing treatment to the patient and relatives

Completing specialized treatment is only the beginning of the patient's recovery process. Primary care clinicians should continue to ask their patients about the problem they were treated for at every office or clinic visit. During these visits, the clinician can monitor the potential for relapse and take any necessary steps to prevent slips from occurring (Brown, 1992).

The primary care clinician also has a responsibility to patients who refuse to accept referral to treatment or drop out before completion. In such cases, the primary care clinician should

  • Continue treating any medical problems, including those related to continuing substance abuse.
  • Reiterate the primary diagnosis and be ready to refer the patient for specialized treatment. If the patient objects to the initial referral, the physician should look for acceptable and appropriate alternatives.
  • Encourage family members and friends to participate in appropriate Al-Anon, Alateen, Adult Children of Alcoholics, or similar groups in order to learn more about the substance use disorder, how to minimize distress, and how to avoid enabling behaviors.
  • Exercise extreme caution in prescribing psychotropic medications for anxiety, insomnia, and other complaints because these drugs may exacerbate continued abuse.

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