Understanding Substance Abuse Treatment...

TREATMENT

Substance Abuse treatment is effective!

Patients who decide to stop drinking can find the treatment and support needed to quit, remain sober, and regain their lives. Like all treatments, having a full understanding of the options is important to making good, informed choices.

PHASES OF TREATMENT

There are FOUR PHASES to treatment.

Assessment and Evaluation:

Of symptoms life problems, treatment choices and plan development.

Detoxification:

Stopping use

Active treatment:

Consists of any and all of the following – Residential programs, therapeutic communities, intensive and regular outpatient treatment, medications for alcohol craving reduction, medications to discourage alcohol use, medications to treat comorbid mental health issues, 12-step programs, other self-help/mutual-help groups.

Maintaining sobriety and relapse prevention:

Ongoing outpatient treatment, 12-step programs, other self-help/mutual-help groups.

Assessment and Evaluation:

Step one is for the Alcoholic to overcome denial and distorted thinking. This is followed by the desire to begin treatment. At this point, the alcohol dependent individual must get help from someone knowledgeable and competent in the treatment of this disorder.

At this stage in the illness, some individuals have lost most control over their alcohol use they may be able to make immediate decisions only. The most basic goal is to quit drinking. You may be able to develop a detailed plan but you may also need to wait until the patient is post-detoxification.

The issues encountered with this stage center around DENIAL. This denial may be almost universal, or the individual may show some level of insight into their problem.

Your treatment plan should be developed based on the level of insight and the amount of the denial an individual exhibits. This is the point where a trained addiction specialist is absolutely necessary to assist the patient.

Detoxification

This phase of treatment involves quitting use. Sometimes called “Cold Turkey.” It can be done on an inpatient setting or in an outpatient setting. Regardless of the setting medical evaluation and treatment are very important at this stage. Many alcohol dependent individuals will develop dangerous withdrawal symptoms that need medical management in a hospital or in an outpatient setting. Simply removing the alcohol does not automatically produce positive, complete outcomes.

Medical Management of Withdrawal Symptoms

Abrupt cessation of drinking, as well as simply “cutting back” may produce a number of specific withdraw symptoms when an individual is physically dependent. These symptoms include:

Sweating                        Rapid heartbeat

Hypertension                 Tremors

Anorexia                        Insomnia

Agitation                        Anxiety

Nausea                           Vomiting.

Delirium tremens:

Is a central nervous system symptom of alcohol withdrawal that may occur in the first 96 hours of quitting alcohol. It is often seen in chronic alcoholism. Symptoms include:

Uncontrollable trembling                        Hallucinations

Severe anxiety                                         Sweating

Sudden feelings of terror.

The Revised Clinical Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar) is a symptom-triggered, 10-item scale that quantifies the risk and severity of alcohol withdrawal. This instrument can be found in Appendix A.

Often, withdrawal symptoms are treated with benzodiazepines. This class of drug reduces related anxiety, restlessness, insomnia, tremors, DT, and withdrawal seizures.

However, both short-acting and long- acting benzodiazepines have their problems. The long-acting benzodiazepines can decrease rebound symptoms and work for long periods of time, but intramuscular absorption can be very erratic. Short-acting benzodiazepines have less risk of over sedation. Yet, breakthrough symptoms can and do occur, and risk of seizure is imminent.

Patients undergoing withdrawal are generally treated with diazepam or chlordiazepoxide. If intramuscular administration is necessary, Lorazepam is the drug of choice.

Anticonvulsants are also used for safe withdrawal. The cannot be abused and there is almost no risk of seizures. Their problems can be dangerous. They do not help with the symptoms of delirium and they can have some liver toxicity.

Detoxification is only one of many steps in the treatment process, and the beginning of a lifelong process.

ACTIVE TREATMENT

The first decision for active treatment is acute hospitalization vs. inpatient detoxification. While hospitalization can be cost-effective, it is not always available..

Inpatient hospitalization is indicated for the following:

acute withdrawal symptoms                                   

failed outpatient detoxification

appears depressed                                                

unstable home situation

possibility of family disruption or job loss

If in doubt, call a physician who specialized in alcohol treatment of error on the side of caution and attempt to secure inpatient hospitalization.

This first three to six months is a period characterized by mood changes, anxiety, depression, insomnia, physiological changes and sleep problems.

This time frame is critical for sobriety. Active support is constantly necessary.

The second phase of active treatment can last for 6 months to many years. Here is where the patient gains the motivation and skills to stay sober. They are in the process of building the support systems they need in order to cope with the daily issues they avoided through their alcohol use.

During this phase, a treatment professional is very important. A professional can help them understand how alcohol has affected their life and can help them develop goals and plans to maintain sobriety.

Some proven medications are available to help with alcohol craving and to discourage alcohol use and will be discussed in detail later in this course.

This stage is where some medications and treatments are most effective. It is also the stage where other medications can be used to treat co-morbid psychiatric conditions including depression and anxiety.

All of our research indicates the longer a patient maintains sobriety, the longer they stay in treatment, the more active and involved their commitment is, the greater the chance to remain sober.

This is a time when support groups, especially AA can help achieve and maintain sobriety.

Maintaining Sobriety and relapse Prevention

The dividing line between active treatment and the maintenance phase of recovery is very blurry. Sometimes, almost impossible to establish.

During the active phase, the patient learns what is needed to stay sober and they develop skills to avoid relapsing. During the maintenance phase the person is using the skills learned to handle the curve-balls life throws at them. Many patient attribute their ongoing sobriety to support group participation. These groups range from AA to NA to Women for Sobriety.

Understanding the Options for Substance Abuse Treatment...

ALCOHOLICS ANONYMOUS

AND OTHER 12-STEP PROGRAMS

The grandfather of alcohol treatment is Alcoholics Anonymous.  AA is a self-help organization founded in 1935.  AA changed the way professionals thought about alcohol dependence and treatment. AA developed a successful 12-step program by combining self-help with a spiritual foundation.  It then firmly planted itself in the fellowship of recovering alcoholics.

You do not need to be religious to be in AA

AA is run solely by recovering alcoholics and is in almost every community with specific programs, meeting and locations.  If you need to find a meeting go to www.aa.org.  It also provides round the clock assistance.

There are no membership dues and it is open to everyone.

AA promotes and provides fellowship.  This fellowship can be very positive and can help counterbalance feelings of grief, loss, and shame associated with alcohol dependence.

AA and other 12-step programs provide effective treatment programs which facilitate long-term abstinence after treatment.

AA also provides an important group process therapy for dependent alcoholics.

AA prescribes keeping it simple, taking it one day at a time, and avoiding the people, places, and things associated with their use. This approach is a powerful tool for relapse prevention.

AA also helps recovering alcoholics to develop positive lifestyles and find new ways to solve old problems. The feeling of fellowship, support, and guidance helps make getting sober and staying sober more likely.

The reduction of shame and guilt fostered by AA along with its message of the acceptance of powerlessness over drinking is often reported by alcoholics after attending meetings every day.

One of AA’s principles is the value of performing services that will help other alcoholics.

Prevention of relapse is an active daily process.

COUNSELING

Cognitive-behavioral therapies (CBTs) are the most frequently used  treatments for  substance use disorders.

CBTs have been shown to be effective in several clinical trials of substance users [82].

Characteristics of CBTs include:

          • Social learning and behavioral theories of drug abuse

          • An approach summarized as “recognize, avoid, and cope”

          • Organization built around a functional analysis of substance use

             (for example: understanding the antecedents and consequences of substance use)

           • Skill training using strategies for:

                   coping with cravings

                   fostering motivation to change

                   managing thoughts about drugs

                   developing problem-solving skills

                   planning for/managing high-risk situations

                   cultivating drug refusal skills

Basic principles of CBTs include:

     • Basic skills should be mastered before more complex ones are given.

     • Material presented by the therapist should be matched to patient needs.

     • Repetition fosters the development of skills.

     • Practice is needed for mastery of skills.

     • The patient is an active participant in treatment.

     • Skills taught are general enough to be applied to a variety of problem areas.

Structured behavior therapy techniques can be effective components of alcohol dependence treatment.

Behavioral therapy techniques are often used in conjunction with CBT’s.

The goal of a CBT is to increase the patient’s engagement in positive activities and  socially reinforcing behaviors.

CBT data confirms that:

Drug abuse patients need motivation and skills to succeed in stopping drug use.

Research has shown that drug abuse behavior can be reduced by offering contingent incentives for abstinence.

The most striking successes have come from positive reinforcement programs that provide contingent incentives for abstinence using money-based vouchers as rewards.

Research provides examples, but treatment providers may need to be creative in discovering reinforcers that can be used for contingency management in their own clinical settings.

MEDICATIONS USED TO TREAT ALCOHOL DEPENDENCE

Some medications are used for detoxification and others are used for relapse prevention. Research has shown that medications must be used in conjunction with talk and other therapies to be most.

ANTABUSE

Also known as Disulfiram.  It was approved for treatment of alcohol dependence by the FDA in 1951.  It works by blocking an enzyme, aldehyde dehydrogenase, the body uses to metabolize alcohol. Drinking while on Disulfiram causes the alcohol at the acetaldehyde stage to accumulate in the blood. This then produces nausea, vomiting, sweating, and even difficulty breathing.

Disulfiram is not recommended for patients with diabetes, cardiovascular or cerebrovascular disease, or kidney or liver failure.  With the advent of more modern and improved medicines, Disulfiram is often used as a last resort.

NALTREXONE

Also called ReVia is an opioid antagonist that interferes with the rewarding or pleasurable effects of alcohol.  This allows it to reduce the alcohol craving.

The FDA approved the use of naltrexone in alcohol dependence in December 1994.

Naltrexone has been proven to:

Reduce alcohol relapses

Decrease the possibility of a slip becoming a relapse

Decrease the total amount of drinking.

The most common side effects are light- headedness, diarrhea, dizziness, and nausea. Side effects tend to disappear quickly. It is not recommended for patients with:

                acute hepatitis

liver failure

for adolescents

pregnant or breastfeeding women

Naltrexone works best integrated into a complete treatment program including traditional 12-step fellowship-based treatments and /or CBT.

NALMEFENE

Also called Revex is newer opioid antagonist.  It is administered intravenously.  It shows no liver toxicity, however method of administration makes its use limited in outpatient settings.

ACAMPROSATE

Also known as Campral is a synthetic compound with a chemical structure similar to naturally occurring amino acid neurotransmitters e.g. homotaurine and GABA.

It was approved by the FDA In July 2004 for the maintenance of alcohol abstinence.

It has been used successfully in Europe and around the world for years.

BACLOFEN

Baclofen is a GABA agonist.   In a study of alcohol-dependent patients with liver cirrhosis, baclofen was also found to work favor- ably in maintenance of alcohol abstinence. Seventy-one percent of baclofen-treated patients maintained abstinence as compared with twenty-nine percent of the placebo group [208].

ANTICONVULSANTS

Topiramate is effective in reducing heavy drinking in alcohol dependent patients.

Side effects of Topiramate include numbness in the extremities, fatigue, confusion, paresthesias, depression, change in taste, and weight loss.

Carbamazepine has proven effective for treating acute alcohol withdrawal.

Side effects include nausea, vomiting, drowsiness, dizziness, chest pain, headache, trouble urinating, numbness in extremities, liver damage, and allergic reaction.

Oxcarbazepine is a carbamazepine derivative, with fewer side effects than Carbamazepine.

BUSPIRONE HYDROCHLORIDE

Also called Buspar, a dopamine antagonist and partial agonist for serotonin, exhibiting anxiolytic properties.

CLOZAPINE

Also called Clozaril is an atypical antipsychotic approved to treat schizophrenia and its resultant symptoms (e.g., hallucinations, suicidal behavior).

It has shown promise in the treatment of comorbid substance use.

Thoughts on Alcohol Depression and Suicide

Alcoholics generally have alcohol problems in conjunction with other medical illnesses and   mental health disorders.  Lapham (2001) reported that about one-half of women and one-third of men who have a history of alcohol abuse or dependence will be diagnosed with at least one other mental health disorder.

 One of the more difficult aspects of alcohol abuse is that alcohol can function as both a stimulant and as a depressant, depending on when the drinking occurs and the quantity of alcohol used.  According to Regier  (1990) one-third to one-half of alcoholics also are afflicted with a Major Depressive Disorder during their abuse. It is important to understand that more than three-quarters of men and women who are identified as alcoholics will also meet the criteria for a Major Depressive Disorder (Regier 1990).  The reason we need to be aware of depression as a comorbid condition with alcoholism, is simple.  If depression is untreated, sometime during the treatment the alcoholic will leave treatment and relapse.

One of the reasons alcoholics are often diagnosed as depressed is due to the similarity of symptoms between alcohol abuse and depression. There is a mimicry which can be hard to sort out during the diagnostic phase.

The fact that ‘binge drinking” and severe alcohol intoxication can also cause mood swings, and the “manic-like” behaviors we associate with Bipolar disorder, does not make the diagnosis any easier.  During the course of the disease, we will also notice insomnia, decreased appetite, temporary depressive symptoms and a general decrease in overall energy, even if the abuser has no history of a depressive illness.

Other things to look for include cirrhosis (swelling) of the liver, anti-social and other personality disorders, nicotine dependence, hepatitis, eating disorders, anxiety disorders,  major depressive disorder and, of course bipolar disorder.

Currently, we do not know by what mechanism  depression and alcohol dependence are intertwined, however, both conditions share very similar risk factors.  It is absolutely important to treat the Co-Morbid disorders your client arrives with, in order to prevention serious adverse consequences much as suicide. 

Because alcohol often makes depression worse, it can be a significant factor in suicide.  Therefore, identifying the risk factors associated with alcohol abuse and dependence are  absolutely essential.

According to the American Association of Suicidality (AAS), Suicide is the 11th leading cause of death overall and the 3rd leading cause among persons 15 to 34 years of age.  According to the AAS, In 2007, 34,598 people in the United States committed suicide and an estimated 864,950 attempted suicide.

Cornelius  (1996) found that as many as 85% of individuals who commit suicide suffer from depression or alcohol dependence, and 70% of alcoholics with comorbid depression report that they have made a suicide attempt at some point in their lives.  Alcohol abuse and dependence can exaggerate depression and increase the chance of an impulsive act including aggression, suicide and violent ideations.

In the alcohol dependent population, fifteen to twenty people out  a hundred will attempt suicide.  Of those who have attempted suicide in the past,  fifteen to twenty people out  a hundred will attempt a second time within five years of the first attempt.

Alcoholism and Suicide:

Effective prevention of suicide and suicidal behaviors can only be achieved if the providers are competent and skilled at obtaining both a substance abuse history and a psychiatric history.  Experience has shown that abstinence from alcohol for fourteen to twenty-one days and good nutrition, the depressive effects of alcohol begin to recede.  Alcohol and drug dependence are second only to age in determining the most important risk factors in a Suicide Risk Assessment.  If you look at the population who have attempted suicide, nine out of ten will have a diagnosable mental health disorder according to Mann (2002).

Among the population that will attempt suicide, alcohol dependence is common.  Alcohol is the number one drug of abuse associated with suicide. The most commonly diagnosed mental health disorders in mental health patients are Major Depressive Disorder and Alcohol Dependence.  This information allows us to target our resources quickly when determining patient triage.  

Often, alcohol is involved in suicide attempts by “driving a vehicle” and suicide by “overdose.”  Some of the reason we believe this connection exists comes from alcohols ability to impair judgment, block physical pain and lowering the survival threshold.  Preuss (2002) have estimated the overall suicide risk for an alcoholic dependent individual was about one in ten, which is five to ten times higher than seen in the general population. Murphy  (1990) has placed the likelihood of suicide for those diagnosed with Alcohol Dependence as sixty to one-hundred twenty times higher than individuals without alcohol involvement.

Murphy GE, Wetzel RD. The lifetime risk of suicide in alcoholism. Arch Gen Psychiatry. 1990;47(4):383-392.

Mann JJ. A current perspective of suicide and attempted suicide. Ann Intern Med. 2002;136(4):302-311.

Preuss UW, Schuckit MA, Smith TL. Comparison of 3190 alcohol-dependent individuals with and without suicide attempts. Alcohol Clin Exp Res. 2002;26(4):471-477.

Cornelius JR, Salloum IM, Day NL, Thase ME, Mann JJ. Patterns of suicidality and alcohol use in alcoholics with major depression. Alcohol Clin Exp Res. 1996;20(8):1451-1455.

American Association of Suicidology. U.S.A. Suicide: 2007 Official Final Data. Available at http://www.suicidology.org/c/document_library/get_file?folderId=232&name=DLFE-232.pdf. Last accessed December 16, 2013.

Lapham SC, Smith E, C'de Baca J, et al. Prevalence of psychiatric disorders among persons convicted of driving while impaired. Arch Gen Psychiatry. 2001;58(10):943-949.

Regier DA, Farmer ME, Rae DS, et al. Comorbidity of mental disorders with alcohol and other drug abuse. JAMA. 1990;264: 2511-2518.