Goldberg Chapter 15

Albia Dugger • Miami Dade College

Chapter 15Substance Abuse

Treatment

The Need for Treatment Programs

• 23.5 million persons aged 12 and older need treatment for either an illicit drug or alcohol

• Only 11.2% of those individuals receive treatment from a specialized facility

• The federal government allocates more than two-thirds of its drug-control budget to law enforcement and interdiction efforts, rather than treatment

Underlying Causes of Drug Abuse

• People in treatment for substance abuse:• Disadvantaged in education and employment• More likely to be male, Caucasian, aged 25 to 45• Increasing trend toward veterans and the elderly

• The goals of a treatment program differ, depending on whether drug abuse is seen as a medical problem, as a breakdown in society, or as a personality weakness

Drug Courts

• Drug treatment courts combine the power of the justice system with effective treatment services

• First drug court was established in 1989 for nonviolent drug offenders whose underlying problem is substance use

• Offenders who complete substance abuse programs may have their sentences dismissed or reduced

Profile of the Drug Abuser

• Most people in drug treatment :• Caucasian males• Average age at admission is 34• Less than one-fourth are employed• One third completed high school or a GED• Many have mental health problems• 30-40% of homeless population are drug abusers• Most use more than one drug

Admissions to Treatment

History of Treatment

• Using drugs to treat drug abuse was common in early treatment programs

• US Public Health Service established two hospitals to serve the growing number of addicts in federal prisons

• The relapse rate of people released in the 1940s through early 1960s ranged between 87% and 96%

Current Treatment Options

• Therapeutic community – a residential facility staffed by former drug addicts

• Methadone maintenance programs – outpatient programs in which opiate addicts receive methadone daily

• Detoxification – a medically supervised program to withdraw from drugs on which they are physically dependent

Current Treatment Options

• Three immediate goals of detoxification:1. To provide safe withdrawal from drugs2. To provide withdrawal that is humane and protects the

person’s dignity3. To prepare the person for ongoing treatment

• Self-help programs based on the principles of Alcoholics Anonymous are growing in popularity

Benefits of Treatment

• Benefits of drug treatment:• Less expensive than incarceration• Reduced use of illicit drugs• Decline in criminal activity• More stable employment• Reduced transmission of AIDS

Drug Treatment and Criminal Activity

National Treatment Improvement Evaluation Study

• Reported benefits:• Drug use declined from 73% before treatment to 38% one

year after treatment• Increase in employment from 51% to 60%• Decline in clients receiving welfare from 40% to 35%• Drop in homelessness from 19% to 11%• 53% decline in substance-related medical visits• 56% reduction in people exchanging sex for drugs• 51% drop in people having sex with an IV drug user

HIV Transmission Categories

Treatment Issues

• Four pertinent issues in treating drug abuse:1. Voluntary or compulsory treatment2. Matching patients to the best treatment3. Effectiveness of treatment programs designed for adults

for adolescent substance abusers4. Programs to address female addicts

Voluntary Versus Compulsory Treatment

• Some studies show that volunteers fare better than those required to be in treatment

• Other studies show that those required to receive treatment make as much progress, as those who enter voluntarily

• The key issue could be how long the person stays in treatment

Matching Patients and Treatments

• Questions to be addressed:• Which treatment produces the best outcomes for a

specific group or person?• Do members of certain ethnic or socioeconomic groups

respond similarly to certain types of treatment?• Is the effectiveness of a specific program linked to age of

participants?• Do females and males differ in their responses to

treatment?

Treating Adolescent Drug Abusers

• In 2009, in the US, 149,277 individuals aged 12 to 17 were admitted to a drug treatment facility

• The primary drug of abuse was marijuana

• More intensive, longer programs (three months) are more effective than short (two session) programs

• Teens who enter treatment do better academically than teens who do not receive treatment

Women and Treatment

• Treatment programs for women are scarce

• Women substance abusers are more likely to have poor family relationships and psychological health than men

• Even when treatment is available, many women are reluctant to enter a program

• Women in female-only drug abuse treatment centers are more likely to benefit from treatment

Reasons Women Avoid Treatment

Problems Associated with Treatment

• Client Resistance to Treatment:• Many treatment facilities are not readily available or

accessible• A large percentage of clients lack insurance and cannot

afford the cost of treatment• Policies and philosophies of some facilities deter drug

abusers from pursuing help• Benefits of using drugs outweigh the disadvantages• Clients think that legal authorities will be made aware of

their drug-taking behavior if they enter treatment


• Community Resistance:• People do not want drug treatment centers in their

neighborhoods• Concerned about more crime, more traffic, exposure of

children to bad influences, and lower property values• NIMBY (not in my backyard) syndrome


• Continuing Drug Use:• The goal of abstinence is often not realized• Treatment of at least six months seems to be necessary to

reduce drug use significantly• One study of adolescents in treatment reported that drug

usage declined somewhat ,but remained high


• Factors that contribute to relapse among alcoholics:1. Negative emotional states such as frustration, anxiety,

depression, anger, or boredom2. Interpersonal conflicts with a spouse, family member,

friend, or employer3. Social pressure from a person or group of people


• Factors in Personnel Recruitment and Retention:• Reluctance to work with drug abusers• Undesirable locations of facilities• Inadequate supply of applicants with professional

experiences and qualifications• Fear of contracting AIDS

Medical or Legal Problem?

Treatment Programs

• Methadone Maintenance• Treatment that involves the dispensing of methadone for

opiate addiction for more than 30 days• Eliminates withdrawal symptoms and prevents euphoria• Given orally, every 24 hours• Effective only for heroin addiction• Psychotherapy in conjunction with methadone yields the

best results• Crime reduction and relapse rates improve with duration of

treatment

Treatment Programs

• Alternatives to Methadone:• Extended-release form of naltrexone allows patients to be

treated on a monthly rather daily basis• Levo-alpha-acetylmethadol (LAAM) works for three

days, but has side effects• Other drugs that block the effects of opiates are

naltrexone, naloxone, clonidine, and buprenorphine• Some narcotic addicts say that methadone withdrawal is

worse than going cold turkey

Treatment Programs

• Therapeutic communities (TCs) • Drug-free residential settings where abusers reside for one

or two years• Philosophy is that drug abuse is incurable, but can benefit

from behavioral intervention• Stress group intervention techniques, especially

encounter groups• Provide vocational and educational assistance and

improve the self-esteem of residents

Longer Treatment is More Effective

Treatment Programs

• Outpatient Treatment:• Most common form of drug abuse treatment• Less disruptive and stigmatizing than inpatient treatment• Ranges from counseling centers to halfway houses to

community centers• Frequently is used after a client leaves methadone

maintenance• Clients often go back to the environments that contributed

to their drug abuse initially

Treatment Programs

• Inpatient Treatment:• Typically hospital based• Expensive• No more effective than intensive outpatient treatment• Tend to be highly structured• Group therapy and drug education are stressed

Cost of Treatment

Treatment Programs

• Self-Help Groups:• Members are bound by a common denominator such as

alcohol, gambling, food, shopping, or sex• Largest self-help group is Alcoholics Anonymous (AA),

based on a 12-step model• Offer fellowship and support• Used in lieu of traditional therapies or after a person stops

other therapies• Cost-effective for maintaining changes and preventing

relapse

Narcotics Anonymous

• Narcotics Anonymous (NA) • Emanated from Alcoholics Anonymous• Open to all drug addicts

• Principles of the NA recovery program:• Admitting there is a problem• Seeking help• Engaging in a thorough self-examination;• Confidential self-disclosure;• Making amends for harm done• Helping other drug addicts who want to recover

Alcohol Treatment

• AA advocates total abstinence, a view that is not universally accepted

• Some treatments advocate a controlled drinking approach in which the patient learns to drink in a nonabusive manner

• Drug therapy in the form of Antabuse (disulfiram) has been used as well

Alcoholics Anonymous

• Started in 1935 by an alcoholic surgeon (Dr. Bob) and an alcoholic stockbroker (Bill W.)

• Goals are sobriety and spiritual renewal

• Based on the premise that alcoholism is a disease over which the person has no control

• Based on a 12-step plan

12 Steps of Alcoholics Anonymous

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

11. Sought through prayer and meditation to improve our conscious contact with God as we understood Him

12. We tried to carry this message to alcoholics and to practice these principles in all our affairs

Moderate Drinking

• Moderation Management (MM) is a controlled drinking model of behavioral self-management

• Drinkers are taught to cope with peer pressure and situations that tempt them to drink excessively

• The longer a person has been an alcoholic, the less likely it is that he or she can return to social drinking

• The controlled drinking model is contrary to the disease model

Medications

• Disulfiram (Antabuse)• Acts as an aversive agent by interacting with alcohol in

such a way that the drinker becomes violently ill

• Naltrexone• Reduces alcohol craving among heavy drinkers, but has

not been shown to result in abstinence

• Acamprosate • Inhibits the craving for alcohol and food

Education

Goldberg Chapter 15