12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 83 4 Copyright American Psychological Association. Not for further distribution. Determining Appropriate Treatment his chapter reviews the treatment options in the continuum of care and offers guidelines for selecting appropriate services. There is a remarkably wide range of activities and interventions in the substance abuse treatment field, and it is likely that psychologists will use only a few, depending on their own base of activity. However, it is important to appreciate the range of possibilities if for no other reason than to give a perspective for referral. This chapter examines how major models and modalities arose, their assumptions about how people change, key interventions or activities, sources of information and data evaluating the effectiveness of the model, and the strengths and limits of each model. Some of the treatment settings are more accessible to working people with insurance, whereas others are funded by federal or state governments for the indigent population. Ironically, the latter may offer highly innovative programs (e.g., long-term residential programs for mothers and their children) not usually available to the middle class or even the very wealthy. In general, long-term programs are more common where the target population is indigent, because the clients have fewer interpersonal, social, and T 83 http://dx.doi.org/10.1037/12312-004 Treating Patients With Alcohol and Other Drug Problems: An Integrated Approach (2nd Ed.), by R. D. Margolis and J. E. Zweben Copyright © 2011 American Psychological Association. All rights reserved. 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 84 TREATING PATIENTS WITH ALCOHOL AND OTHER DRUG PROBLEMS Copyright American Psychological Association. Not for further distribution. vocational skills to reclaim. Thus, they are more likely to need “habilitation” rather than rehabilitation. However, these distinctions may blur in practice. Many clients in public sector programs were originally working class or middle-class professionals but downwardly mobile because of their alcohol and drug use, and they return to a working- or middle-class lifestyle once in recovery. TREATMENT SETTINGS AND MODALITIES Substance abuse treatment occurs in both inpatient/residential and outpatient settings but has a unique variety of modalities. These range from specialty clinics that use medications as an integral part of addiction treatment to social model programs that rely heavily on recovering peers. It is important for clinicians outside the addiction treatment system to understand these modalities in order to make effective referrals. Residential/Inpatient Treatment Live-in programs include a range of treatment environments in which there is 24-hour supervision, thereby offering a protected setting in which the client or patient is insulated to some extent from the triggers and stressors of drug use. These may be hospital based, such as inpatient programs offering medical interventions (e.g., medically managed withdrawal) as well as programming aimed at psychosocial issues. The term residential is applied to a wide range of programs that exist outside medical settings as freestanding programs of variable duration, using a variety of approaches. These include therapeutic communities, inpatient programs, and social model recovery homes. Therapeutic Communities Therapeutic communities (TCs) are long-term residential programs that emerged in the 1960s as an alternative treatment for heroin addiction. They are based on a self-help model developed by Synanon founder Charles Dederich and a group of recovering alcohol- and drug-addicted members, 84 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 85 Copyright American Psychological Association. Not for further distribution. DETERMINING APPROPRIATE TREATMENT with major influences from Alcoholics Anonymous (AA) and religious healing communities dating back a considerable period of time (Deitch, 1973; de Leon, 1994a). Over time, the resident population diversified and professionals were integrated. Currently, there are a wide range of settings, a variety of lengths of stay, and numerous adaptations that may or may not conform to the therapeutic community model. Two of the best-known programs are Daytop and Phoenix House. The traditional, long-term residential programs have been studied continuously since their inception. Although it does not appear possible to conduct randomized, blind clinical trials, the empirical data support the conclusion that TCs result in the positive outcomes of reduction of illicit drug use and other criminal activity and an increase in economically productive behavior and other measures of positive outcome (Gerstein, 1994; Gerstein & Harwood, 1990). Newer adaptations, such as programs serving the severely mentally ill or adaptations of the model for outpatient settings, have been demonstrated to be effective for these challenging populations (Sacks & Ries, 2005). In the TC model, drug abuse is viewed as a disorder of the whole person, which can affect some or all of the person’s functioning (de Leon, 1994a). Thus, the intervention must be comprehensive, addressing in particular those psychological difficulties or social deficits that undermine the ability to maintain a drug-free lifestyle. Indeed, TCs are often said to promote habilitation rather than rehabilitation because residents frequently had never acquired prosocial attitudes and skills. Therefore, the program must develop qualities in its members that were never there, instead of reclaiming those that were temporarily lost. Recovery entails a shift in personal identity as well as lifestyle. The essential ingredient in change is affiliation, with the community as the primary agent. George de Leon (1994b) elaborated in detail the essential concepts in using community as a method. Individuals contribute directly to all activities of daily life in the TC, which provides learning opportunities through engaging in a variety of social roles (e.g., peer, friend, coordinator, tutor). The primary sources of instruction and support for individual change are the observations and authentic reactions by peers. In addition, each member 85 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 86 Copyright American Psychological Association. Not for further distribution. TREATING PATIENTS WITH ALCOHOL AND OTHER DRUG PROBLEMS of the community has the responsibility of serving as a role model to peers. Collective formats guide individual change. Individual sessions, though they may be available, are viewed as adjuncts to the group activities. Education, training, and therapeutic activities occur in groups, meetings, seminars, job functions, and recreation. Beliefs and values stressing “right living” are explicit guidelines and are expressed in the vernacular and culture of each TC. “Act as if you are a responsible person and you can grow into it.” Open communication of private thoughts and feelings is an essential feature of the TC. Relationships with particular individuals, peers, and staff are essential to encourage the individual to engage and remain in the change process. These relationships are also the basis for the social network needed to sustain recovery beyond treatment. The organization of the work (e.g., the varied job functions, chores, and management roles) needed to maintain the daily operations of the facility is a primary vehicle for teaching self-development. Learning occurs not only through specific skills training but also through adhering to the orderliness of procedures and systems, through accepting and respecting supervision, and through behaving as a responsible member of the community on whom others are dependent. TCs typically define stages of treatment: orientation–induction, primary treatment, and reentry. In contrast to the assumption that treatment readiness can be quickly assessed, TCs assume the initial period will clarify such issues as the resident becomes a participant in the activities of the community. Ambivalence is a given, and the orientation period (0–60 days) is designed to assimilate the individual and promote understanding and acceptance of the TC’s norms. The isolation of the individual from the wider community, often a source of misunderstanding by professionals and significant others, is designed to bond the resident to the community by eliminating outside influences as much as possible. Dropout is greatest during this early period. Primary treatment (2–12 months) consists of educational and therapeutic meetings, groups, job functions, and peer and staff feedback. As residents display an understanding and acceptance of both the TC perspective and the daily regimen, they ascend in status and privileges in the leadership structure of the community, including job 86 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 87 Copyright American Psychological Association. Not for further distribution. DETERMINING APPROPRIATE TREATMENT hierarchies. In this way, at the end of their stay in primary treatment, they set an example for others. Additional privileges include things such as greater privacy and desirable job responsibilities. The therapeutic process takes place in all facets of community life, from groups specially designed to focus on psychological issues (e.g., traumatic experiences, sex-role identity and conflicts) to job performance in which the feedback process is ongoing. The reentry process prepares the individual for more autonomous functioning at a future time when he or she will no longer be in direct contact with the TC. Typically there is a reduction in structure, and the resident progresses to a looser form of affiliation. Many TCs offer gradations such as satellite apartments, in which residents who shared the common program experience live together without program supervision. In this way, the culture of the TC is transplanted into the wider community setting so that gradual transitions can promote stable progress. Common stereotypes of the TC assume harsh confrontation, a feature of the original Synanon model that has evolved in productive directions in the more mature TC systems. In the 1970s, more participation by professionals led to the introduction of gestalt techniques, cognitive–behavioral strategies, and other approaches intended to broaden the repertoire of tools. Most TCs also endorse a family model in which the community is seen as a substitute family, often an improved version of what residents may have experienced in childhood. The TC family participates in holiday rituals and graduation for those who complete the program and offers support and caring as the context for exploration of difficult issues. Certainly TCs vary in the extent to which they establish a healthy and positive climate, but there are many examples in which the family spirit is vigorous, and the TC provides a culture for all involved that is more cohesive and inspiring than many available in the fragmented world of the typical addicted individual. The Minnesota Model The dominant paradigm for short-term inpatient treatment was developed in Minnesota during the 1950s at the fledgling facilities of Hazelden and Willmar (McElrath, 1997). Prior to that time, the prevailing belief that 87 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 88 Copyright American Psychological Association. Not for further distribution. TREATING PATIENTS WITH ALCOHOL AND OTHER DRUG PROBLEMS alcoholism was a psychological vulnerability to be treated in mental health units had failed to produce effective treatment. Guided by their successful experiences in AA, the founders of Hazelden and Willmar adapted these principles to create a new treatment model and brought it into hospital-based treatment. Over time, proponents of the model refined their treatment practices and restructured institutional relationships to emphasize the collaboration between professionals and noncredentialed recovering persons. By 1954, nondegreed counselors on alcoholism, usually recovering alcoholics, shared the responsibility and decision making for the treatment. Subsequently, national and state certification programs established training standards and document completion by counselors without graduate or undergraduate degrees. There are also an increasing number of licensed professionals in recovery in clinical and administrative roles. The essential features of the model are its goals of complete abstinence and behavior change, its intimate link with the 12-step process of AA (discussed in more detail in Chapter 8) and program participation, and its multidisciplinary approach (McElrath, 1997). The Minnesota model became the prototype for hospital-based inpatient programs. McElrath (1997) described the key elements as follows: 䡲 䡲 䡲 䡲 䡲 䡲 䡲 the grace of a beautiful environment that promotes respect, understanding, and acceptance of the dignity of each patient; a treatment based essentially on the program and process of AA; the belief that a respite from the familiar environment and association with other alcoholics is central to recovery; simple behavioral expectations, including making your bed, comporting yourself “as a gentleman [sic],” attending the daily lectures on the 12 steps, and talking with one another; a multidisciplinary team approach; a systematic approach to the treatment of an illness defined as a primary disorder distinct from mental illness; and the need for and value of an aftercare program. With many contributions from others, a model was developed and disseminated that viewed recovery as a physical, psychosocial, and spiritual 88 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 89 Copyright American Psychological Association. Not for further distribution. DETERMINING APPROPRIATE TREATMENT process with recovering personnel as the primary element in delivering the service. The term chemical dependency emerged during the cocaine epidemic and was extended to apply to all mood-altering drugs. Although this term is still used, it is not necessarily accepted by providers in other treatment modalities. Differences in historical origin and in populations served (e.g., heroin users on methadone maintenance) make the term alien to some providers; hence, it should not be assumed to be generic to addiction treatment. A practical decision based on seasoned clinical opinion, but no data, shaped the modality for decades to come. McElrath (1997) reported that in the mid-1970s, when the state of Minnesota asked how much time was necessary to treat alcoholics, the response was “at least a month.” With the subsequent mandate of 28 days of insurance coverage in the 1970s, the Minnesota model became more defined and proliferated. In McElrath’s (1997) opinion, the huge expansion of inpatient programs in the 1980s also fostered a certain rigidity as incidental elements (e.g., the 28-day duration of treatment) diminished treatment innovation and creativity. Much controversy existed about the necessity for 28-day rehabilitation programs even before the period of their rapid demise as a result of changing insurance reimbursement policies. Several decades of studies yielded equivocal results, partly because of inadequate methodological strategies. Within the private sector, the Chemical Abuse/Addiction Treatment Outcome Registry (CATOR) was developed to document positive outcomes. This private Minnesota corporation contracted with treatment programs to track individual patients. Data were collected during treatment and transmitted to CATOR, which conducted and reported on the follow-ups (Institute of Medicine, 1990). Although these data are useful in exploring treatment issues, the information is often used in marketing efforts without adequate cautions that it is unwarranted to assume that a positive outcome reflects treatment efficacy. For example, studies following a matched sample concluded that given certain patient characteristics, improvement will follow minimal or no intervention as well as intensive intervention. A well-known review of outcome data comparing inpatients 89 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 90 Copyright American Psychological Association. Not for further distribution. TREATING PATIENTS WITH ALCOHOL AND OTHER DRUG PROBLEMS and outpatients concluded that, in general, the data did not justify costly inpatient treatment (W. R. Miller & Hester, 1986). However, intensive treatment may be differentially beneficial for those who are more severely deteriorated and less socially stable; these are not the individuals who have ready access to such programs. Randomized controlled trials provide the most rigorous means of evaluating outcome, but they are expensive, time consuming to conduct, and may be precluded by ethical concerns. Meanwhile, managed care companies established in the 1980s to contain rapidly escalating costs dramatically reduced access to inpatient treatment and shifted the emphasis to outpatient modalities (Rawson, 1990–91). Researchers are in the process of clarifying questions of how to match people to programs or treatments, such as criteria for intensive services, and guidelines are rapidly evolving and being refined. In the 1990s and beyond, growing acknowledgement of the prevalence of co-occurring psychiatric disorders led to the integration of services at the clinical level, despite difficulties with funding mechanisms. In addition, the growing emphasis on implementing evidence-based practices brought a questioning of rigid ideological positions in favor of utilization of data to improve outcomes (W. R. Miller, Zweben, & Johnson, 2005). Studies do support the efficacy of AA-based treatment (Project MATCH Research Group, 1997), but many of these programs in the community incorporate a variety of approaches, although they may emphasize their allegiance to the 12-step model. The Social Model and Other Environmental Approaches Social and community model approaches represent an important influence on a variety of treatment and prevention activities. They can form the basis of complete programs, or they can be components or elements in other types of programs. The goals of social model programs are to provide recovering people with alternative social environments that support recovery and to promote changes in larger communities to prevent alcohol problems and support abstinence-based recovery (Dodd, 1997). Emphasis is on the micro and macro community rather than on the individual, who is generally the focus of clinical model programs. 90 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 91 DETERMINING APPROPRIATE TREATMENT The characteristics of social model programs are summarized as follows (Wright, Clay, & Weir, 1990): 䡲 䡲 Copyright American Psychological Association. Not for further distribution. 䡲 䡲 䡲 䡲 Experiential knowledge about recovery is the basis of authority. The primary therapeutic relationship is between the person and the program rather than between the person and a staff member, therapist, or other professional. The program is peer oriented, and hierarchy is minimized. The fundamental framework is derived from AA principles and emphasizes the values of honesty, tolerance, willingness to try, and emphasis on helping others. In addition, social model programs endeavor to make good use of community resources such as public health clinics, social services, therapists, and any other activities that benefit participants. A positive sober environment is crucial, with clean, homelike, comfortable surroundings setting the tone. Alcohol problems are not only individual problems but are also defined in terms of families, communities, and the larger society. The range of social model programs includes social setting detoxification, alcohol recovery homes (short- and long-term; also referred to as halfway houses), and community recovery centers. Social model detoxification programs were developed initially at the Addiction Research Foundation in Canada in 1970, and shortly thereafter a model was opened as a demonstration in Stockton, California. The goal was to create a system to provide services to intoxicated people in crisis or emergency situations when there was no medical indication for costly hospitalization or outpatient medical management. This system was also designed to foster appropriate use of alcoholism programs and other community agencies, organizing the referral process and creating a continuum of care in a network of community services. Consistent with the larger social model perspective, the physical setting and environment were designed to protect the alcoholic from the stigma frequently encountered in other settings and to promote constructive behavior changes. “Sobering centers” provide a comfortable and supportive environment for those withdrawing from alcohol. Medication is not used in most of these settings, but staff members are 91 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 92 Copyright American Psychological Association. Not for further distribution. TREATING PATIENTS WITH ALCOHOL AND OTHER DRUG PROBLEMS trained to observe warning signs of potential problems. Linkages with hospitals permit immediate transfer in the case of medical complications (O’Bryant & Peterson, 1990). Alcohol recovery homes surround the alcoholic with a community that supports the lifestyle changes needed to promote recovery. Like therapeutic communities, residents participate fully in the operation of the home, but the atmosphere of recovery homes tends to be less structured and less confrontational. The presence of role models and community reinforcement are key change factors. Peer influence, rather than control by the social service, health care, or criminal justice systems, is the dominant force. Community recovery centers are another form of social model program that may include the sobering services and residential services described earlier and also a wide range of other activities identified as useful to support recovery. Typically center staff are knowledgeable about community resources and also willing to devise strategies to create resources that are needed but do not currently exist. They view themselves as “guides” rather than case managers, coaching participants in the appropriate use of resources outside the program itself. Other activities include discussion groups on specific topics such as parenting skills, stress reduction, women’s issues, and recreational activities designed to promote clean and sober fun, especially during weekends, holidays, and other times when recreation was previously organized around drinking. Centers also create a comfortable environment to provide unstructured opportunities to relax and meet people in a friendly, undemanding, alcohol-free setting (Wright et al., 1990). These centers provide important safe havens in drug-infested inner cities. The great contribution of social model programs is to emphasize, by example, the importance of the support system outside the boundaries of professional treatment. In many cases, this may be entirely adequate to promote the transition to an alcohol- and drug-free lifestyle. Clinicians may forget that we see a subgroup of people in distress; there are many who find the path to healing outside professional treatment. For those who use professional assistance, social model programs provide a context 92 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 93 DETERMINING APPROPRIATE TREATMENT for that effort with the potential to greatly amplify the impact of the treatment effort. It is also a model with applicability to mental health and other social problems. Copyright American Psychological Association. Not for further distribution. Outpatient Treatment Outpatient treatment programs can be brief or long term and can stand alone or be integrated into larger medical systems or attached to residential programs. Their labels do not have consistent meanings, and it is important for clinicians making referrals to inquire about the availability of specific services, for example, medications for psychiatric conditions. Because of the focus on cost savings in the private sector and the lack of resources in the public sector, appropriate services may not always be available. Outpatient/Intensive, Outpatient/Partial Hospitalization Throughout the 1980s, 28-day programs dominated the landscape for insured populations, and outpatient treatment was viewed as “second best.” Under pressure to offer a service that was less disruptive to employed patients, short-term outpatient models were developed, often by scaling down the inpatient version and offering programming for 3 to 4 hours on weekday evenings. These programs typically lasted 5 to 8 weeks, following which the patient participated in aftercare of considerably reduced intensity. In the sector serving the indigent population, outpatient programs were of longer duration and increased their range of services as the Center for Substance Abuse Treatment appeared in 1990 and began to encourage the provision of comprehensive services. Current outpatient programs vary considerably in content, intensity, and duration. The lack of standardization in program design (e.g., the same program may be called intensive outpatient or partial hospitalization by different providers) and evaluation methodology makes it difficult to identify effective ingredients. However, with the development of patient placement criteria (PPC) by the American Society of Addiction Medicine (ASAM; 2001), greater consistency in definitions can promote research efforts. For example, a matching study using a computerized version of the PPC indicated that mismatching 93 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 94 Copyright American Psychological Association. Not for further distribution. TREATING PATIENTS WITH ALCOHOL AND OTHER DRUG PROBLEMS patients to a lower level of care may be associated with excessive hospital use (Sharon et al., 2003). Despite the variety of programs available, ASAM offers general guidelines. Level I outpatient treatment is described as a professionally directed alcohol and other drug (AOD) treatment occurring in regularly scheduled sessions usually totaling fewer than 9 hours a week. It consists of a combination of individual and group sessions in conjunction with self-help group participation. Level II intensive outpatient treatment (also referred to as partial hospitalization or day treatment) is a more structured program with a minimum of 9 hours of treatment a week. Patients can live at home or in special residences supervised to ensure they remain clean and sober (ASAM, 2001). Program sites include hospital-based facilities, homeless shelters, and community-based organizations. PPC are discussed in more detail later. Opioid Maintenance Treatment Methadone maintenance is a major treatment modality for opioid users who have tried abstinence but not succeeded. Initially it was offered to heroin users, but the rise of prescription opiate abuse in the past decade has brought a new group of patients to methadone maintenance. It is considered the last resort for “intractable” heroin addicts. In the mid-1960s, the upsurge of heroin addiction and its higher visibility in young (15–35 years old) and middle-class populations led to increased federal efforts to develop effective treatment modalities. This era produced the resources to establish, proliferate, and study both methadone maintenance and therapeutic communities, which have been the subject of continuous study since that time. As of 2007, there were approximately 262,684 patients in methadone maintenance treatment in 1,200 programs across the country (Substance Abuse and Mental Health Services Administration, 2008), more than twice as many as reported in the first edition of this book. Methadone maintenance treatment (MMT) was developed in the mid-1960s by two physicians, Vincent Dole and Marie Nyswander, who postulated that a metabolic defect accounted for the inability of heroin addicts to remain abstinent for more than brief periods of time and intended 94 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 95 Copyright American Psychological Association. Not for further distribution. DETERMINING APPROPRIATE TREATMENT for methadone to be used indefinitely as a corrective medication. As methadone was being formally approved for clinical use, professional and public opinion shifted to a new goal: to use it to transition heroin users to a drug-free lifestyle. Once this was accomplished, methadone was to be discontinued. Research in the following decades indicated that fewer than 20% of those who are on methadone will be able to discontinue methadone and remain drug free (Zweben & Payte, 1990). In work for which he won the Lasker Award, Dole (1988) postulated that a receptor system dysfunction resulting from chronic heroin use leads to permanent alterations, which the clinical community does not now have the means to reverse. Thus, indefinite maintenance is corrective but not curative, in much the same way that thyroid or insulin replacement normalizes body functioning. Studies have indicated that methadone is a relatively benign medication that shows stability of receptor occupation and thus permits interacting systems to function normally (Martin, Zweben, & Payte, 2009). It is this stability that results in evenness in functioning. This distinguishes it from heroin, a short-acting narcotic producing rapid changes that make a stable state of adaptation impossible. A user maintained on heroin would go through 4-hour cycles of intoxication and withdrawal; even if supplied with a clean and legal source, the short duration of action makes heroin undesirable as a maintenance drug. Even with long-term use (20 years or more), methadone continues to have a withdrawal prevention effect in which patients do not experience craving or other withdrawal phenomena and are able to function normally without somnolence (Martin et al., 2009). MMT in combination with educational, medical, and counseling services has been thoroughly documented to assist patients in reducing or discontinuing illicit drug use and associated criminal activity, improving physical and emotional well-being, becoming responsible family members, furthering their education, obtaining and maintaining stable employment, and resuming or establishing a productive lifestyle (Gerstein & Harwood, 1990; Hubbard et al., 1989). Despite 3 decades of research confirming its value and safety, MMT remains perhaps the most stigmatized of all drug treatment modalities and the one that is least understood (Murphy & Irwin, 1992). It remains a source of contention among treatment providers, 95 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 96 Copyright American Psychological Association. Not for further distribution. TREATING PATIENTS WITH ALCOHOL AND OTHER DRUG PROBLEMS the general public, and health care policymakers. After a long period of isolation from other forms of treatment and recovery interventions, the AIDS epidemic stimulated a reexamination and renewed interest in this modality. MMT has been demonstrated through education, reduced needle use, and increased safer sex practices to slow the spread of HIV disease and to slow the progression of the disease in those who have contracted it (Batki & Selwin, 2000). On closer examination, the “controversies” about MMT usually reflect several common misunderstandings rather than a difference of opinion between informed parties. One primary source of opposition is the notion that use of methadone is “just substituting one addicting drug for another.” This notion is often shared by the patients themselves, who may lack information and have usually internalized the stigma. Technically, this is correct; MMT is drug replacement therapy in which a long-acting, orally administered medication is substituted for a short-acting illicit opioid that is used intravenously. These differences have significant consequences. The long duration of methadone’s action (24–36 hours) allows most patients to receive a daily dose and function in a stable manner because their blood level remains relatively constant. This stands in contrast to the 4-hour cycles of euphoria and withdrawal that are characteristic of heroin use. It is this feature that promotes lifestyle changes by permitting normal functioning. In addition, there is widespread misconception among both the public and professionals about what constitutes addiction. Addiction treatment professionals increasingly distinguish between physical dependence and addiction (see Chapter 2, this volume). Physical dependence itself is a factor to be considered but one that in and of itself does not constitute addiction, which is characterized by behavior that is compulsive, out of control, and persists despite adverse consequences. The key question is whether functioning is improved or impaired by use. Benzodiazepines are an example of a medication that is dependence-producing at therapeutic doses but that can be used beneficially for long periods for people with anxiety disorders. Patients with chronic pain are another example in which assessment focuses on whether the patient’s functioning is improved or impaired rather than on physical dependence itself as the deciding factor. 96 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 97 Copyright American Psychological Association. Not for further distribution. DETERMINING APPROPRIATE TREATMENT Another common misconception is that “methadone keeps you high,” which reflects misunderstanding of a properly adjusted dose. While a patient’s dose is being stabilized, he or she may experience some subjective effects, but these usually diminish or disappear once stabilized. This is precisely why methadone is a good tool: Once stabilization is achieved, the patient should be able to function normally. Extensive research on safety has indicated that long-term use of methadone results in no physical or psychological impairment of any kind that can be perceived by the patient, observed by a physician, or detected by a scientist (Zweben & Payte, 1990). There is no impairment of balance, coordination, mental abilities, eye–hand coordination, depth perception, or psychomotor functioning. Patients on methadone who are identified through workplace drug testing and threatened with negative consequences have succeeded, through advocacy efforts, in maintaining their jobs; the Americans with Disabilities Act of 1990 contributes to their protection. Because of historical disputes and political controversies, the current treatment system is overburdened by regulations and inappropriate expectations (Rettig & Yarmolinsky, 1995), producing a delivery system so dehumanizing that programs usually make efforts to assist the patient wishing to taper off methadone. However, it is important to remember that studies have indicated that although it is common for patients to remain opiate-free for a short time, relapse is the norm for 80% or more (Ball & Ross, 1991; McLellan, 1983). Because a history of treatment failures is required, only a subset of opiate users qualify for methadone maintenance, and it is likely that neurobiological factors significantly raise the vulnerability to becoming addicted to opiates (Dole, 1988). High motivation is necessary, but not sufficient, for successfully tapering off methadone. It is unfortunately common for uninformed professionals, family members, and others to encourage or coerce patients on methadone to discontinue their medication (Zweben & Payte, 1990). The decision to taper should be made by the patient in collaboration with professionals experienced in methadone treatment and should not be based on bias against this medication. The relapse rates of methadone users are so extraordinarily 97 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 98 Copyright American Psychological Association. Not for further distribution. TREATING PATIENTS WITH ALCOHOL AND OTHER DRUG PROBLEMS high that the risks are considerable. Therapists should be cautious about encouraging a patient to discontinue methadone maintenance because pressure is often applied by the family or by other treatment providers on the basis of stigma instead of careful review of the case. The results of misguided interventions such as these can be lethal. Therapists dealing with patients on methadone who continue to use opiates should first rule out the possibility of an inadequate dose of methadone, because this can occur for a variety of reasons. The usual dose range is between 60 and 100 mg daily, with more being required for some patients. Once the medication dose is adequate, the yield is much greater for psychosocial intervention. The majority of patients in the MMT system are indigent or working class; of these, many are downwardly mobile from the middle class as a result of their drug and alcohol use. However, depending on clinic location, there may be surprising numbers of successful and high-functioning individuals who conceal their participation in MMT from colleagues and even family members. Prescription drug abusers are increasingly represented in this group. It is possible that under better circumstances, MMT would be the treatment of choice for multiple relapsing opioid users with more middle-class characteristics. Clinicians have observed such patients who flounder for long periods, unable to maintain abstinence, or who substitute alcohol and deteriorate. The addiction treatment programs in which they were likely to seek treatment often claimed an expertise they did not possess in treating opiate users, particularly heroin users, and they lacked long-term follow-up studies to assess the efficacy of their efforts. Such patients report being highly stigmatized by the more populous cocaine users because their drug preference was heroin, and they report being labeled “more disturbed” by treatment staff. An Empire Blue Cross and Blue Shield (EBCBS) study concluded there is a large population of opiate users who may be excluded from the estimates of overall number of opiate users because they are less likely to be counted by contact with government agencies (Eisenhandler & Drucker, 1993). They estimated that between 1982 and 1992, EBCBS (New York metropolitan area) insured approximately 141,000 opiate users, 98 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 99 Copyright American Psychological Association. Not for further distribution. DETERMINING APPROPRIATE TREATMENT 85,000 of whom were insured with them at the time of the study. They recommended that the social characteristics of opiate users should be reconsidered because many middle-class heroin users may be overlooked and undertreated. Despite progress in removing regulatory barriers and addressing stigma, the use of methadone remains highly charged. Illicit use of oxycodone (OxyContin) has led to high death rates in some states, resulting in physicians shifting to methadone as a way to manage pain. This in turn led to increased quantities available for street sale, with a predictable increase in deaths, especially when it is used with other substances (Cone et al., 2003; Cone et al., 2004). In addition, a rapid increase in nonmedical use of opiate medications beginning about 1995 has brought new populations into treatment (Wunsch, Boyd, & McMasters, 2009). Many of these would not consider, or do not have access to, methadone treatment. In this context, buprenorphine was a welcome new addition to the tools available to practitioners. Buprenorphine is a partial opioid agonist that became available through the Drug Addiction Treatment Act of 2000. It binds to the receptor but has less strength than a full agonist such as methadone. However, buprenorphine binds tightly to the receptor (high affinity), blocking the action of heroin or other opiates if they are used. This has given it a significant advantage of a high margin of safety with little chance of a lethal overdose. The ceiling on agonist activity reduces the danger of overdose as well as the abuse liability (Fudala & O’Brien, 2005; Stine, Greenwald, & Kosten, 2003). For example, there is much less chance of severe drug-induced respiratory depression with buprenorphine. Because of this, the U.S. Food and Drug Administration permitted its administration in office settings (rather than specially licensed clinics) by qualified physicians who have completed the educational requirements to be granted a waiver. This opened the door to widespread use by patients who find methadone, or the settings in which it can be obtained to treat addiction, to be unacceptable. It is important for clinicians providing psychosocial treatment to recognize that patients with a high opiate tolerance may find buprenorphine inadequate to control their symptoms because of the inherent dose ceiling. 99 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 100 Copyright American Psychological Association. Not for further distribution. TREATING PATIENTS WITH ALCOHOL AND OTHER DRUG PROBLEMS They may experience significantly better results with methadone, though they may be resistant to trying it. It is difficult for some patients and therapists alike to accept that motivation is important, but brain chemistry has a profound influence on outcomes, including the influence on the efficacy of psychosocial interventions. It is easy to criticize opiate users for being inconsistent in their motivation or unwilling to make full use of therapy or the self-help system. However, many have been given poor advice by professionals, including those in the addiction field, and have lost years or decades in repeated struggles with relapse. High-prestige treatment settings may be the least conducive to raising the possibility of using an opioid agonist or may fasten on buprenorphine as the only acceptable medication and for short term use only. Ultimately, it is important to acknowledge that long-term maintenance on buprenorphine may be necessary for many patients who hope that detoxification will be enough. Smoking Cessation Smoking cessation was initially offered mainly in primary health care settings or by smoking cessation specialists and remained relatively unintegrated with the rest of the addiction field. Attention began to focus on it in the mid-1980s, as reflected in Wallace’s (1986) editorial “Smoke Gets in Our Eyes: Professional Denial of Smoking.” He challenged the minimization of health consequences and the complacency about addressing it, especially given the high percentage of smokers among patients in treatment for addiction. He also noted that the prevalence of smokers among recovering staff members presented a troublesome role model and constituted a source of resistance to no-smoking policies. Since that time, research has documented the significantly higher frequency of smoking among alcoholics and polydrug users, established that smoking cessation does not in itself increase relapse as previously feared, and refined intervention techniques to promote success (Jarvik & Schneider, 1992). Smoking cessation has become much more integrated into addiction treatment and also continues to be provided by health care organizations and private practitioners. As insurers and the government focus on the many costs associated with smoking-related illnesses, one can expect increasing support for identification and treatment 100 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 101 Copyright American Psychological Association. Not for further distribution. DETERMINING APPROPRIATE TREATMENT outside addiction treatment settings as well. In addition, recent magnetic resonance imaging studies suggest that neurobiological recovery in abstinent alcoholics is adversely affected by chronic smoking (Durazzo, Gazdzinski, & Meyerhoff, 2007), thus providing added incentives for clinicians to promote smoking cessation as a part of addiction treatment. Short-term behavioral therapies have long been prominent in smoking cessation. Many are able to achieve high initial cessation rates, but success rates at 1 year averaged 15% to 30%, unrelated to the initial quit rates (Jarvik & Schneider, 1992). This may be related to a lack of emphasis on relapse prevention. The behavioral strategies that are effective in initiating abstinence are different from those needed to maintain it, and reliance on short-term treatment makes it less likely that long-term maintenance strategies will be provided at the time they actually become relevant. The recent development of effective pharmacological withdrawal agents has been shown to greatly augment the success of behavioral strategies (Fiore et al., 2008). Nicotine dependence and craving varies among smokers, and these agents significantly decrease discomfort. Nicotine replacement in the forms of transdermal patches, sublingual nicotine tablets and lozenges, nasal spray, and inhalers are available. Bupropion (Zyban) is a nonnicotine product that is effective in promoting abstinence and reducing relapse (Hurt, Ebbert, Hays, & Dale, 2003). Varenicline (Chantix) is a partial agonist that reduces cravings and decreases the pleasurable effects of smoking. Clinicians are enthusiastic about the results of its use. The Smoking Cessation Guidelines from the federal Agency for Health Care Research and Quality (Fiore et al., 2008) summarize the issues pertaining to selection and application of both pharmacological and psychosocial treatments. Studies have supported the view that combination therapies show greater effectiveness than pharmacotherapy or behavioral interventions alone. Social support is a key element in smoking cessation, as with other drugs; thus, the proliferation of antismoking regulations at the work site and in other public settings will likely improve treatment success rates. Psychiatric comorbidity has emerged as a key element in successful smoking cessation; therefore, treatment planning should take this into account. Strong relationships have been reported between depression and 101 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 102 Copyright American Psychological Association. Not for further distribution. TREATING PATIENTS WITH ALCOHOL AND OTHER DRUG PROBLEMS smoking. In the early 1990s, Glassman (1993) reported that both major depression and depressive symptoms are associated with a high rate of cigarette smoking, and lifetime history of major depression has an adverse impact on smoking cessation. In this vulnerable group, there is also a significantly higher likelihood of the patient developing a depressed mood during the first week of withdrawal, and the entire withdrawal syndrome was more severe. Emergence of depressive symptoms predicts failure of the attempt to quit. Therefore, it is important that the clinician assess depression and include appropriate interventions in the treatment plan. For example, it may be advisable to wait until the patient has been stabilized on antidepressant medication before encouraging action on quitting. A variety of behavioral strategies designed to enhance affect regulation have also been demonstrated to be effective for this group (Kahler, Leventhal, & Brown, 2009). Clinicians working with patients with schizophrenia have a more complex dilemma. Although the serious health risks are indisputable, it appears that nicotine confers some benefits that must be considered in smoking cessation efforts. Reviews have noted the high rates of smoking among people with schizophrenia: between 74% and 92%, compared with 35% to 54% for all psychiatric patients and 30% to 35% for the general population (Goff, Henderson, & Amico, 1992). Current smokers with schizophrenia received significantly higher neuroleptic doses and displayed less parkinsonism and more akathisia (i.e., restless movements induced by neuroleptics). Patients reported that it produces relaxation, reduces anxiety, reduces medication side effects, and ameliorates psychiatric symptoms (Goff et al., 1992). It has been postulated that nicotine provides transient symptomatic relief through stimulation of cholinergic nicotinic receptors, enhancing the gating mechanism that permits patients to filter out irrelevant stimuli (Freedman et al., 1994). Thus, efforts to promote smoking cessation in people with schizophrenia, especially abruptly when they enter smoke-free hospital environments, must take into account these complex considerations. Success will likely depend on a better understanding of the mechanisms of the positive benefits of smoking and development of alternatives (e.g., transdermal patches for nicotine maintenance). 102 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 103 DETERMINING APPROPRIATE TREATMENT In summary, the wide recognition of health consequences for smokers and those around them, along with stricter laws targeting smoking, will likely result in increasing demand for assistance, in which both clinicians and researchers will play an active role. Copyright American Psychological Association. Not for further distribution. Psychotherapy in the Treatment of Addiction Although psychotherapy alone is not usually considered an appropriate treatment for addiction, in reality many therapists in the community diagnose and attempt to address addictive behaviors ranging from mild to severe. Increasingly, they combine their efforts with a referral or insistence on AA or Narcotics Anonymous attendance. For many, the issue of drinking and using is given priority and the combination of psychotherapy with self-help group participation is considered adequate, although there is no referral to formal addiction treatment. There are no empirical data on how often this process occurs and how effective it is. Many addiction specialists view the community therapist as being in a prime position to do effective early intervention, arresting problems before serious deterioration occurs. However, it is also apparent that some therapists in the community are not sufficiently concerned about lack of progress in changing behavior. They do not inquire regularly about AOD use unless there has been a recent crisis. It would be valuable to study this therapeutic process in more detail, defining parameters for effective intervention in this context, looking at outcome, and formulating guidelines for when referral to the specialty system is advisable. TREATMENT IN THE CRIMINAL JUSTICE SYSTEM The greatest expansion of addiction treatment services is occurring in the criminal justice sector, which is rapidly becoming a major employer of professionals. Treatment monies are diminishing steadily in the health care system and increasing in the criminal justice system. As managed care creates discouraging work conditions, increasing numbers of professionals are migrating into the criminal justice sector, where they face new challenges to provide appropriate care. 103 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 104 Copyright American Psychological Association. Not for further distribution. TREATING PATIENTS WITH ALCOHOL AND OTHER DRUG PROBLEMS The majority of those incarcerated have an alcohol and/or drug problem to which their offenses are directly or indirectly related (Office of National Drug Control Policy, 2010). It is estimated that 70% of inmates in state prisons and 80% in federal institutions are serving time on charges related to drug trafficking and possession (Robert Wood Johnson Foundation, 2001). Criminal justice system interventions take place both in the community and inside the institutions. Various forms of intervention have been developed for different targets in the criminal justice system. These include pretrial and diversion efforts after arrest and before trial, treatment inside jails and prisons, and community treatment for probationers and parolees (Peters & Wexler, 2005). It has been known for some time that treatment is effective in reducing recidivism. A rigorous review by the Institute of Medicine in 1990 suggested that despite disappointing findings in the overall research literature on prison-based treatment, addiction treatment programs that are sufficiently comprehensive and well-integrated into the criminal justice system do achieve a significant reduction in recidivism (Anglin & Hser, 1991; Gerstein & Harwood, 1990; Vigdal, 1995). The therapeutic community movement has been particularly influential in prison treatment, partly because of outcome data supporting effectiveness and partly because its tight structure makes it more acceptable to corrections personnel than more loosely structured models. Appropriate treatment in prison leads to reduced drug use on release and fewer arrests and episodes of reincarceration (Field, 1989; Wexler, Falkin, & Lipton, 1992). Best results are obtained when there is a relatively seamless transition into community treatment (Field, 1998; Hubbard et al., 1989; Wexler, de Leon, Thomas, Kressel, & Peters, 1999). A growing number of states have enacted legislation and provided funding for treatment in lieu of incarceration. Drug courts and other diversion initiatives represent ways to use the criminal justice system to promote initiation, engagement, and retention in a treatment effort. Studies have supported the benefit of mandated treatment in improving outcomes (Kelly, Finney, & Moos, 2005). Efforts to use the leverage of the criminal justice system to promote outpatient treatment efforts began in the 1960s with the Civil Addict Pro104 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 105 Copyright American Psychological Association. Not for further distribution. DETERMINING APPROPRIATE TREATMENT gram, which committed addicted people to compulsory drug treatment (Anglin & Hser, 1991; Vigdal, 1995). More recently, there has been a rapid expansion of special problem-solving courts requiring participating in treatment, monitoring it closely, and applying sanctions for noncompliance and rewards for progress. Drug courts began in Miami, Florida, in 1989 and have spread throughout the United States and abroad. Outcome data have supported their effectiveness (Huddleston, Marlowe, & Casebolt, 2008). The drug court model has been expanded to include other types of problemsolving courts, such as those centered on mental health, domestic violence, truancy, veterans, and many other problems (see http://www.ncsconline.org/ D_Research/ProblemSolvingCourts/Resources.html). In these models, the courts collaborate with community treatment providers to integrate the treatment with legal case processing. Other community corrections programs include contracts with the criminal justice system to purchase residential beds or outpatient capacity outside the institutions. Findings about the success of coerced treatment are particularly important in the light of a belief on the part of many professionals that such treatment does not work. In fact, in addiction treatment, retention is the variable most highly correlated with a positive outcome. Those who remain in treatment longer than 6 months look similar, independent of whether the treatment attempt was initiated voluntarily or through legal coercion. Clinicians have noted the positive effects of pressure from social services or Supplemental Security Income, which brought many individuals into treatment who had never sought it before and influenced them to remain long enough to begin to see benefits for themselves. From the clinical perspective of the addiction specialist, this is not surprising. People who are actively using alcohol and drugs do not make good decisions. Once this cycle is interrupted and they get some distance from alcohol and drug use, they are more likely to take a different view of their circumstances, particularly if offered an opportunity for selfexamination in a supportive treatment setting. Many current drug users come from families in which there may have been multiple generations of alcohol and drug users. They have no model for an alternative lifestyle and no conviction that a better life is possible for them. Coercion may provide 105 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 106 Copyright American Psychological Association. Not for further distribution. TREATING PATIENTS WITH ALCOHOL AND OTHER DRUG PROBLEMS the opportunity and impetus to enter a recovery process, the motivation for which gradually becomes internal. The AA motto “Bring the body; the mind will follow” is wisdom that is repeatedly confirmed in the area of coerced treatment. It is important for the clinician to focus on the development of a new identity and life goals as recovery progresses. Currently, the criminal justice system severely limits the clinician’s ability to determine appropriate treatment because many options are simply not available. However, there are several reasons to believe that the wider application of existing approaches has great potential for improving treatment outcome in criminal justice populations. Outcome studies of therapeutic communities and methadone maintenance have consistently shown reductions in criminal behavior (Gerstein & Harwood, 1990; Hubbard et al., 1989). Making quality treatment more available to those with criminal justice system involvement can be expected to produce meaningful gains, reducing the cost of long-term incarceration for some in this system. A second promising avenue of investigation is the value of consistently integrating treatment for psychiatric disorders within treatment efforts focused on criminal justice populations. A large-scale epidemiological study reported that in institutional settings comorbidity of addictive and severe mental disorders was highest in the prison population (Regier et al., 1990). Schizophrenia, antisocial personality disorder (APD), bipolar disorder, and dysthymia were the most common, with a 90% concurrence of an addictive disorder among this group. Jails may contain disproportionate numbers of severely mentally ill persons with alcohol and drug abuse disorders; Abram and Teplin (1991) noted that police often arrest the mentally ill when treatment alternatives would have been preferable but are unavailable. McFarland, Faulkner, Bloom, Hallaux, and Bray (1989) interviewed family members about their chronically mentally ill male relatives and documented that substance abuse significantly predicted arrest. More than half were arrested after unsuccessful attempts by the family to commit the patients during a crisis. In Abram and Teplin’s (1991) analysis, the narrow parameters of the caregiving systems serve as a formidable barrier to treatment. The mentally ill, particularly those with comorbid disorders, engage in disruptive behaviors and become criminal106 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 107 Copyright American Psychological Association. Not for further distribution. DETERMINING APPROPRIATE TREATMENT ized. Abram and Teplin noted that “jails, unlike many treatment facilities, have no requirements or restrictions for entry” (p. 1042). Despite the fact that comorbidity is especially high in the criminal justice client, treatment programs still may not provide adequate services to address the needs of both the addictive and the comorbid disorders. This is an area in which investigation is likely to be of increasingly great importance. Though skeptics may object that many of those in the criminal justice system are diagnosed with APD and thus have a poor prognosis, there are reasons to be cautious about such a conclusion. Overdiagnosis of APD is likely to lead the clinician to assume a poor prognosis and discourage efforts to secure quality treatment. It is crucial to assess APD independent of substance abuse (Gerstley, Alterman, McLellan, & Woody, 1990). When this is done rigorously, the percentage of those with a primary antisocial disorder declines dramatically. Gerstley et al. (1990) speculated that those whose antisocial activity is directly related to their drug use might show a better treatment response, a view shared by other clinicians. Gerstley and colleagues also discussed the possibility that antisocial behavior can be an expression of an affective disorder. Another important factor is the extent to which the context (i.e., court-related referral) biases the clinician to see the patient’s pathology in antisocial terms (Travin & Protter, 1982). More recently, it has become clear that those who are high on the numbing cluster of posttraumatic stress disorder symptoms (e.g., avoidance, detachment, restricted range of affect) can also be misdiagnosed with APD. Thus, childhood histories of abuse may be associated with violent behavior in adulthood. The clinical complexities of adjudicated populations are becoming better understood as professionals have increasing access to these populations. GUIDELINES FOR SELECTING APPROPRIATE TREATMENT Before reviewing treatment options for individual patients, it is useful to elaborate on collaboration, a skill as important as therapeutic skills in addressing addiction. It is rare to find an addicted patient whose 107 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 108 Copyright American Psychological Association. Not for further distribution. TREATING PATIENTS WITH ALCOHOL AND OTHER DRUG PROBLEMS treatment does not warrant collaboration with other professionals and systems. Precisely because addiction is a biopsychosocial disorder, the clinician must be prepared to interact with physicians, social workers, psychologists, lawyers, probation officers, and other addiction treatment professionals with specialty credentials. It is useful to think of the other disciplines as “subcultures” with their own language and assumptions about what people need in order to change. Mental health providers often underestimate the need for integrated addiction treatment, assuming that if the mental health disorder were addressed, the addictive behavior would correct itself. Physicians may underestimate the importance of sustained participation in psychosocial interventions. In working with the criminal justice system, divergent interests (e.g., promoting public safety vs. individual welfare) may overshadow the common interest of achieving stable recovery. The more the practitioner understands the perspectives of those with whom he or she is collaborating, the greater the likelihood of the kind of teamwork that leads to success. The individual therapist may need to be the patient’s advocate, educate other professionals, and assist in problem solving to formulate and implement a treatment plan. The existing system is fraught with obstacles that multiply with the number of problem areas in the individual patient. The separate systems in which various disorders (e.g., psychiatric disorders, medical problems) normally are treated have different assumptions about what goals are desirable and how people can achieve them, a different language, and to some extent, different values. For example, goals are formulated differently when one focuses on a terminal illness such as AIDS than when one has a relatively normal life expectancy. Abstinence goals, the usual organizing principle of addiction treatment, may result in harsh treatment when inflexibly applied to a deteriorating AIDS patient. The right of the individual to make certain value judgments about drug use must be weighed against the social cost of permissiveness about alcohol and drug use. There is an abundance of other evidence that alcohol and drug use increases medical costs in an otherwise healthy population. Indeed, a key priority of the 2010 National Drug Control Strategy is to identify, assess, 108 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 109 Copyright American Psychological Association. Not for further distribution. DETERMINING APPROPRIATE TREATMENT do brief interventions, or refer to specialty treatment the approximately 68,000,000 Americans who present in the health care system with varying levels of “harmful use” (Office of National Drug Control Policy, 2010). With the exception of those recently trained, most mental health practitioners are not skilled in motivating their patients to address their AOD use; this issue was seldom addressed in their basic training. They attempt to address the AOD use by referral to the addiction treatment system, which is not well equipped to deal with those who are highly ambivalent in their motivation and not prepared to make a wholehearted commitment. Thus, a large group in need of attention and amenable to appropriate intervention does not usually get their needs met in either system. Private practitioners or therapists in other settings are in an excellent position to develop “treatment readiness” in the patients through the application of the motivational enhancement strategies described in Chapter 5. SEQUENTIAL, PARALLEL, AND INTEGRATED TREATMENT MODELS Although it is widely acknowledged that the social services, mental health, addiction, and criminal justice systems are seeing many of the same people, in many communities it is still necessary to deal with multiple systems to get an appropriate treatment plan implemented. Many obstacles are inherent in this process. At best, it is time consuming, and it frequently overwhelms the patient with the task of meeting contradictory expectations. HIV adds the dimension of fatigue and susceptibility to other people’s diseases, as well as the inability to drive or use public transportation. By contrast, integrated treatment models permit addressing multiple client needs within one system. Ries (1993, 1994) discussed the strengths and limits of sequential, parallel, and integrated models for different patient profiles and described treatment approach similarities and differences. Private practitioners doing psychotherapy may need to match the patient with mental health or addiction treatment services in the community to provide missing elements. It is important to consider which model best meets the goals that need to be achieved. 109 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 110 Copyright American Psychological Association. Not for further distribution. TREATING PATIENTS WITH ALCOHOL AND OTHER DRUG PROBLEMS In sequential treatment, the patient is treated by one system (addiction or mental health) and then by the other. Many clinicians believe that the addiction treatment must always be initiated first, and the patient must be abstinent before psychiatric treatment can be effective. Some psychotherapists, impressed by the futility of ignoring alcohol and drug use, insist that the patient address the addictive behavior first before work on other issues can proceed. Indeed, there are times that this is the preferred approach, although the rigidity of some clinicians is cause for concern. It is more likely that the therapist will need to make the case over a period of time for an abstinence commitment and focus on exploring the patient’s resistance to doing so. Patients with severe psychiatric disorders may need to have those addressed first. First, it is important to rule out the possibility that the symptoms are substance induced. Once this is done, it is important to stabilize the patient who has symptoms of a mental health disorder. Addiction treatment may be ineffective until antipsychotics take effect or antidepressant blood levels are higher. In parallel treatment, the patient is simultaneously involved in addiction and mental health treatment. For example, a woman with depression may be placed on antidepressants, participate in psychotherapy, and attend classes on coping with depression at a mental health center while participating in 12-step meetings, recovery group, and alcohol- or drug-refusal classes in an addiction treatment program. These forms of treatment are provided by clinicians within different systems or who are peripheral to them and who may rarely if ever communicate with each other. If the patient becomes caught between conflicting expectations and philosophies, there may be no obvious mechanism for resolving issues. This situation is likely to interfere with good treatment outcome. In integrated treatment, mental health and addiction treatment are combined into a unified and comprehensive treatment program involving clinicians who have been cross-trained in both approaches. This includes a unified case management approach that makes it possible to monitor and treat patients through both psychiatric and AOD crises. The burden of treatment consistency and continuity is placed on staff in a setting designed for simultaneous treatment of both disorders. 110 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 111 Copyright American Psychological Association. Not for further distribution. DETERMINING APPROPRIATE TREATMENT Models for the treatment of coexisting disorders are rapidly evolving and under extensive study, but it is not currently possible to make data-based comparisons between models. Many clinicians working in this area are convinced that the integration of psychiatric treatment within the treatment and recovery setting has the greatest chance of success with most patients. Even with aggressive case management, follow-through on referrals may be difficult, especially because multiple diagnoses magnify stigma, and patients are keenly sensitive to the negative attitudes they encounter. Bouncing between two or three systems usually results in the patient being given conflicting messages with inadequate opportunity for resolution and diminishes the chance of compliance with any treatment plan. However, sequential or parallel treatment may work well when patients have a severe problem in one area but a mild problem in the other. The therapist in private practice should be prepared to play a coordinating and advocacy role to assist the patient who becomes caught in conflicting expectations or practices. Therapists searching for a good program should make a careful inquiry when a program markets itself as “dual diagnosis” or “co-occurring disorders.” Some programs have done nothing more than add a consulting psychologist or psychiatrist who comes in several hours a week for patients with obvious symptoms. The ASAM PPC, discussed later in this chapter, describe the kinds of staffing patterns and activities appropriate to differing levels of psychiatric severity. The impetus to shorten the length of stay and reduce the intensity of treatment runs counter to the needs of patients with not one but several chronic relapsing disorders. In the addiction field, treatment outcome research done on public sector populations over the past 3 decades has been consistent in its findings about the relationship between retention and outcome (Gerstein & Harwood, 1990; Hubbard et al., 1989). The longer people stay in treatment, the better they do. Gains begin to be enduring after about 6 months’ participation. Such findings suggest that in a managed care environment, many with multiple disorders will not receive care that is effective by objective measures. The “positive outcomes” described by some managed care organizations appear to be based on an absence of immediate casualties 111 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 112 Copyright American Psychological Association. Not for further distribution. TREATING PATIENTS WITH ALCOHOL AND OTHER DRUG PROBLEMS or protest by members. They do not use the same treatment outcome criteria as the addiction or mental health provider. The National Institute on Drug Abuse (NIDA) offers a good summary of effective principles and practices in its Principles of Drug Addiction Treatment: A Research-Based Guide (http://www.nida.nih.gov/PODAT/PODATIndex.html). Individual psychotherapy can fit into the following models and situations in a variety of ways. Often the patient arrives at the door of the addiction treatment system referred by his or her therapist, who may continue to see the patient during and after specialty treatment is completed. Others seek psychotherapy after a period of sobriety, to address many painful issues once obscured by alcohol and drug use. Limited psychotherapy is even becoming available to adjudicated populations, as recognition grows that inadequate resources have brought many with psychiatric disorders into the criminal justice system as their untreated symptoms escalated and appropriate help was unavailable. It is imperative that the individual therapist familiarize himself or herself with the expectations and constraints of the relevant systems and be flexible enough to tailor treatment to accommodate the extensive and sometimes conflicting demands of the patient. Providing education, support, and therapy for family members while a patient is away at residential treatment is an important function, especially if treatment is out of state and family members have a hard time accessing the treatment center’s family program. FORMULATING A TREATMENT PLAN We now look briefly at attempts to standardize principles for deciding level of care and a range of services that should be included and how they can be matched with patient needs. Although these principles are under continuous revision, they provide sensible guidelines for current practice. It should be noted that most of the vast literature on matching in both alcohol and drug treatment modalities has failed to yield dependable, practical methods for assigning patients to programs or particular treatments. For example, a national study found that three commonly used approaches 112 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 113 Copyright American Psychological Association. Not for further distribution. DETERMINING APPROPRIATE TREATMENT were effective but for most of the hypotheses did not obtain evidence about which matching variables indicated which treatment. Only psychiatric severity demonstrated relevance as a matching variable (Project MATCH Research Group, 1997). Most studies in the literature used a patient– program matching strategy in which efforts are made to match particular types of patients to particular types of programs. Attempts to apply these matching principles encountered access barriers in the programs selected. Long waiting lists made admission difficult, and geographical obstacles limited participation. Programs rapidly emerged and disappeared in the unstable funding climate. Patient–program matching has increasingly come to be viewed as impractical. PROBLEM–SERVICE MATCHING A well-known group of researchers in Philadelphia reviewed conceptual and methodological issues in an effort to chart a more productive course for this complex endeavor (McLellan & Alterman, 1991). Research by this group has focused on problem–service matching, a promising strategy that can be used by individual private providers as well as by agencies. Despite the commitment to individualizing treatment, research has shown that many programs do comprehensive assessment but assign patients to the same treatment activities. In problem–service matching, specific problem areas are identified with the Addiction Severity Index (McLellan, Alterman, Cacciola, Metzger, & O’Brien, 1992), and a brief patient interview (Treatment Services Review; McLellan, Kushner, et al., 1992) is used between short intervals to make sure the patient is receiving needed services. The programs that provided the most services that were focused on a specific treatment problem generally showed the best outcome. Thus, the specificity and relevance of the treatment services actually delivered to each individual appears to have a major influence on differential effectiveness. A subsequent study demonstrated that even well-trained clinicians in accredited programs did not necessarily match their level of attention to the patient’s most severe problem areas in the absence of a disciplined quality assurance process (McLellan et al., 1997). 113 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 114 TREATING PATIENTS WITH ALCOHOL AND OTHER DRUG PROBLEMS Copyright American Psychological Association. Not for further distribution. CENTER FOR SUBSTANCE ABUSE TREATMENT COMPREHENSIVE CARE MODEL The Center for Substance Abuse Treatment (CSAT) offers a detailed framework for matching patient needs with services in public sector programs. These patients typically have far more complex practical problems (e.g., housing, medical, educational, vocational) and often require more comprehensive services to stabilize their psychosocial functioning. In 1990, CSAT began (as the Office for Treatment Improvement) with the task of expanding the availability of effective services for addiction treatment. A key element in CSAT’s mission is to facilitate the application of the vast body of knowledge generated by the research institutes, NIDA, and the National Institute on Alcohol Abuse and Alcoholism. This necessitated engaging the system of state and local government agencies and public and private treatment providers responsible for the delivery of addiction treatment services (Primm, 1990). In an effort to upgrade the standard of care, CSAT articulated in detail the ingredients in effective treatment for the population it serves. Guidelines for model treatment programs were disseminated widely by CSAT through vehicles such as its request for applications for funds, treatment improvement protocols, and various other publications carrying a range of economic and other incentives. These guidelines may prove useful for those trying to select either a public or private sector program for a particular patient. The guidelines include comprehensive assessment, rapid intake, provision of medical care and health education, random drug testing, pharmacotherapeutic interventions, a variety of types of counseling, peer support groups, liaison services, social and recreational activities, housing, clinical supervision, and evaluation of outcomes. A “one-stop shop” is considered the most desirable, but services are often obtained through collaboration with other community organizations. Thus, AOD use is the ticket through the door, but the goal is to attend to the needs of the whole person. Implementation of these guidelines was imperfect, but the impact was to enlarge the vision of treatment providers and map out a process for upgrading quality. Although not all of these 114 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 115 DETERMINING APPROPRIATE TREATMENT services are necessary for higher functioning patients, this is a useful framework to help evaluate the strengths and limits of particular programs. Copyright American Psychological Association. Not for further distribution. AMERICAN SOCIETY OF ADDICTION MEDICINE PATIENT PLACEMENT CRITERIA Clinicians in the private sector rely on a variety of guidelines in selecting appropriate settings. Decision making takes into account various barriers to access, particularly financial limitations. Those with health insurance coverage have access to different types of programs than those who do not, though the relationship among quality, cost, and outcome is often elusive. Programs with fine reputations and impressive staffing do not necessarily produce outcomes that are superior to those that occur in populations with good prognostic factors at the outset. Though assessments are conducted, placement often has more to do with ideology and availability of reimbursement rather than on empirically derived matching criteria. Outcome data have often emanated from the marketing department and have not stood up to rigorous scrutiny. Communities vary in the options available for the indigent population; federal funding provides more opportunities in some locations than others. Recent efforts are intended to systematize this process and strengthen its empirical database. ASAM has refined a biopsychosocial model to specify the treatment which that matches the patient’s clinical severity. This necessitates accurate assessment of the nature and severity of the patient’s medical, psychological, and social problems and the availability of services to respond to the needs identified. ASAM’s goal is to arrive at uniform PPC to determine appropriate levels of care. The latest revision addresses the needs of patients with co-occurring disorders (recognized as the norm, not the exception) and strengthens the criteria for adolescents (ASAM, 2001). The following dimensional criteria are used to select levels of care (Mee-Lee & Schuman, 2009): 䡲 䡲 acute intoxication and/or withdrawal potential, coexistence of biomedical conditions or complications, 115 12370-05_CH04_rev.qxd 2/16/11 10:50 AM Page 116 TREATING PATIENTS WITH ALCOHOL AND OTHER DRUG PROBLEMS 䡲 Copyright American Psychological Association. Not for further distribution. emotional/behavioral conditions and complications (e.g., psychiatric conditions, psychological or emotional/behavioral complications of known or unknown origins, poor impulse control, changes in mental status, transient neuropsychiatric complications), 䡲 readiness to change, 䡲 recovery environment, and 䡲 recovery/living environment. These criteria are used to determine an appropriate level of early intervention, outpatient, intensive outpatient, inpatient, or residential care. Staffing patterns and available services are described in detail for each level of care. The PPC represent a basic framework that encourages the use of multidimensional assessments to make placement decisions and provides criteria sufficiently objective to facilitate research. The PPC are expected to be elaborated more fully and to be continuously validated through empirical research. CONCLUSION There are a variety of conceptual frameworks used in the addiction field to determine appropriate treatment. The problem–service matching strategy permits assessment, quality assurance, and outcome evaluation to be accomplished in a relatively straightforward manner. The CSAT comprehensive care model offers a way of identifying basic elements of treatment that can be found in a wide variety of settings. ASAM’s PPC are widely used as a means of determining what level of care is appropriate for the patient. All these frameworks are used, more or less explicitly, by practitioners in the addiction field. In the arena of coerced treatment, state-of-the-art practices combined with adequate evaluation will be important to justify allocating resources to treatment rather than to a purely punitive approach. Clinicians will increasingly find themselves interacting with these systems and will hopefully be able to meet the collaborative challenge. 116 1. ACA Code of Ethics Review the ACA Code of Ethics website. URL: http://www.counseling.org/knowledge-center/ethics 2. Online Assessment Measures Explore the "Online Assessment Measures," located on the American Psychiatric Association website. You will be referring to this site when completing the assignment. URL: http://www.psychiatry.org/practice/dsm/dsm5/online-assessment-measures 3. Utilizing the Assessment Instruments Review "Utilizing the Assessment Instruments." 4. Determining Appropriate Treatment Read “Determining Appropriate Treatment,” by Margolis & Zweben, from American Psychological Association (2011). URL: https://lopes.idm.oclc.org/login?url=http://search.ebscohost.com.lopes.idm.oclc.org/login.aspx ?direct=true&db=pzh&AN=2010-21509-004&site=ehost-live&scope=site 5. Collaborative Family Healthcare Association Commentary on the Joint Principles: Integrating Behavioral Health Care into the Patient-Centered Medical Home Use the following as a resource: "Collaborative Family Healthcare Association Commentary on the 'Joint Principles: Integrating Behavioral Health Care into the Patient-Centered Medical Home,'" by Runyan & Khatri, from Families, Systems, & Health (2014). URL: https://lopes.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=p dh&AN=2014-24217-006&site=eds-live&scope=site 6. Addressing Asian American Mental Health Disparities: Putting Community-Based Research Principles to Work Use the following as a resource: "Addressing Asian American Mental Health Disparities: Putting Community-Based Research Principles to Work," by Okazaki, Kassem, A. M., & Tu, from Asian American Journal of Psychology (2014). URL: https://lopes.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=p dh&AN=2014-12688-002&site=eds-live&scope=site 7. Some Like It Specific: The Difference Between Treatment Goals of Anxious and Depressed Patients Read “Some Like It Specific: The Difference Between Treatment Goals of Anxious and Depressed Patients," by Grosse Holtforth, Wyss, Schulte, Trachsel, & Michalak, from Psychology & Psychotherapy: Theory, Research, & Practice (2009). URL: https://lopes.idm.oclc.org/login?url=http://search.ebscohost.com/login.aspx?direct=true&db=p syh&AN=2009-11615-004&site=ehost-live&scope=site 8. Case Formulation and the Diagnostic Process Review the “Case Formulation and the Diagnostic Process” media piece in preparation for this week’s discussion questions. URL: https://lc.gcumedia.com/mediaElements/gcu-sequenceapplication/v3.1/#/showcase/sequence/39/view 9. Co-occurring Disorders Visit the SAMHSA website to learn about the importance of coordination and collaboration with mental health services. URL: http://media.samhsa.gov/co-occurring/topics/healthcare-integration/index.aspx
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