Which Of The Following Services Has The Highest Likelihood Of Being A Covered Service?

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Chief intendance clinicians need to be familiar with available treatment resources for their patients who have diagnosed substance abuse or dependence disorders. The clinician's responsibility to the patient does not end with the patient'southward entry into formal treatment; rather, the physician may become a collaborative role of the treatment team, or, minimally, proceed to treat the patient'south medical weather during the specialized treatment, encourage continuing participation in the program, and schedule followup visits after treatment termination to monitor progress and assistance forbid relapse.

Agreement the specialized substance abuse treatment system, all the same, tin can be a challenging job. No single definition of treatment exists, and no standard terminology describes different dimensions and elements of treatment. Describing a facility as providing inpatient care or convalescent services characterizes merely one aspect (albeit an important one): the setting. Moreover, the specialized substance abuse treatment system differs effectually the land, with each Country or metropolis having its own peculiarities and specialties. Minnesota, for example, is well known for its array of public and private alcoholism facilities, more often than not modeled on the stock-still-length inpatient rehabilitation programs initially established by the Hazelden Foundation and the Johnson Institute, which subscribe to a stiff Alcoholics Anonymous (AA) orientation and take varying intensities of aftercare services. California also offers a number of community-based social model public sector programs that emphasize a 12-Step, self-help approach as a foundation for life-long recovery. In this chapter, the term treatment volition be limited to describing the formal programs that serve patients with more serious alcohol and other drug problems who practice not respond to brief interventions or other office-based management strategies. It is as well causeless that an in-depth cess has been conducted to establish a diagnosis and to determine the most suitable resource for the individual's detail needs (see Chapter 4).

Directories of Local Substance Abuse Treatment Systems

The first step in understanding local resource is to collect information about the specialized drug and alcohol handling currently bachelor in the customs. In most communities, a public or individual bureau regularly compiles a directory of substance abuse treatment facilities that provides useful information about program services (e.g., blazon, location, hours, and accessibility to public transportation), eligibility criteria, cost, and staff complement and qualifications, including linguistic communication proficiency. This directory may be produced by the local wellness department, a council on alcoholism and drug corruption, a social services organization, or volunteers in recovery. Additionally, every Land has a single State-level alcohol and other drug authority that usually has the licensing and programme review authority for all handling programs in the State and often publishes a statewide directory of all alcohol and drug handling programs licensed in the State. Some other resource is the National Council on Booze and Drug Dependence, which provides both cess or referral for a sliding calibration fee and distributes gratuitous information on handling facilities nationally. Also, the Substance Abuse and Mental Wellness Services Assistants distributes a National Directory of Drug Corruption and Alcoholism Treatment and Prevention Programs (i-800-729-6686).

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

Goals and Effectiveness of Treatment

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

Reducing substance corruption or achieving a substance-free life
Maximizing multiple aspects of life performance
Preventing or reducing the frequency and severity of relapse

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

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

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

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

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

No single handling arroyo is effective for all persons with booze problems, and in that location is no overall advantage for residential or inpatient treatment over outpatient care.
Treatment of other life problems associated with drinking improves outcomes.
Therapist and patient (and problem) characteristics, handling process, posttreatment aligning factors, and the interactions among these variables as well decide outcomes.
Patients who significantly reduce alcohol consumption or become totally abstinent unremarkably better their functioning in other areas (Establish of Medicine, 1990).

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

Treatment Dimensions

The terminology describing the different elements of handling treat people with substance utilize disorders has evolved every bit specialized systems have developed and as handling has adapted to changes in the wellness care arrangement and financing arrangements. Of import differences in language persist between public and private sector programs and, to a lesser extent, in treatment efforts originally developed and targeted to persons with booze- as opposed to illicit drug-related issues. Programs are increasingly trying to meet private needs and to tailor the program to the patients rather than having a single standard format with a fixed length of stay or sequence of specified services.

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

Handling Models and Approaches

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

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

These 3 models have been woven into a biopsychosocial approach in most contemporary programs. The four major treatment approaches now prevalent in public and private programs are

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

Handling Settings

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

Initially, however, it is important to match the patient'due south needs to a treatment setting. The goal is to place patients in the least restrictive environment that is still safe and constructive and and so motion them along a continuum of intendance as they demonstrate the chapters and motivation to cooperate with handling and no longer need a more structured setting or the types of services offered only in that surroundings (i.e., medical or nursing supervision and room and board). Move, withal, is not always in the direction of less intensive care equally relapse or failure to respond to 1 setting may require moving a patient to a more restrictive environment (American Psychiatric Clan, 1995; Landry, 1996).

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

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

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

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

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

Handling Techniques

Within each handling approach, a multifariousness of specialized treatment techniques (also known as elements, modalities, components, or services) are offered to achieve specified goals. Each patient is likely to receive more one service in various combinations as handling proceeds. The accent may change, for example, from pharmacological interventions to relieve withdrawal discomforts in the initial stage of treatment to behavioral therapy, self-help support, and relapse prevention efforts during the primary care and stabilization stage and standing AA participation afterwards discharge from formal treatment. A patient in methadone maintenance treatment volition receive pharmacotherapy throughout all phases of intendance, in addition to other psychological, social, or legal services that are selected every bit appropriate for achieving specified private treatment goals. Again, the categorization of these techniques is not standardized and the terminology differs amid programs. Still, the main elements are

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

Pharmacotherapy

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

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

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

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

Because prescribing psychotropic medications for patients with dual diagnoses is clinically complex, a conservative and sequential 3-stage approach is recommended. For a person with both an anxiety disorder and booze dependence, for example, nonpsychoactive alternatives such every bit practise, biofeedback, or stress reduction techniques should exist tried first. If these are not constructive, nonpsychoactive drugs such as buspirone (or SSRIs for depression) should be administered. Simply if these do non convalesce symptoms and complaints should psychoactive medications be provided. Proper prescribing practices for these dually diagnosed patients encompass the following six "Ds" (Landry et al., 1991a):

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

Psychosocial Interventions

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

Grouping therapy is one of the most often used techniques during primary and extended care phases of substance abuse treatment programs. Many unlike approaches are used, and at that place is little agreement on session length, coming together frequency, optimal size, open or airtight enrollment, duration of grouping participation, number or preparation of the involved therapists, or style of group interaction. Near controversial is whether confrontation or support should exist emphasized.

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

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

Behavioral Therapies

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

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

Relapse prevention helps patients start recognize potentially loftier-gamble situations or emotional "triggers" that have led to substance corruption, and so acquire a repertoire of substitute responses to cravings. Patients besides develop new coping strategies for treatment external stressors and acquire both to accept lapses into substance abuse as function of the recovery process and to interrupt them before adverse consequences ensue. Controlled studies have establish relapse prevention to be every bit effective equally other psychosocial treatments, particularly for patients with comorbid sociopathy or psychiatric symptoms (American Psychiatric Clan, 1995). Cognitive-behavioral strategies, the improvement of self-efficacy, self-command training, and cue exposure and extinction accept all been used as components of relapse prevention. In contempo years, relapse prevention has become a vital part of most handling efforts, learned during the intensive stage of handling and practiced during aftercare (Institute of Medicine, 1990; American Psychiatric Clan, 1995; Landry, 1996).

Self-Assist Groups

Common back up, 12-Step groups such as Alcoholics Bearding, Narcotics Anonymous, Cocaine Anonymous or more contempo alternatives (eastward.grand., Rational Recovery and Women for Sobriety) are the courage of many treatment efforts as well as a major course of continuing care. While AA and related groups are widely used, the success of this technique has not been rigorously evaluated. Nevertheless, these fellowships apparently assistance persons at whatsoever point in the recovery process to change old beliefs patterns, react responsibly to drug cravings, maintain hope and determination to go and remain abstinent. Self-help groups can too assistance people build a new social network in a community of understanding peers, find satisfactory drug-free activities and recreational skills, establish healthy intimate relationships, and avoid stressful social situations and environments.

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

Patients who do non take the spiritual focus and abstinence orientation of AA may benefit from Rational Recovery groups or the Recovery Training and Cocky-Assistance (RTSH) programs in some communities. Patients who are prescribed psychotropic medications for comorbid psychiatric disorders (e.k., antidepressants or neuroleptics) or are maintained on methadone or LAAM must attend fellowships or groups where pharmacotherapy is accustomed equally advisable treatment. Immature persons, persons of color, and gays and lesbians frequently notice more than acceptance in groups where at to the lowest degree some members have similar characteristics. Friends and relatives of persons in recovery and of those who refuse handling tin can benefit from Al-Anon, Alateen, Nar-Anon, and similar groups that offering support and didactics about the affliction of alcoholism or other forms of substance corruption and teach participants to curb their own "enabling" behaviors. Improvements in substance-abusing behavior amidst meeting participants are associated with frequent attendance, obtaining a sponsor, "working" the 12 steps, and leading meetings (National Institute on Drug Corruption, 1993; American Psychiatric Clan, 1995; Landry, 1996).

Other Primary and Ancillary Services

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

The Treatment Process

All the components, approaches, techniques, and settings discussed in a higher place must be monitored and adjusted every bit treatment progresses. Primary intendance clinicians should sympathise the following aspects of appropriate intendance.

Repeating assessments to evaluate a patient'due south changing medical, psychological, social, vocational, educational, and recreational needs, specially every bit more basic and acute deficits or crises are resolved and new problems emerge or become amenable to handling. For instance, homelessness or acute withdrawal symptoms will need to be treated before family interactions tin exist identified or resolved. Suicidal thoughts or deportment will need prompt attention whenever they sally.
Developing a comprehensive treatment programme that clearly reflects all identified issues, has explicit goals and strategies for their attainment, and specifies techniques and services to be provided by designated specialists at detail frequencies or intensities.
Monitoring progress and clinical status through written notes or reports that describe responses to treatment approaches and outcomes of services provided, including counseling sessions, group meetings, urine or other biological testing, concrete examinations, administered medications, and referrals for other care. Each patient should have an individual handling record that includes all appropriate materials yet maintains the patient's privacy.
Establishing a therapeutic alliance with an empathic chief therapist or counselor who tin can gain the confidence and trust of the patient and pregnant others or family unit members and accept responsibility for continuity of care. This is particularly important in the early on stages of treatment to foreclose dropout and encourage participation.
Providing education to help the patient and designated others understand the diagnosis, the etiology and prognosis for the disorder, and the benefits and risks of predictable treatment(s). Patients with special issues volition need more than all-encompassing information. Equally with other medical treatments, informed consent to potentially risky procedures should always be obtained (American Psychiatric Association, 1995).

Treatment Programs for Special Populations

A variety of substance corruption treatment programs have been developed to encounter the particular needs of special populations, including women, meaning and postpartum mothers, adolescents, elderly persons, members of various minority groups, public inebriates or homeless persons, drinking drivers, and children of alcoholics. These special programs are institute in the public and private sectors and include both residential and ambulatory care settings using therapeutic community, Minnesota model, outpatient drug-free, and methadone maintenance approaches. Researchers have not confirmed that these separate programs for special populations are superior to mainstream efforts with respect to outcomes, and experts question their cost-effectiveness and applicability to heterogeneous groups with overlapping characteristics that complicate placement of a item patient in one grouping over another. Clinicians must be wary of defining any patient in relation only to age, gender, racial grouping membership, or functional characteristics, especially since other patient-related variables accept been found to have greater implications for successful outcomes (e.1000., addiction severity, employment stability, criminal involvement, educational level, and socioeconomic condition). Nonetheless, clinical observations do betoken that treatment of special populations may be enhanced if their particular needs are considered and met. Notable components of these divide programs for special populations are equally follows (Plant of Medicine, 1990; American Psychiatric Association, 1995; Landry, 1996).

Women are more likely than men to have comorbid depressive and anxiety disorders, including posttraumatic stress disorders as a outcome of by or current concrete or sexual abuse. Although women tended in the past to become involved with dissimilar substances than men (eastward.1000., prescription drugs), their drug use patterns accept become more than like to males' in recent years. Treatment components can accost women'due south special issues and needs for child intendance, parenting skills, building healthy relationships, avoiding sexual exploitation or domestic violence, preventing HIV infection and other sexually transmitted diseases, and enhanced cocky-esteem. A high ratio of female staff and same-sex groups are also thought to amend treatment retention.

Meaning and postpartum women and their dependent children have numerous special needs, including prenatal and obstetrical intendance, pediatric intendance, noesis of kid development, parenting skills, economic security, and safe, affordable housing. Pregnant women -- and those in their childbearing years -- need to know almost birth control likewise as the risks to pregnancy and fetal evolution of continuing substance use (east.k., spontaneous abortion, abruptio placentae, preeclampsia, early on and prolonged labor, birth defects, dumb fetal growth, depression birth weight, stillbirth, and neonatal withdrawal syndrome). Methadone maintenance throughout pregnancy and the postpartum flow is often the treatment of choice for opioid-dependent women with seriously compromised lifestyles who are non probable to remain abstemious. However, many other medications used in the treatment of addiction, including disulfiram and naltrexone, should not exist prescribed for pregnant substance abusers. Meet Appendix A and *TIP 2, Pregnant, Substance-Using Women (CSAT, 1993a).

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

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

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

Confidentiality

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

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

The Role of the Main Care Clinician Throughout Treatment

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

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

Completing specialized treatment is just the outset of the patient's recovery process. Primary care clinicians should continue to enquire their patients near the problem they were treated for at every office or clinic visit. During these visits, the clinician can monitor the potential for relapse and accept any necessary steps to forestall slips from occurring (Chocolate-brown, 1992).

The primary care clinician as well has a responsibility to patients who turn down to accept referral to handling or drib out before completion. In such cases, the primary care clinician should

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