However, there has been limited independent research on the costs and benefits of patient matching, and managed care providers and others are matching patients to treatments without empirical evidence that the matching they perform yields the most cost-effective outcomes Hser, Further, there is limited research on the optimal, most cost-effective configuration of services for different groups of patients. Yet some managed care contracts place severe limits on the addiction-focused services e.
In some cases, state guidelines require separate licensing for drug abuse and mental health services and separate administration of drug abuse treatment from psychiatric, medical, family, and other related services. The result of these practices can be less service delivery McLellan et al. McLellan, University of Pennsylvania, personal communication, and may defeat the principle of matching patients to the most effective treatments.
A related issue is treatment of patients with co-occurring psychiatric disorders and drug abuse. The prevalence of co-occurring disorders is much higher in this population than in the general population Regier et al. These patients are an important population because they are more expensive to treat, they usually require more complex and costly interventions, and they relapse more frequently Garnick et al. A long-standing problem has been the difficulty in correctly identifying psychiatric disorders that occur in drug abusers.
Drug-produced psychiatric disorders can result from acute drug effects, chronic intoxication, drug withdrawal, or effects that persist for months or years after detoxification has been completed Woody et al. Examples of psychopathology resulting from acute drug effects are alcohol-induced depression, stimulant-induced psychoses, or withdrawal-induced depression and anxiety.
Examples of persistent drug effects are dementia associated with chronic alcohol, sedative, or inhalant dependence, or ''flashbacks" from hallucinogens such as lysergic acid diethylamide LSD APA, Research has clearly demonstrated that drug-produced psychiatric disorders can appear identical to primary, independent psychiatric disorders. Differentiation on the basis of presenting signs and symptoms alone is often impossible APA, Correct identification is critical because it has important treatment implications.
Primary psychiatric disorders tend to run a long-term course and require extended treatment. Drug-produced psychiatric disorders tend to follow the course of the drug abuse; usually resolve when the drug abuse remits; and often need only observation, supportive counseling, or short-term pharmacotherapy. Additional study of persistent drug-produced psychiatric disorders e. Among persons with drug abuse or dependence, the rates of depression reach 26 percent, a higher rate than that found in the general population Regier et al.
Progress has been made in the treatment of depression in clients with opioid or alcohol dependence.
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Some of this depression may be drug induced and resolve with sustained abstinence Schuckit, Several well-controlled studies have shown that antidepressant pharmacotherapies, such as desipramine or imipramine, can be very helpful with carefully selected depressed patients who are drug dependent Nunes et al. However, due to the possible contribution of the drug abuse to the development of depression, there has been some controversy about the conditions under which antidepressants and other pharmacotherapies should be used in this population. Few studies, however, have been performed on the use of pharmacotherapies and psychotherapies for other co-occurring psychiatric disorders.
One controversial group of pharmacotherapies for anxiety disorders among patients with drug abuse has been benzodiazepines. They are generally considered safe and effective for a range of anxiety disorders and are among the most widely used pharmacotherapies Tyrer, However, there is clear evidence that some benzodiazepines have a significant abuse liability Sellers et al. Consequently, the use of benzodiazepines in patients with a history of drug abuse or dependence is often judged to be contraindicated. However, not all benzodiazepines are equally prone to abuse. Medications such as oxazepam, clorazepate, or others with longer duration to onset of peak effect not only might be useful in treating patients with co-occurring anxiety, but may have little risk of abuse when taken orally.
Studies to determine the usefulness of benzodiazepines with slow onset to peak effects for patients with drug abuse and anxiety disorders would be helpful in providing data on this issue. Additionally, since U. For example, a medication intended to prevent relapse to cocaine dependence should be tested for adverse consequences when used in combination with alcohol or opiates since these drugs are commonly used together. This is an area in which the behavioral models discussed in Chapter 2 could make significant contributions.
Further, pharmacokinetic studies of medications are typically carried out in healthy individuals, whereas many drug abusers have multiple health problems. Thus, the interactions among abused drugs, medications for drug abuse or dependence, and medications for psychiatric and medical problems may be altered in drug abusers. To optimize treatment strategies and to prevent adverse health outcomes, pharmacokinetic studies are needed to determine these possible interactions.
Additionally, comparative studies of pharmacotherapies and psychotherapies for specific, well-defined depressive or anxiety disorders with this population drug abuse and psychiatric disorders could provide important data about the most appropriate therapies. There is a dearth of research on drug-abusing women, prisoners, and adolescents. For reasons discussed below, it is extremely important for those populations to gain access to, enter, and remain in treatment. Most of the research opportunities center on treatment access, retention, and effectiveness.
There are large gaps in our knowledge of these areas, much of which is attributable to methodological difficulties. The health consequences of drug abuse can be more serious for women than for men, in spite of the fact that fewer women abuse drugs. Women can contract HIV through injection drug use or prostitution to purchase drugs. Maternal drug use can result in transmitting the disease to their fetus, premature delivery with serious complications, and impairments in parenting.
Yet research has documented more barriers to treatment entry for female than for male alcoholics Weisner and Schmidt, ; Schmidt and Weisner, Some of the obstacles for women are the cost of treatment, the possible loss of custody of their children, and the lack of child care Beckman, Similar barriers to treatment may be operating for male drug abusers, but the extent of the problem is unknown.
A recent study of more than 12, clients in treatment found that women tended to drop out of treatment at higher rates than men Mammo and Weinbaum, It is possible that women have difficulty making child care arrangements, fear retribution, or feel uncomfortable talking about their problems when being treated in programs that are predominantly male.
Some programs, in an attempt to overcome these barriers, have experimented with women-only groups and with on-site facilities for child care. Studies have also shown that women with drug abuse disorders typically have more psychiatric disorders including depression and anxiety than males Blume, Many drug-dependent women have been sexually abused as children, suffer from posttraumatic stress disorder, and have significant problems forming healthy relationships with males SAMHSA, b. Abusive relationships with drug-abusing males are common, sometimes characterized by situations in which the male exerts control by providing drugs.
These complex issues indicate that psychiatric assessment and treatment constitute a particularly important aspect of drug abuse treatment for women. Few studies have been done to examine the effect of integrating psychiatric treatment into the ongoing services of programs that treat drug-abusing women. In spite of those problems, research shows that when women remain in treatment, they benefit just as much as men do Sanchez-Craig et al.
Methadone maintenance programs for pregnant women are the best studied, but outcomes in many other settings indicate that women benefit at least as much as men from the range of treatments that are currently available Hubbard et al.
There is a dearth of studies on programs that deliver services tailored to women's needs. Problems continue to be greatest for pregnant women. In the past, many treatment programs automatically excluded pregnant women because of liability concerns or concerns about lack of expertise with medical complications of pregnancy. Some areas of the country have enacted laws that classify drug abuse during pregnancy as a form of child abuse, which would lead to the placement of children in foster care.
These laws do not seem to reduce drug abuse, but they may have the negative effect of discouraging pregnant drug users from seeking treatment see Chapter Exclusion of pregnant women from treatment programs is beginning to diminish, however.
Acupuncture therapy for drug addiction
A recent survey of drug treatment programs in five cities revealed that the majority of programs percent accepted pregnant women. Fewer programs, however, accepted women who were Medicaid recipients, and even fewer programs provided child care Breitbart et al. When pregnant women succeed in gaining access to treatment, they face yet another hurdle—the lack of pharmacotherapies specifically approved for use in pregnancy IOM, b. This problem is true for medications of all kinds, not just for those used in drug abuse treatment.
Pharmaceutical firms rarely, if ever, seek Food and Drug Administration FDA approval for use of their products in pregnancy, mostly because of liability concerns. When pregnant heroin drug users, for example, need treatment to reduce drug use and the risk of HIV transmission to themselves and their unborn, their doctors are strongly discouraged by federal treatment regulations and by the manufacturer from prescribing LAAM. According to federal treatment regulations, pregnant women are offered methadone, which is not formally approved by the FDA for use in pregnancy.
FDA has drafted guidelines recommending that future studies of antiaddiction medications include women, but the guidelines do not provide advice for a mechanism dealing with increased risk for product liability Woody et al. Treatment programs have recently become more prominent in some correctional settings, with therapeutic communities among the most common modalities.
The therapeutic community provides a total treatment environment isolated from the rest of the prison population—separated from the drugs, the violence, and the norms and values that mitigate against treatment, habilitation, and rehabilitation. Treatment programs based in correctional settings sometimes include aftercare in the community after release from prison. Although therapeutic communities appear to be the most visible drug abuse treatment programs in correctional settings, there are numerous other modalities, many of which are grounded in individual and group counseling and step approaches.
However, there is limited information about these programs in the drug abuse literature. There are virtually no methadone maintenance programs offered in correctional settings, which is most likely a result of policies to eliminate the availability of a medication that is itself a controlled drug. Most treatment of drug-involved offenders takes place in community-based settings as a condition of parole or probation or in lieu of prison.
Treatment in the community is made possible through programs that link the criminal justice system with specialty drug abuse treatment programs. Other programs linking treatment to parole and probation have experienced favorable results Chavaria, ; Van Stelle et al. Although there are extensive studies of drug-involved offenders who are treated effectively in community settings, there is a dearth of information about drug treatment programs in prisons or about the best means of treating drug abusers in these settings.
What is known is that for the few prisoners who succeed in gaining access to a limited number of prisonbased therapeutic communities, treatment is effective. Many in the drug treatment community believe that prisoners have the most profound treatment system needs in light of the pervasive violence and widespread availability of illicit drugs within the prison system. The co-occurrence of addictive and severe psychiatric disorders is also highest in the prison population Regier et al. Adolescents are also vulnerable to the consequences of drug abuse, including health effects, accidents and injuries, involvement with violence resulting from illegal activities, and the transmission of HIV Czechowicz, Adolescent drug abusers differ from adult drug abusers in several ways that are significant for treatment.
The majority of adolescent drug abusers have a shorter history of drug abuse; have less severe symptoms of tolerance, craving, and withdrawal; and usually do not have the long-term physical effects of drug abuse Kaminer, However, they are at the greatest risk for developing lifelong patterns of drug abuse Dusenbury et al.
Adolescents accounted for about There is increasing recognition of the need to implement and evaluate treatment programs designed specifically for adolescents IOM, b. A new study of treatment effectiveness for 3, adolescents enrolled in standard treatment programs is under way, with findings to be reported in R. There are additional opportunities to design and evaluate the effectiveness of special programs with services tailored to adolescents.
Results from such studies will enable the development of targeted treatment and prevention programs. Substantial progress has been made during the past 20 years in our knowledge of drug abuse treatment. Continued research on drug abuse treatment is needed in many priority areas. The committee recommends that the appropriate federal and private agencies continue to support research to improve and evaluate the effectiveness of drug abuse treatment.
This includes studies on optimal strategies for matching patients to the most appropriate treatment modalities; development of medications for the treatment of drug abuse and dependence; the efficacy of pharmacotherapies and psychosocial therapies to treat individuals with co-occurring psychiatric disorders and drug abuse; the natural history of HIV infection among drug users and effective models of health care delivery for HIV-infected drug abusers; and the efficacy of treatment programs designed toward addressing the needs of special populations i.
Victims of early-life trauma, abuse, neglect, and violence are more likely as adults to develop personality disorders e. A cost-benefit analysis assigns monetary values to all of the costs and benefits of a program or policy to determine whether the benefits outweigh the costs. A cost-effectiveness analysis strives to identify which of the different programs can attain a desired objective at the lowest cost Center of Alcohol Studies, Directly observed therapy for tuberculosis is the most effective means of ensuring compliance and preventing the spread of tuberculosis Bayer and Wilkinson, ; Chaulk et al.
Medications, including methadone and clonidine, are often used to detoxify drug abuse patients and to manage withdrawal symptoms. Turn recording back on. National Center for Biotechnology Information , U. Search term.
Treatment Options Treatment is provided in a variety of settings, and within each treatment setting a range of interventions may be available e. Pharmacotherapy Pharmacotherapies have been developed or are being tested for the full spectrum of clinical needs: overdose, detoxification, l dependence, and relapse prevention. Psychosocial Treatments Psychosocial treatments include counseling, psychotherapy, and cognitive skills development.
Treatment Effectiveness The effectiveness of treatment for drug addictions has been reviewed extensively see Simpson and Sells, , ; IOM, b, a,b; Prendergast et al. Treatment Cost-Benefit and Cost-Effectiveness Drug abuse treatment is a judicious public investment and is less expensive than the alternatives Figure 8.
Clinical Assessment and Diagnostic Differentiation Research advances in diagnosis have made it possible to conduct detailed assessments of clients in treatment. Medical Complications Although injection drug users IDUs display the host of typical HIV related illnesses and complications, there are some unique differences from non-drug-using HIV-infected populations. TABLE 8. Health Care Services As research continues to address the best treatment modalities for HIV-infected drug abusers, studies are needed on the issues of access and utilization of treatment that are unique to that population.
Matching Patients to Treatments Matching patients to treatments means tailoring treatments to patient needs in an effort to improve outcomes, in contrast to giving the same treatment to all patients with the same diagnosis. Treatment of Patients with Co-Occurring Psychiatric Disorders and Drug Abuse A related issue is treatment of patients with co-occurring psychiatric disorders and drug abuse. Assessment and Diagnosis A long-standing problem has been the difficulty in correctly identifying psychiatric disorders that occur in drug abusers. Pharmacotherapy Among persons with drug abuse or dependence, the rates of depression reach 26 percent, a higher rate than that found in the general population Regier et al.
Special Populations There is a dearth of research on drug-abusing women, prisoners, and adolescents. Women The health consequences of drug abuse can be more serious for women than for men, in spite of the fact that fewer women abuse drugs. Prisoners Treatment programs have recently become more prominent in some correctional settings, with therapeutic communities among the most common modalities.
Adolescents Adolescents are also vulnerable to the consequences of drug abuse, including health effects, accidents and injuries, involvement with violence resulting from illegal activities, and the transmission of HIV Czechowicz, Effectiveness and costs of inpatient versus day hospital cocaine rehabilitation. Journal of Nervous and Mental Disease Treatments for cocaine dependence.
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Principles of Drug Addiction Treatment: A Research-Based Guide (Third Edition)
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New England Journal of Medicine 7 National Drug Control Strategy, The Effectiveness of Treatment for Drug Abuse. Stages and processes of self-change: Toward an integrative model of change. Toward a comprehensive model of change. Treating Addictive Behaviors: Process of Changes. New York: Plenum Press. Relapse prevention strategies in outpatient substance abuse treatment. Psychology of Addictive Behaviors Heterogeneity of psychiatric diagnoses in treated opiate addicts. Rydell C, Everingham S. Focusing on fundamental neurophysiological processes that overlap between drug addiction and other CNS disorders, this volume covers the translation of basic research into novel therapies, not only of drug addiction but a spectrum of related CNS disorders, including pain.
Provides a comprehensive overview of physiological, biochemical, and genetic pathways underlying drug addiction, and resultant efforts to develop novel treatment strategies dealing with drug addiction and other CNS disorders where the neurophysiological processes overlap, such as treatment of pain Focuses on the translation of fundamental addiction research to a variety of treatments Brings together scientists with wide ranging expertise see more benefits. Buy eBook. Buy Hardcover.
Buy Softcover. FAQ Policy. About this book Drug Addiction: From Basic Research to Therapy provides a comprehensive overview of physiological, biochemical, genetic and behavioral pathways underlying drug addiction.