Substance Use

Disorders
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Substance Use
Disorders
Edited by

Antoine Douaihy, MD
Western Psychiatric Institute and Clinic
Pittsburgh, PA

Dennis C. Daley, PhD

Western Psychiatric Institute and Clinic
Pittsburgh, PA

1
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Library of Congress Cataloging-in-Publication Data
Substance Use Disorders / edited by Antoine Douaihy, Dennis C. Daley.
p. ; cm. — (Pittsburgh Pocket Psychiatry series)
Includes bibliographical references and index.
ISBN 978–0–19–989816–9 (alk. paper) — ISBN 978–0–19–933719–4 (alk. paper) —
ISBN 978–0–19–933720–0 (alk. paper)
I. Douaihy, Antoine B., 1965– II. Daley, Dennis C. III. Series: Pittsburgh Pocket Psychiatry
series.
[DNLM: 1. Substance-Related Disorders. WM 270]
RC564
616.86—dc23 2013012121

The science of medicine is a rapidly changing field. As new research and clinical
experience broaden our knowledge, changes in treatment and drug therapy occur.
The author and publisher of this work have checked with sources believed to be
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in light of the possibility of human error or changes in the practice of medicine,
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 v

Series Introduction

We stand on the threshold of a new Golden Age of clinical and behav-

ioral neuroscience with psychiatry at its fore. With the Pittsburgh Pocket
Psychiatry series, we intend to encompass the breadth and depth of our
current understanding of human behavior in health and disease. Using the
structure of resident didactic teaching, we will be able to ensure that each
subject area relevant for both current and future practicing psychiatrists is
detailed and described. New innovations in diagnosis and treatment will
be reviewed and discussed in the context of existing knowledge, and each
book in the series will propose new directions for scientific inquiry and
discovery. The aim of the series as a whole is to integrate findings from
all areas of medicine and neuroscience previously segregated as “mind”
or “body,” “psychological” or “biological.” Thus, each book from the
Pittsburgh Pocket Psychiatry series will stand alone as a standard text for
anyone wishing to learn about a specific subject area. The series will be
the most coherent and flexible learning resource available.

David J. Kupfer, MD
Michael J. Travis, MD
Michelle S. Horner, DO
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 vii

About Substance Use

Disorders

We are pleased to offer you this book, Substance Use Disorders, which
focuses on the common clinical problem of substance use disorders, and
one in which health care practitioners can make a difference. The chapters
were written by highly experienced researchers, educators, and clinicians
in diverse medical, academic, and clinical settings. This essential volume
explores what key clinical issues, treatment, and prevention would look
like if they were to be based on the latest science available. It also pro-
vides a menu of evidence-based approaches and practical recommenda-
tions for reduction of the huge personal and societal burden associated
with substance use disorders. Throughout this book, we have been careful
about the terminology to describe clinical conditions rather than label-
ing individuals. In describing conditions, we have adhered to the current
terms of “substance use disorder” as well as “alcohol and drug problems,”
“addiction,” and “dependence.” And for people who are under profes-
sional care, we have used the terms “patient” as well as “client,” “people,”
and “individuals.” Similarly, for practitioners who provide treatment for
substance use disorders, we have used “trainees,” “fellows (addiction),”
“clinicians,” “practitioners,” and “residents.”

The development and editing of this book was supported in part by the
National Institute on Drug Abuse grant # 5U10DA020036-08.
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 ix

Contents

1 Epidemiology and Diagnostic Classification

of Substance Use Disorders 1
Adam Ligas and Antoine Douaihy

2 Neurobiology of Substance Use Disorders 17

Antoine Douaihy and Jody Glance

3 Psychological Aspects of Substance Use

Disorders, Treatment, and Recovery 27
Michael Flaherty

4 Socioenvironmental Aspects of Substance

Use Disorders 63
Marilyn Byrne and Laura Lander

5 Substances of Abuse and Their

Clinical Implications 93
James H. Berry, Carl R. Sullivan, Julie Kmiec, and Antoine Douaihy

6 Screening, Diagnostic Approaches, and

Essential Elements of Treatment for
Substance Use Disorders 137
Thomas M. Kelly and Antoine Douaihy

7 Pharmacotherapy of Substance Use Disorders 169

Julie Kmiec, Jack Cornelius, and Antoine Douaihy

8 Psychosocial Interventions for Substance

Use Disorders 213
Dennis C. Daley and Lisa Maccarelli
x CONTENTS

9 Relapse Prevention 247

Dennis C. Daley and Lisa Maccarelli

10 Hepatitis C Virus, Human Immunodeficiency

Virus, and Substance Use Disorders 269
Shannon Allen and Antoine Douaihy

11 Co-occurring Disorders 283

Dennis C. Daley, Antoine Douaihy

12 Adolescent Substance Use Disorders 311

Duncan B. Clark

13 Prevention and Harm Reduction Interventions 337

Inti Flores and Antoine Douaihy

Online Resources List for Substance

Use Disorders and Co-occurring Disorders 359

Index 387
 xi

Contributors

Shannon Allen, MD Jody Glance, MD

Department of Psychiatry Department of Psychiatry
University of Pittsburgh School University of Pittsburgh School
of Medicine of Medicine
Pittsburgh, PA Pittsburgh, PA
James H. Berry, DO Inti Flores, MD
Department of Psychiatry Department of Psychiatry
West Virginia University School University of California at
of Medicine San Francisco
Morgantown, WV San Francisco, CA
Marilyn Byrne, MSW Thomas M. Kelly, PhD
Department of Behavioral Department of Psychiatry
Medicine and Psychiatry University of Pittsburgh School
West Virginia University of Medicine
Morgantown, WV Pittsburgh, PA
Duncan B. Clark, MD, PhD Julie Kmiec, DO
Department of Psychiatry Department of Psychiatry
University of Pittsburgh School University of Pittsburgh School
of Medicine of Medicine
Pittsburgh, PA Pittsburgh, PA
Jack Cornelius, MD Laura Lander, MSW
Department of Psychiatry Department of Behavioral
University of Pittsburgh School Medicine and Psychiatry
of Medicine West Virginia University
Pittsburgh, PA Morgantown, WV
Dennis C. Daley, PhD Adam Ligas, MD
Department of Psychiatry Department of Psychiatry, Mercy
University of Pittsburgh School Behavioral Health System
of Medicine Pittsburgh, PA
Pittsburgh, PA
Lisa Maccarelli, PhD
Antoine B. Douaihy, MD Counseling Center
Department of Psychiatry University of Pittsburgh
University of Pittsburgh School Pittsburgh, PA
of Medicine
Pittsburgh, PA Carl R. Sullivan, MD
Department of Psychiatry
Michael Flaherty, PhD West Virginia University School
Clinical Psychologist and Founder of Medicine
Institute for Research Education Morgantown, WV
and Training in the Addictions
Pittsburgh, PA
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Substance Use
Disorders
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 Chapter 1 1

Epidemiology and
Diagnostic Classification
of Substance Use
Disorders
Adam Ligas and Antoine Douaihy

Key Points 2
Epidemiology of Substance Use Disorders 4
DSM Classification of Substance Use Disorders 6
Acknowledgment 12
References and Suggested Readings 14
2 Substance Use Disorders

Key Points
• Understanding the initiation, development, and maintenance of
substance use disorders is a complex problem.
• The 12-month prevalence rates of substance dependence in U.S. adults
are 12% for alcohol and 2% to 3% for illicit drugs.
• In U.S. youth, the lifetime prevalences for substance use disorders are
8% for alcohol and 2% to 3% for illicit drug use.
• The increases in substance use disorders across adolescence into early
adulthood are significant.
• Genetic factors have a major influence on progression of substance
use to dependence, whereas environmental factors may play a
larger role in exposure, initiation, and continuation of use past an
experimental level.
• Proposed changes in the American Psychiatric Association’s Diagnostic
and Statistical Manual of Mental Disorders (APA-DSM), 5th edition,
include a new name of “Substance Use and Addictive Disorders,”
dropping of abuse and dependence as disease categories, addition of
“drug craving” as a criterion, and dropping of “encounters with law
enforcement” as a criterion.
• Substance use disorders occur along a continuum of severity.
The incidence and prevalence of substance use disorders (SUDs) continue to
present major costs to individuals, families, and societies at large. According
to the National Institute on Drug Abuse (NIDA, 2004), approximately
$484 billion is spent each year on substance abuse–related costs, including
treatment, health care expenditures, lost productivity, and crime. In addi-
tion to the public cost statistics, SUDs are associated with involvement in
risky impulsive behaviors, such as condom nonuse and sharing drug equip-
ment, and in subsequent medical and psychosocial consequences (Wallace,
2001). The high 12-month prevalence rates of substance dependence in
U.S. adults (12% for alcohol use and 2% to 3% for illicit drugs) approximate
those of other mental illnesses as well as chronic physical disorders with
significant public health impact. This chapter aims to provide an overview
of the epidemiological patterns of SUDs in the general population of adults
and adolescents and discusses the history of diagnoses in the American
Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders
(APA-DSM) and the evolving definitions and concepts of SUDs.
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4 Substance Use Disorders

Epidemiology of Substance
Use Disorders
Prospective Studies of Substance Use
Many prospective studies of population-based samples of youths and
young adults across the world have provided data regarding the risk fac-
tors for use and progression into problematic patterns (Fergusson et al.,
2008). Some studies have also examined the extent to which adolescent
substance, alcohol, and drug use predicted subsequent problematic use
of alcohol, and others provided data on the role of cannabis use patterns
and risk for progression of drug use (McCambridge et al., 2011; Swift et al.,
2012). For example, adolescents who engage in heavy episodic use of can-
nabis are at greater risk for subsequent illicit drug use (Patton et al., 2007).
Other studies examined the characteristics of polysubstance users
and identified cannabis, nicotine, and alcohol as substances used com-
monly together and in conjunction with other drugs (Fergusson et al.,
2008; Patton et al., 2007). Individuals who are polysubstance users are
also more likely to have SUDs (Merikangas et al., 1998). Some studies
looked at the consequences of substance use, such as the increased risk
for incident psychosis among cannabis users (Hall & Degenhardt, 2011).
NIDA, the National Institute on Alcohol Abuse and Alcoholism (NIAAA),
and the Services Administration for Mental Health and Substance Abuse
(SAHMSA) have provided significant data on tracking patterns of sub-
stance use and abuse and their consequences. For instance, data from
the Monitoring the Future Survey (MTF), which is a descriptive ongoing
study of the behaviors, attitudes, and values of American secondary school
students, college students, and young adults, included 46,482 participants
in 2010 (Johnston et al., 2011) and found increases in the overall rate of
illicit drug use for all grades (8th, 10th, and 12th). Older students (12th
graders) showed increases in the use of marijuana and high rates of alcohol
use (Johnston et al., 2011). The MTF does not evaluate the problematic
patterns of use.

Prevalence and Rates of Substance

Use Disorders in the United States
Adults
Moving beyond simply using licit and illicit drugs, three nationally represen-
tative surveys collect data on substance use prevalence in U.S. adults: the
National Comorbidity Survey Replication (NCS-R) (Kessler et al., 2004);
the National Epidemiological Survey on Alcohol and Related Conditions
(NESARC) (Grant et al., 2004); and the National Survey on Drug Use and
Health (NSDUH) (SAMHSA, 2011). These studies provide data on the
prevalence of substance abuse and dependence as defined by DSM-IV and
DSM-IV-TR. The prevalence of alcohol use disorders in the NESARC study
were greater than those estimated in the NCS-R survey: 4.7% and 3.8%
for 12 months and 17.8% and 12.5% for lifetime abuse and dependence,
respectively, in the NESARC and 3.1% and 1.3% for 12 months and 13.2%
 1 EPIDEMIOLOGY AND DIAGNOSTIC CLASSIFICATION 5

and 5.4% for lifetime abuse and dependence, respectively, in the NCS-R.
The estimates of drug use disorders were comparable in the two studies.
Youth
New findings from the nationally representative samples of youths
between the ages of 13 and 18 years showed that the lifetime prevalence
of alcohol use disorders is approximately 8% and that of illicit drug use
disorders is 2% to 3% (Merikangas et al., 2010; SAMHSA, 2011; Swendsen
et al., 2012). These rates point to the importance of identifying early-onset
SUD in adolescents and providing treatment. In addition, Individuals
who develop serious consequences with substance use in adolescence
are more likely to have these problems persist into adulthood (Grant &
Dawson, 1997; Rohde et al., 2001).
Sociodemographic Data
Use patterns may differ by gender and age. For example, the NSDUH
study (2011) includes the full age spectrum from adolescence through
adulthood and showed that males have nearly double the rates of both
alcohol and drug use disorders compared with females, which is highly
consistent across studies. The gender differences are more pronounced
in adults than in adolescents (Merikangas et al., 2010), in whom males are
only 1.3 times more likely to have an SUD than females. Although SUDs
in general are more common among males than females, females have
greater rates of abuse of some specific substances such as cocaine and
psychotherapeutic drugs (Cotto et al., 2010). In regard to age, the com-
bined NCS-R and NCS-A (Adolescent Supplement) (Merikangas et al.,
2010; Swendsen et al., 2012) showed that the peak prevalence of both
alcohol and illicit drug use disorders occurs in late adolescence and early
adulthood, and this trend is confirmed from the findings from NESARC
study (Grant et al., 2008; Merkingas et al., 2010). Although sociodemo-
graphic factors are important to consider, progression from use to abuse
and dependence is complex and related to other individual, genetic, and
familial factors (Merikangas & McClair, 2012).
Genetic Epidemiology
Genetic epidemiology focuses on the role of genetic factors that interact
with other domains of risk to enhance vulnerability or protection against
disease. It is population-based research, and its goal is to detect the joint
effects of genes and environment (Merikangas & Low, 2005). Multiple
studies have consistently demonstrated that genetic factors have a major
influence on progression of substance use to dependence, whereas envi-
ronmental factors may play a larger role in exposure, initiation, and con-
tinuation of use past an experimental level (see Merikangas & McClair,
2012, for review). However, no single gene or environmental factor will
explain the risk for onset or chronicity. The genetic contribution to SUD
is complex and involves multiple neuropathways. Future studies identifying
more data on genetic associations and environmental effects may result in
progress in the prevention and treatment of SUDs.
6 Substance Use Disorders

DSM Classification of Substance

Use Disorders
In the early 1950s, the first edition of the DSM (DSM-I, 1952) clustered
alcoholism and drug addiction with sociopathic personality disturbances,
identifying individuals with addictions as suffering from “deep-seated
personality disturbance.” There is no clear description of the clinical
manifestations of people with addictions, just a brief paragraph on the
presumed etiology of the disorder. In DSM-II (1968), alcohol and drug
addictions remained as subcategories of “personality disorders and cer-
tain other nonpsychotic mental disorders.” Several new terms emerged,
such as episodic excessive drinking, habitual excessive drinking, and alcohol
addiction. Similarly, drug dependence was developed to include subcat-
egories by specific drug class, with some description of physiological
signs and symptoms of dependence. DSM-III (1980) was the first to iden-
tify substance abuse and dependence as separate pathological condi-
tions. The separation of abuse and dependence was based on findings
from longitudinal research showing that many people with a history of
alcohol problems never progressed to dependence (Cahalan, 1970). As
of DSM-III, “alcoholism” was no longer used as a diagnosis. In DSM-III,
there was a separate category for substance use disorders instead of
being represented under personality disorders. In addition, DSM-III
suggested that social and cultural factors contributed to the abuse
and dependence, but no references were made to any specific etiolo-
gies. This is a shift from considering addiction as personality pathology.
DSM-III defined abuse and dependence, and “abuse” was the presence
of drug-related problems in the absence of physiological changes. In
DSM-III-R (1987), the behavioral aspects of substance use disorders were
incorporated with the physiological components. The “abuse” diagnosis
remained a residual category for people who had never met criteria
for dependence. DSM-IV (1994) continued the definitions of abuse and
dependence and added more than 100 different substance-related dis-
orders for 12 different classes of drugs. DSM-IV clearly separated the
criteria for dependence from those of abuse. A transitional text revision
(DSM-IV-TR, 2000) defined “substance abuse” as meeting any one or
four criteria revolving around recurrent problems related to the sub-
stance and “dependence” as meeting three or more of seven physiologi-
cal or behavioral criteria. The criteria for SUDs within DSM-IV are often
marked by significant overlap, which points to the issue of whether these
diagnoses really account for two fundamentally separate disorders or
whether they may be better understood by gradations of a single dis-
order on a continuum of severity (O’Brien, 2011; West & Miller 2011).
Proposed Diagnostic Changes from DSM-IV to DSM5
The fifth edition of the DSM (DSM5) revisits the classification and criteria
of substance use disorders. The planned revisions based on DSM5 task
force publications and announcements (available at the time of this book’s
publication) are explained below (APA, May 2012a).
 1 EPIDEMIOLOGY AND DIAGNOSTIC CLASSIFICATION 7

DSM Section Changes

The first major change is a renaming of the DSM section itself. In
DSM-IV-TR, the section was called “Substance Related Disorders.” The
committee that published that section agreed on how the disorders should
be defined, but not on what the disorders should be called. There was
a split among committee members regarding using the term “addiction”
versus “dependence.” There were concerns that the term “addiction” was
pejorative and would lead to stigma and alienation of the patients who
were looking for help (O’Brien, 2011a). The more neutral term “depen-
dence” was eventually chosen by the committee by the margin of a single
vote. The problem was that “dependence” was already in use by clinicians
to define withdrawal symptoms that occurred with medications used to
treat pain, depression, or anxiety (O’Brien, 2011a). The overlapping termi-
nology resulted in confusion among physicians and patients (O’Brien, 2011a;
O’Brien et al., 2006). To assist in clarifying the confusion that resulted from
previous DSM terminology, the “Substance Related Disorders” section is
proposed to carry the name “Substance Use and Addictive Disorders.”
The inclusion of “addictive” represents the fact that the word “addiction”
has become more commonplace and may now lack the same pejorative
influence debated during the DSM-III revision. Unfortunately, there is a lack
of studies as to whether “addiction” is pejorative. Furthermore, the con-
notations of words can change over time and between cultures (O’Brien,
2011a). To address this possibility and to “minimize controversy” (O’Brien,
2011a), the DSM5 proposal names the individual disorders with the more
neutral “substance use disorders” (O’Brien, 2011a).
The test-retest reliability of DSM-IV “dependence” was uniform and was
very good to excellent, whereas the reliability of “abuse” was more variable
and lower (APA, May 2012c; Hasin et al., 2006). It was assumed that abuse
was a prodrome of dependence; however, several studies have shown that
this assumption was erroneous (APA, May 2012c; Grant et al., 2001; Hasin
et al., 1997; Schuckit et al., 2008;). Studies showed that abuse was most com-
monly diagnosed through the “hazardous use” criterion and raised concerns
about whether the sole symptom of risky behavior indicated a true psychi-
atric diagnosis (APA, May 2012c; Hasin et al., 1999). Additionally, there were
individuals who met two criteria for dependence, yet no criteria for abuse.
These individuals could have substance problems at the severity of those with
a diagnosis, but were left undiagnosed by the DSM-IV criteria. Authors com-
menting on this phenomenon termed these individuals “diagnostic orphans”
(Degenhardt et al., 2002, p. 10; Hasin & Paykin, 1999; Lynseky & Agrawal,
2007; Martin et al., 2008; Ray, 2008). The DSM website indicated multiple
studies that demonstrated high correlations between dependence and abuse.
The above factors considered, and with the available evidence, the DSM5
proposal eliminates the diagnosis of “substance abuse” (APA, May 2012c).

Severity Specifiers and Criteria Changes

The severity specifiers of each disorder are also being reconsidered for
DSM5. The proposed changes would include a severity scale that includes
“no diagnosis,” mild, moderate, and severe. The severities will depend
on the number of diagnostic criteria met (APA, Apr 2012a). The criteria
8 Substance Use Disorders

counts help determine severity between individuals, but there is a lack

of data on whether counts of criteria met can usefully measure change
in severity in a person over relatively brief periods of time (APA, Apr
2012a). The substance-related disorders workgroup recommends that
the following three measures obtained at intake and follow-up are used
for within-subjects, across-time changes in severity over periods of a few
days, weeks, or months according to studies from clinical trials litera-
ture: (1) self-reported frequency of use; (2) similar reports from another
closely involved observer when possible; and (3) appropriately timed test-
ing for substances through urine, blood, hair, saliva, or breath (Antone et al.,
2006; APA, Apr 2012a; Crits-Cristoph et al., 1999; O’Malley et al., 2007).
The DSM5 proposal includes adding “craving or a strong desire or urge
to use [given substance]” to the criteria list for diagnosing substance use
disorders. The DSM website cites the prevalence of the symptom with
tendency to exist on the severe end of the severity spectrum, the use as an
outcome measure in many clinical trials and population studies, and brain
imaging studies demonstrating subjective cravings that are precipitated by
drug-related cues as the reasons to include craving as a criterion for diag-
nosis (APA, Apr 2012b). The criteria for “legal difficulties” were found to
be influenced heavily by local laws and customs, and were removed from
the criteria list (APA, 2000; APA, May 2012a; APA, Apr 2012b; O’Brien,
2011b). The DSM website cites that statistical analysis of population stud-
ies indicates that the legal problems criterion has low prevalence relative
to other criteria and that the removal of it from the criteria list will have
very little effect on the prevalence of substance use disorders (APA, Apr
2012b). The remainder of symptoms created for diagnosing substance
dependence in DSM-IV-TR remain unchanged to diagnose substance use
disorder in DSM5 (APA, Apr 2012b; O’Brien, 2011a). To diagnose a sub-
stance use disorder two (or more) criteria will need to be met instead
of the previous three (or more) criteria for the diagnosis of dependence
(APA, Apr 2012b).
The proposal also includes the revision of the criteria for opioid use
disorder. It will no longer include tolerance or withdrawal for individuals
who are taking medications under medical supervision. The specifier “on
agonist therapy” will be changed to “on maintenance therapy” to reflect
individuals who are prescribed agonist medication such as methadone or
buprenorphine and in whom no criteria for a substance use disorder have
been met for that class of medication (except tolerance to, or withdrawal
from, the agonist), and individuals who are maintained on a partial agonist,
an agonist or antagonist, or a full antagonist such as oral naltrexone or
depot naltrexone. (APA, Apr 2012b)
Specifiers for remission will include early remission and sustained remis-
sion and will no longer include the “partial” or “sustained” specifiers pres-
ent in DSM-IV-TR. The early remission specifier will be used if, for at least
3 months, but for less than 12 months, the individual does not meet any
of the criteria for a substance use disorder with the exception of cravings.
The sustained remission specifier will be used if none of the criteria are
met with the exception of cravings (APA, Apr 2012b).
 1 EPIDEMIOLOGY AND DIAGNOSTIC CLASSIFICATION 9

The Substance Use and Addictive Disorders General Section

This section will be organized by substance in DSM5 instead of by diag-
nosis as it was in DSM-IV (APA, 2000; APA, May 2012a). The substance
disorders work group is working with other work groups regarding the
substance-induced disorder criteria. The disorders will be listed in the
Substance Use and Addictive Disorders section as well as the chapter con-
taining the induced disorder. These disorders are proposed to include the
following: substance-induced psychotic disorder; substance-induced bipo-
lar disorder; substance-induced depressive disorder; substance-induced
anxiety disorder; substance-induced obsessive-compulsive or related
disorders; substance-induced sleep-wake disorder; substance-induced
sexual dysfunction; substance-induced delirium; and substance-induced
neurocognitive disorder (APA, May 2012a). Substance-induced dissocia-
tive disorder will be removed. A new class of drug-specific “not elsewhere
classified” diagnoses will also be included (APA, May 2012a).
In addition to reorganization, the following represents newly named
disorders: hallucinogen disorders; sedative/hypnotic-related disorders;
and stimulant disorders. The proposed DSM5 will include the following
disorders in the section of disorders that warrant further research for
potential inclusion in future versions of the DSM: neurobehavioral disor-
der associated with prenatal alcohol exposure, caffeine use disorder, and
internet use disorder (APA, May 2012a).
“Gambling disorder” will be transferred from the section of DSM-IV-TR
Impulse Control Disorder Not Otherwise Specified to the DSM5 section
of Substance Use and Addictive Disorder (APA, May 2012b). The crite-
ria for diagnosis is much the same as in DSM-IV-TR with the exception
of elimination of legal problems, a decrease of threshold of symptoms
required for diagnosis the disorder from five or more criteria to four or
more criteria, and inclusion of a 12-month period of symptom presence
required to make a diagnosis (APA, 2000; APA, May 2012b). The diagno-
sis is proposed to include specifiers of episodic, chronic, or in remission.
(APA, May 2012b)
The proposed DSM5 includes the addition of cannabis withdrawal as a
diagnosis as well as criteria for diagnosing cannabis use disorder in DSM5.
Based on the DSM5 website, the criteria to determine a true drug with-
drawal syndrome consists of a cluster of symptoms that (1) are valid and
reliably observed, (2) have a clear time course that includes onset closely
following cessation of the drug and a return to baseline levels, (3) are
pharmacologically specific to deprivation of the drug or one of its compo-
nents, (4) are not rare among dependent users, and (5) are associated with
clinically important consequences (APA, 2000; APA, Apr 2012b; Hughes
et al., 1990). Published literature reviews suggest that cannabis withdrawal
meets the criteria for a “true” withdrawal (Budney et al., 2004, 2006). The
proposed criteria include requiring heavy or prolonged use of cannabis
and the presence of three or more symptoms of withdrawal that occur
within a week of discontinuation of cannabis use (APA, Apr 2012b). The
most controversial aspect of including cannabis withdrawal in DSM5 and a
factor that contributed to its omission in DSM-IV is the clinical significance
of the withdrawal syndrome. Studies supporting the clinical significance of
10 Substance Use Disorders

the withdrawal syndrome by linking the syndrome to relapse risk, correlat-

ing symptom count and distress or impairment, and comparing severity of
cannabis withdrawal and nicotine withdrawal syndrome (APA, Apr 2012b;
Budney & Hughes, 2006; Budney et al., 2008; Vandrey et al., 2008).
Substance Use Disorders in Adolescents
There are concerns that the proposed changes in DSM5 do not address
issues related to substance use during adolescence. The physiologic
changes that occur during adolescence, as well as the changes that occur
from “experimentation” to regular use, lead to questions regarding the
validity of using “tolerance” as a criterion for diagnosis of substance use
disorders during adolescence (Chung et al., 2004; Spear, 2002; Winters
& Chang, 2011). Furthermore, more research is needed to examine the
validity of craving in adolescents (Winters & Chang, 2011). The concerns
regarding applying the two-symptom threshold for diagnosis include apply-
ing a stigmatized label of substance use disorder when the severity may
be mild, more intermittent, and more likely to remit than the same diag-
nosis in the adult population. Withdrawal is also a fairly rare phenomenon
in adolescents given the time course of use required for withdrawal to
emerge, although in the few adolescents who report it, its presence may
have relevance for prognosis (Winters & Chang, 2011). Concerns also
exist that adolescents may misreport “hangover” effects as withdrawal
symptoms, leading to false-positive symptoms (Chung & Maric, 2001). One
proposal for addressing these concerns is to include a separate category of
adolescent substance use as a way to address differences in this population
compared with the adult population (Ray & Dhawan, 2011).
Substance Use Disorders in Elderly People
The elderly population is growing, and the number of older people who
use illegal substances is increasing as well. Doctors in the United States are
poor at diagnosing abuse of prescription drugs and alcohol among older
individuals (Beynon, 2011; Boddiger, 2008). The sensitivity of the proposed
DSM5 criteria in detecting drug use in the older population may need
more research before the DSM5 is endorsed as a useful screening tool in
this population (Beynon, 2011).
In summary, the DSM5 proposal includes changes in the nomenclature
used to describe the pathology related to substance use through inclu-
sion of the term “addictive” in the section title. This allows the inclu-
sion of gambling in a section that previously held only substance-related
disorders. Removing withdrawal and tolerance as criteria for diagnos-
ing opiate use disorders in individuals receiving pain medications may
prevent unnecessary labeling of patients and may change prescribing
practices in this population. The addition of cannabis withdrawal as a
diagnosis helps the DSM remain current with the latest available evi-
dence. The addition of cravings and elimination of the legal difficulties
in the criteria lists will likely change the focus of diagnosis, treatment,
and research related to SUD. Changes to the diagnostic specifiers may
alter the view of severity, remission, and treatment. Concerns continue
that specific issues present in the adolescent and elderly populations are
not reflected in the current proposal. The proposed changes indicate a
 1 EPIDEMIOLOGY AND DIAGNOSTIC CLASSIFICATION 11

move toward recognizing addiction as occurring along a continuum of

severity and that “abuse” is not separate from or necessarily antecedent
to dependence. Ongoing research will help determine the impact these
revisions will have on the field of addiction psychiatry and the focus for
future revisions of the DSM.
12 Substance Use Disorders

Acknowledgment
The preparation of this chapter was supported in part by the National
Institute on Drug Abuse grant #5U10DA020036-08.
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14 Substance Use Disorders

References and Suggested Readings

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16 Substance Use Disorders

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 Chapter 2 17

Neurobiology of
Substance Use Disorders
Antoine Douaihy and Jody Glance

Key Points 18
Neurobiology of Drug Reward and Addiction 20
Acknowledgment 25
References and Suggested Readings 26
18 Substance Use Disorders

Key Points
• Addiction is a neurobiological illness in which repetitive substance
abuse dysregulates the circuitry of rewarding and adaptive behaviors
resulting in a drug-induced neuroplasticity.
• Genetic predisposition, environmental factors, and changes in the
brain’s reward and stress systems contribute to the vulnerability for
development of dependence and relapse in addiction.
• Understanding the neurobiological processes of addiction allows for a
theoretical pharmacological approach to treating addictions.
Drug addiction, also known as substance dependence, is recognized as
a neurobiological disorder whereby repetitive drug use dysregulates the
normal circuitry of motivation, reward, and adaptive behaviors. This leads
to neuroplastic changes in the brain, manifesting as a compulsion to seek
and take the drug, a loss of control in limiting intake, continued use despite
negative consequences, and persistent vulnerability to relapse even after
an extended period of sobriety (Kalivas & O’Brien, 2008). There has been
significant progress in the field of neurobiology, resulting from the applica-
tion of new techniques ranging from in vitro molecular methods to brain
neuroimaging procedures in subjects performing specific tasks. This chap-
ter reviews the neurobiological processes involved in the various stages of
addiction, with a focus on the changes associated with the transition from
drug initiation to abuse and dependence and the vulnerability to relapse.
Addiction has been conceptualized as a chronic brain illness that pro-
gresses from impulsivity (acting without significant forethought) to com-
pulsivity (excessively acting out repeated behaviors in an attempt to avoid
distress). As one patient stated, “At first it was all about getting high, but
then it became more about not getting too low.” Addiction is a result
of interactions among several variables in the context of repeated drug
use, including biological factors such as genetic vulnerability. Addiction
has a significant genetic component. In fact, approximately 40% to 60% of
the risk for developing a substance use disorder is thought to be due to
genetic heritability (Goldman, Oroszi, & Ducci, 2005; Hiroi &Agatsuma,
2005). The estimates of heredity include the percentage of the variance
attributed to genetic factors by themselves as well as the percentage of the
variance that is attributed to gene–environment interactions. Additionally,
the presence of a psychiatric and/or medical illness, potency of the drug,
mode of administration, and environmental and socioeconomic factors
such as access and peer pressure have been implicated in the development
of substance use disorders.
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20 Substance Use Disorders

Neurobiology of Drug Reward and

Addiction
In order to understand the neurobiological processes of addiction, we
review the underlying neurocircuitry and neuropharmacology involved in
biologically rewarding behaviors, and then we focus on the various stages
of addiction: drug initiation, progression to abuse and dependence, and
vulnerability to relapse.
Neurobiology of Reward
Three major regions in the brain have been identified as mediat-
ing “natural” rewarding and adaptive behavior such as sex, food, and
social affiliation (Figure 2.1): the nucleus accumbens (NAcc), mediating
reward-related activities (positive valence); the amygdala (Amyg), involved
in fear-motivated behaviors (negative valence); and the prefrontal cortex
(PFC), responsible for decision making and the prediction of rewarding
behaviors by determining salience attribution of environmental stimuli and
regulating the intensity of behavioral reaction (Kalivas & Volkow, 2005).
The core reward circuitry consists of an “in-series” circuit linking the
ventral tegmental area (VTA), NAcc, and ventral pallidum via the medial
forebrain bundle. This circuitry is believed to be functionally encoding the
hedonic tone, attention, expectancy of reward, disconfirmation of reward
expectancy, and incentive motivation. “Hedonic dysregulation” within this
circuitry may lead to addiction (Gardner, 2011).
Neurobiology of Initiation of Addiction
and Neuroplasticity
All drugs with addictive liability enhance (directly or indirectly, or even
trans-synaptically) mesolimbic dopaminergic (DA) reward synaptic func-
tion in the NAcc (from the VTA to the NAcc). Drug self-administration
is regulated by nucleus accumbens dopamine levels and is done to keep
nucleus accumbens dopamine within a specific elevated range (to maintain
a desired hedonic level). Although DA appears to be the primary mecha-
nism of the initiation of drug reinforcement, other neurotransmitters have
been also implicated indirectly in the acute reinforcing effects of addictive
substances such as gamma-aminobutyric acid (GABA), opioid peptides,
glutamate, serotonin, acetylcholine, and endocannabinoids. These neu-
rotransmitters may work synergistically with the DA system or may work
through independent pathways of reinforcement (Koob, 2008).
GABAergic interneurons provide an inhibitory feedback on the release
of DA in the VTA and NAcc. The opioidergic system plays a modula-
tory role on the dopaminergic system most likely by inhibiting GABAergic
interneurons that usually provide a tonic inhibition to the dopaminergic
system in the VTA (Wise, 2003). Furthermore, the opioidergic system
has been also implicated in the reinforcing effects of alcohol, and possibly
cannabis, and may be involved with other impulsive/compulsive disorders
such as pathological gambling (Grant, Brewer, & Potenza, 2006).
The cholinergic system from the pedunculopontine or laterodorsal teg-
mental nucleus provides excitatory input to the VTA, causing release of
 2 NEUROBIOLOGY OF SUBSTANCE USE DISORDERS 21

NAcc

PFC Reward
DA Initiation
AMYG Dependence
NAcc=Nucleus Accumbens
PAC=Prefrontal Cortex
Amyg=Amygdala C
DA=Dopamine
C=Nucleus Caudate
CSMC=Cortical Striatal Motor Circuitry

PFC NAcc CSMS

GABA/ Opioid
Peptide

DA AMYG
Glutamate

Dopamine
Figure 2.1 Mediators of reward and addiction. The nucleus accumbens,
amygdala and prefrontal cortex are the three major brain regions involved in the
establishment and perpetuation of addiction. Reinforcing effects of addictive drugs
are mediated by neurotransmitters including dopamine, gamma-aminobutyric acid,
opioid peptides and glutamate.

DA in the area of VTA-NAcc. Nicotinic cholinergic α and 4β2 receptors

have been implicated in the reinforcing effects of nicotine (Heidbreder,
2005). It is possible that serotonergic (5HT) compounds potentially modu-
late the mesolimbic DA system (Walsh & Cunningham, 1997). Regarding
the endocannabinoid system, the cannabis type 1 (CB1) receptors medi-
ate the reinforcing effects of cannabinoids that facilitate the release of
DA in the NAcc. Activation of the endocannabinoid system may be impli-
cated in the motivational, DA-releasing and reinforcing effects of many
drugs of abuse. As a result, CB1 antagonists/inverse agonists represent a
potential class of medications targeting the treatment of addiction.
Excitatory glutamatergic input from many cortical structures in the brain
facilitates DA release in the VTA and NAcc. This explains paradoxically
how certain NMDA antagonists such as phencyclidine exert their reinforc-
ing effects. In addition to the addictive liability of some NMDA antagonists,
others may be associated with antiaddictive properties in humans, includ-
ing memantine in alcohol and opioid use disorders and acamprosate for
alcoholism (Krupitsky et al., 2007; Littleton, 2007). The relative balance or
ratio of NMDA blockade to enhanced glutamate transmission (a function
of dose, route of administration, and potency at the receptor) may explain
22 Substance Use Disorders

why some NMDA antagonists are more reinforcing than others and why
some of them may have greater antiaddictive properties (Ross, 2008).
Substances of abuse are able to markedly elevate the levels of NAcc DA
to supraphysiological levels for a significant period of time, leading to a
dysregulation and corruption of the initial process of reward process-
ing. The hedonic nature of the substance does not predict the addictive
liability. For example, nicotine has greater addictive potential in humans
than even intravenous heroin or cocaine, leading to a dependence syn-
drome in one third of people versus one fourth of people for intravenous
heroin and cocaine, despite the fact that the subjective effects of nico-
tine are much less euphorigenic then either heroin or cocaine (Anthony,
Warner, & Kessler, 1994).
In addition to the factors described above, addiction is also a disease of
neuroplasticity. The essence of the addiction continues long after the last
dose of the drug, often lasting for years (O’Brien, 2009). Neuroplasticity is
manifested by compulsive drug-seeking behavior. Substances that directly
activate the reward system may produce learning that diverts the indi-
vidual to those behaviors that repeat the drug-induced feelings of reward.
The DA release caused by a drug of abuse tends to be greater than that
of natural rewards, and will continue to increase with repeated expo-
sure rather than diminish (as is the case with natural, expected rewards)
(Schultz, 1998). This pharmacologically induced, enhanced, and maintained
DA increase relative to biological stimuli causes more significant learned
associations with environmental stimuli, and the brain gets the message
that drug-related cues are more associated with reward than biologi-
cally relevant ones (Hyman, 2005). This “overlearning” of drug acquisi-
tion behaviors greatly contributes to the initiation of an addiction cycle,
and may explain the enhanced vulnerability to craving and relapse by
cue-induced environmental triggers (Kalivas, 2007).
Evidence of the plasticity that occurs with the development of addic-
tion can be identified by brain imaging studies that show rapid activa-
tion (increased blood flow to reward pathways) when drug-related cues
are shown to addicts who have been free of drugs for at least a month
(Childress et al., 1999). The strength of the craving reported by an addict
during brain reward system activation is related directly to the amount
of endogenous dopamine released in reward structures, as measured by
displacement of labeled raclopride in positron emission tomography (PET)
studies (Volkow et al., 2006).
Transition from Reward to Addiction
In the transition from abuse to dependence, all major drugs of abuse, and
particularly alcohol, powerfully dysregulate the brain “stress” system by
increasing corticotropin-releasing factor (CRF), an effect that may have
important implications for understanding the neurobiology of addiction
and relapse. During the development of dependence, there occurs both
a change in the function of neurotransmitters with the acute reinforcing
effects of drugs of abuse (dopamine, opioid peptides, serotonin, GABA)
and an involvement of the brain stress system neurotransmitters (CRF
and norepinephrine) and dysregulation of the neuropeptide Y brain anti-
stress system. Taken together, activation of these brain stress systems
 2 NEUROBIOLOGY OF SUBSTANCE USE DISORDERS 23

contributes to the negative emotional state associated with acute absti-

nence and withdrawal states and to the vulnerability to stressors seen
in protracted abstinence and relapse; therefore, CRF1 antagonists may
represent a new class of antiaddictive medications.
Drug addiction progresses from occasional recreational use to impul-
sive use to habitual compulsive use. This correlates with a progression
from reward-driven to habit-driven drug-seeking behavior. The neuro-
circuitry shifts from a DA-based behavioral system to a predominantly
glutamate-based one, continuing to rely on the influence of DA release
(see Figure 2.1). This behavioral progression correlates with a neuroana-
tomical progression from ventral striatal (NAcc) to dorsal striatal control
over drug-seeking behavior.
The three classical sets of reinstatement paradigms (craving and relapse
triggers) are (1) drug priming, (2) stress, and (3) reexposure to environ-
mental cues (conditioned cues: people, places, things) previously associ-
ated with drug-taking behavior. Drug-triggered relapse involves the NAcc
and DA. Stress-triggered relapse involves (a) the central nucleus of the
Amyg, the bed nucleus of the stria terminalis, and the neurotransmitter
CRF; and (b) the lateral tegmental noradrenergic nuclei of the brain stem
and the neurotransmitter norepinephrine. Cue-triggered relapse involves
the basolateral nucleus of the Amyg, the hippocampus, and the gluta-
mate system. In the reinstatement paradigms, DA release in the PFC and
Amyg stimulates glutamatergic transmission between the PFC and Amyg
and glutamate release in the pathway from the PFC to the NAcc core,
constituting a final common pathway for initiating drug-seeking behavior
(Kalivas, 2007).
A core part of the executive dysfunction is related to two important
structures: the orbitofrontal cortex (OFC) and the anterior cingulate
gyrus (ACG). Impairment in the OFC would be predicted to result in
impaired decision making and drug craving, whereby drug-related cues
would be erroneously deemed to have greater salience value than natural
reinforcers. An important role of the ACG is the inhibitory control of
behaviors and a decrease in the activity of ACG, rendering people with
addictive disorders unable to control urges to get the drug (Volkow et al.,
2004). In addition, genetic and environmental factors can contribute to
vulnerability to any part of the dysregulation of neurocircuitry during the
development of dependence.
Addiction Circuitry Model
Dr. Nora Volkow from the National Institute on Drug Abuse (NIDA) has
proposed a useful model integrating all previously discussed overlapping
circuitry that incorporates the following four pathways: (1) primary rein-
forcing effects of drugs of abuse and neuroplastic changes with memory
formation in the mesolimbic DA system from the VTA to NAcc; (2) con-
ditioned learning of drug-related stimuli in the Amyg and hippocampus
(Hip); (3) motivation, drive, and regulation of emotional responses and
salience attribution in the OFC, with DA neurons projecting from the
VTA; and (4) cognitive and executive inhibitory control functions of the
PFC and ACG (Baler & Volkow, 2006) (Figure 2.2). These neural pathways
are modulated by the DA system and interact with each other through
24 Substance Use Disorders

(a)
PFC
ACG

OFC HIP
NAcc
VP
Amyg

(b) NON-ADDICTED BRAIN ADDICTED BRAIN

PFC PFC
ACG ACG

GO
NO GO
NAcc VP NAcc VP OFC
OFC

HIP HIP
Amyg Amyg

Figure 2.2 (a) Addiction circuitry. Hypothetical model of addiction as the result
of impaired information processing within the reward network. (b) Compared with
the nonaddicted state (left), the salience value of a drug (red) and its associated
cues (purple) is enhanced in the addicted state (right), whereas the strength
of inhibitory control is weakened (blue), setting the stage for an unrestrained
motivation (green), favoring a positive-feedback loop (GO vs. NO GO), and
resulting in compulsive drug-taking without regard to potentially catastrophic
consequences.

GABAergic and glutamatergic connections. The transition to addiction

involves neuroplasticity in all of these structures that may begin with
changes in the mesolimbic DA system and a cascade of neuroadaptations,
and eventually a dysregulation of the PFC, ACG, and brain stress systems.
 2 NEUROBIOLOGY OF SUBSTANCE USE DISORDERS 25

Acknowledgment
The preparation of this chapter was supported in part by the National
Institute on Drug Abuse grant #5U10DA020036-08.
26 Substance Use Disorders

References and Suggested Readings

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miology of dependence on tobacco, alcohol, and inhalants: Basic findings from the National
Comorbidity Survey. Experimental and Clinical Psychopharmacology, 2, 244–268.
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 Chapter 3 27

Psychological Aspects of
Substance Use Disorders,
Treatment, and Recovery
Michael Flaherty

Key Points 28
Definitions 30
Cost and Effects of Substance Use 31
Macro Psychology of Addressing the Disorder 32
Individual Psychological Aspects of Treatment and the
Transtheoretical Model of Change 34
Process of Natural Change 36
Motivational Processes in Substance Use Disorders 38
Psychology of Treatment and Recovery 44
Recovery 50
Conclusion 56
References and Suggested Readings 58
28 Substance Use Disorders

Key Points
• Although substance use disorders (SUDs) are conceptualized as a
chronic, relapsing medical illnesses, they remain most often treated as
acute illnesses with specific treatment episodes.
• Successful treatment is based on proper assessment and the availability
of resources and time to treat the illness over its course.
• Using the transtheoretical model of change helps individualize
patients’ treatment plan based on their readiness to change,
improved level of motivation to change, and real-world application
of that motivation.
• The process of natural recovery and assisted recovery are connected
to each other in many ways, and formal treatment can facilitate the
process of attaining and sustaining either.
• Motivation for change is a reliable predictor of success in treatment
and is strongly influenced by interpersonal interactions of the client
with the treating clinician, supportive others in recovery, the family,
and the community where the person lives.
• Brief screening and interventions and motivational interviewing (MI),
motivational enhancement therapy (MET), and medication-supported
treatment (MST) are helpful in assessing and facilitating behavior
change in patients with SUDs, particularly in early acuity (MI) and
chronic severity (MET, MST).
• A key in early treatment is placing the patient at the right level of
needed care for the right length of time; the appropriate level of
care should be based on the American Society of Addiction Medicine
Patient Placement Criteria for the Treatment of Substance-Related
Disorders.
• Four major dimensions define recovery: health, home, purpose, and
community.
• Recovery can be strengthened by continued post-treatment check-ups
and linkage of the individual and family from the very beginning with
recovery support programs and peers in recovery from an addiction.
Substance use, misuse, and addiction represent one of America’s foremost
health problems and the largest preventable health problem in our soci-
ety today. Based on data from emergency department visits, the use and
abuse of prescribed medications now equals or exceeds the use of illicit
or street drugs, the number of deaths related to drug poisonings have
more than quadrupled since 1990, and drug overdose deaths are now
the second leading cause of unintentional deaths in America (Califano,
2009; CESAR Fax, September 19, & May 23, 2011). Nearly 80% of those
in prison are there as a result of a substance use–related crime (IOM,
2006). Nearly 70% of the cases in a local Children and Youth Services
agency are from families with substance use problems; 800,000 babies are
born annually with a passive substance involvement; 25% of children live
in a family in which substances are abused; 20% of 10th graders have used
an illicit substance in the past month; 6.5 million Americans use illicit sub-
stances while working; and 1 in 5 older Americans now struggle with a
 3 PSYCHOLOGICAL ASPECTS OF SUDS, TREATMENT, & RECOVERY 29

substance use disorder outside of any formal treatment ( IOM, 2012,

IRETA, 2011). Beyond the estimated 21 million Americans reporting using
drugs (age 12 years and older) (SAMHSA/NSDUH, 2010) who need treat-
ment, White (2012) identifies that there are an estimated 25 to 40 million
Americans estimated now in recovery (not including those in remission
from tobacco) who also may need continuing care or support at all levels
of medical care.
30 Substance Use Disorders

Definitions
Users of alcohol or drugs may show a variety of patterns of use with vary-
ing adverse affects. Drug use refers to the use of a medication or illicit sub-
stance without a prescription, without a legitimate need for it, or without
medical oversight. Drug abuse or misuse refers to repeated or excessive
drug use or noncompliant medication use.Problematic use refers to the use
of a licit substance in amounts greater than normal for gender, age, and so
forth (e.g., beyond 14 drinks a week for an adult male, 7 drinks a week for
an adult female) (Babor & Higgens-Biddle, 2001).
Dependence was sometimes used to refer to a more psychological need
(without physical withdrawal or characteristics) created for a substance but
is today more often used synonymously with dependency on medications
(i.e., they will likely have physical withdrawal symptoms if they suddenly
stop taking their medication). The term is not meant to be pejorative in any
sense. All dependence has some physiological basis, but with dependence,
the cravings may appear more psychological than physiologically evident.
Addiction is defined as a collection of symptoms that may include physical
dependence, but the definition requires other behavioral symptoms indi-
cating loss of control over use, exacerbation of problems because of use,
and continued use despite negative consequences. Addiction is a chronic
relapsing disease characterized by compulsive drug-seeking and abuse
and by long-lasting chemical changes in the brain (NIDA, 2002). In the
recent American Psychiatric Association Diagnostic and Statistical Manual
of Mental Disorders, 5th edition (DSM-5) “Substance Related and Addictive
Disorders” replaces dependence and abuse. However the understanding
of all definition scan still be helpful to clinicians.
Another language distinction is between “drug use” and “medication
use.” Drugs are typically used to alter or enhance reality. Medications are
intended to help an individual participate in reality or life—not to escape
it. This is a distinction critical in assuring persons in recovery that indeed
they may need medications and that their recovery is no less valid because
of the presence of them. The intent of use is more critical.
 3 PSYCHOLOGICAL ASPECTS OF SUDS, TREATMENT, & RECOVERY 31

Cost and Effects of Substance Use

The cost of illicit substance use and the related problems to our society is
estimated to be $184.6 billion for alcohol abuse and $143 billion annually
for drug abuse (Mark et al., 2005). Indeed, given all the related societal
costs, it can be argued that screening, assessing, intervening, and properly
treating SUDs presents the single greatest potential cost savings in health
care to our society. In this calculation, the author includes the actual costs
of health care, to productivity, to communities, to criminal justice, to the
families of those involved, and to the noncompliance with other health
needs by those abusing or addicted to substances, including alcohol, drugs,
medications, and tobacco.
Today only 10% to 15% of individuals with SUDs receive professional
help (SAMHSA, 2007). When clinical care is provided, it needs to accu-
rately assess the origin of the presenting illness, its nature as a substance
use problem (e.g., when, why, how used, how long), any co-occurring
mental health issues, the drugs of use (i.e., type and whether prescribed or
illicit), and the severity of the illness to complete proper patient matching
and level of continuing care.
Despite many unintended societal consequences, only when addiction
is perceived and defined as an illness is it treated as such. Sadly, adequate
treatment depends on the availability of clinical skills, available resources,
and the patient and practitioner having the time and motivation needed to
treat and manage the illness properly over time. Too often, incarceration,
repeated hospitalization, or death becomes the alternative.
32 Substance Use Disorders

Macro Psychology of Addressing

the Disorder
Perhaps nothing negatively affects our ability to properly understand and
treat SUDs more than our society’s continued denial and minimization of
the true magnitude of the problem; our rationalization of its full impact
(e.g., the true societal costs or not seeing SUD as the root cause of at
least 20 other major medical illnesses, and the related medical comorbid-
ity costs from the condition itself); or the failure of no treatment (i.e.,
incarceration or death, with family and community devastation); or the
futile projection of blaming other problems for it (e.g., poverty, racism,
social epidemic, moral failure, poor individual choices, poor economy).
This being said, we will now focus on the clinical presentation and psycho-
logical aspects of each phase of use.
Our current understanding of addiction and SUDs is that they are ill-
nesses best comprehended as not being acute in nature (e.g., like a cold
or a broken arm) but rather as being more chronic in nature and best
approached clinically, appreciating that potential, even if not evident at the
very moment (Dennis & Scott, 2007; Flaherty, 2006; McLellan et al., 2000;
White & McLellan, 2008). As such, substance use and SUD can be treated
with methods adapted from a chronic disease model of care in which
life-world interventions are conducted earlier to prevent or minimize
occurrence and, when needed, with accurate assessment and treatment of
acuity and with continuing care—often for years—if only ultimately with
self-care. As with diabetes, hypertension, HIV, and depression, SUDs are
best addressed from within a chronic illness framework that can offer the
best reduction of harm for all through enhanced prevention, earlier inter-
vention, treatment, and continuing care to sustain remission and ongoing
recovery—the addiction continuum of care.
Often problematically, our treatment systems and payment method-
ologies remain more acute in their financial support with limited, reac-
tive, and restrictive episodes and units of care often addressing the most
medically demanding issues to the neglect of earlier intervention, early
treatment, and continuing care. Although addiction is “conceptualized as a
chronic, progressive disease” (Flaherty, 2006; McLellan et al., 2000; White,
1998), it remains too often treated as an acute illness with time-specific
treatment episodes in acute models and episodes of care. In recent years,
major shifts in our understanding of the nature of the illness and the value
of early screening, assessment, and urgent and continuing treatment of it
have emerged that will eventually redefine new financial methodologies to
effectively support addressing the illness at any point in its trajectory and
for the time needed to be effective.
Coincidental to this paradigm shift in understanding the illness and
its treatment, our understanding of the neurobiology of addiction has
exploded. Other key advancements have been made in the relevance of
genetics, family history, and culture in understanding potential “predispo-
sition” to the illness and assessing a person’s true vulnerability to it. All
these factors must be considered in a thorough assessment of the prob-
lem for each individual. In summary, addiction and dependence are often
 3 PSYCHOLOGICAL ASPECTS OF SUDS, TREATMENT, & RECOVERY 33

defined as a “biopsychosocial” illness (Donovan & Marlatt, 1988; Glantz &

Pickens, 1992). Others, particularly those in recovery themselves, add or
see “spiritual” aspects unique to this illness, such as faith, regained pur-
pose, or even lost and found meaning in life, making it a biopsychosocial
spiritual illness.
34 Substance Use Disorders

Individual Psychological Aspects of

Treatment and the Transtheoretical
Model of Change
Science provides a number of proven evidence-based practices appli-
cable for all levels of individual use of substances. Most encompassing
is DiClemente and Prochaska’s (1998) transtheoretical model (TTM) of
intentional behavioral change, which has stood for more than two decades
as a proven cornerstone to understanding how a person can become both
aware and well again. The TTM respects the person-centered nature and
unique starting point of care.
Using the TTM, a person-centered, individualized treatment plan can
be formulated. TTM attempts to bring together the diverse etiological
perspectives (e.g., socioenvironmental, educational, genetic and physi-
ological, biological, personality, intrapsychic, conditioning and reinforce-
ment) brought forward over time. TTM focuses on how individuals
change behavior and how they can progress through such change by
identifying key change dimensions involved in their progress (DiClemente
& Prochaska, 1998). TTM sees a common personal pathway, in addition
to the type of person or environment, as the best way to integrate and
understand the multiple influences involved at whatever level of acquir-
ing or halting problematic use or addiction. Beginning and sustaining use
involves the individual and his or her unique choices. The choices are
influenced by both character (personality) and social forces. There is an
interaction between the individual and the risk and protective factors that
influence whether the individual becomes addicted and whether he or she
engages recovery. According to DiClemente and Prochaska (1998), the
acquisition of the awareness of an addictive behavior and recovery from
it require a personal journey through intentional or desired change and
levels of change summarized below. Each practitioner must assess where
the individual is in his or her present awareness of the problem and then,
beginning with that knowledge, assist or motivate the patient to intention-
ally process and change his or her behavior accordingly. The effect of the
drugs must also be considered in assessing a patient’s ability to actuate his
or her will. Patients can and do move back and forth between these stages
in either direction, and can even do so throughout the course of one ses-
sion. The stages of change are as follows:
1. Precontemplation—the stage at which there is no intention to change
behavior in the foreseeable future. Many individuals in this stage are
unaware of or minimize their problems. This maybe because the
person has never regarded the behavior to be a problem and thus
sees no need for change. It may also be that the person has tried
to change and did not succeed and feels resigned and not willing to
trying again.
2. Contemplation—the stage in which people are aware that a problem
exists and are seriously thinking about making a change within the
next 6 months but have not yet made a commitment to take action.
People are typically ambivalent and can remain stuck, weighing pros
 3 PSYCHOLOGICAL ASPECTS OF SUDS, TREATMENT, & RECOVERY 35

and cons of the problem and its solution, for long periods without
internal or external motivation to change.
3. Preparation—the stage that combines intention and behavioral
criteria for planning action. Individuals in this stage are intending
to take action in the next month. Such actions can include the
reduction of use and movement toward abstinence. Although they
have made some reductions in their problem behaviors, individuals
in the preparation stage have not yet reached a criterion for effective
action. They are intending to take such action in the very near future.
4. Action—the stage in which individuals modify their behavior,
experiences, or environment in order to overcome their problems.
Although obvious to the person and practitioner, actions must not be
equated with change unless the altered addictive behavior is sustained
from 1 day to 6 months. Successfully altering the addictive behavior
means reaching a particular goal, such as abstinence or other markers
of recovery.
5. Maintenance—the task here is to hold onto and continue gains
through action leading to a consolidation of the change.
36 Substance Use Disorders

Process of Natural Change

Addressing the problematic pattern of substance use is a complex process.
Multiple factors appear to moderate the development of the addiction
and interfere with entering and/or exiting the problematic use process.
For example, there is limited evidence that simply starting to smoke or
drinking alcohol is a gateway for other substance use. In fact it is the early
onset of illicit substance use and the escalation of that use that are more
strongly associated with both abuse and dependence on alcohol and drugs
in later life. These factors include the age at which an individual starts
the problematic use, family behaviors and genetic influences, relation-
ships and social network systems, and cultural and moral values. Clearly
there are social and interpersonal influences that can foster problematic
use or problem discontinuation. For example, the self-change process is
promoted by shifts in social support networks that might involve fam-
ily, friends, and places of use while taking more responsibilities (reducing
problematic alcohol use).
The process of natural change is affected by multiple factors, including
environmental, developmental considerations, and access to resources.
For example, individuals acknowledging their homosexual identity can
engage in heavy drinking. This pattern of drinking can change without the
involvement in formal treatment once the individuals realize the problem-
atic aspect of their drinking. The natural change appears to be related to
maturation in individuals who have the capacity, personal factors, and less
problematic environment that facilitate the exiting from the problematic
use early on in their lives. Another associated factor that fosters the pro-
gression of substance use and affects natural change is the co-occurrence
of mood or anxiety disorders. The individuals who struggle with these
disorders early in adolescence or young adulthood have more difficulty
controlling their substance use that becomes linked to their psychiatric
problems and make natural change of their problematic use less likely
to happen. There are no consistent differences between individuals who
were able to self-change and individuals who are treatment seekers.
Several studies of self-change have included individuals with long histories
of addiction who have been able to achieve complete abstinence even
without involvement in formal treatment or mutual help groups (White,
2006; White & Kurtz, 2006). It is evident that for individuals with severe
SUD, the process of self-change is more challenging but not impossible.
Treatment usually interacts with the process of self-change and can facili-
tate the process of natural recovery. The processes of natural recovery
and assisted recovery are connected to each other in many ways, and
this connection is not clearly conceptualized. Promoting natural recovery
could be done with the use of brief interventions that take advantage
of naturally occurring circumstances and negative consequences or that
deliver a short therapeutic encounter with personalized feedback, encour-
agement, and advice.
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38 Substance Use Disorders

Motivational Processes in Substance

Use Disorders
Concept of Motivation
Motivation is a multidimensional phenomenon with interchangeable
dimensions such as problem recognition, desire or willingness, pros and
cons of change, perceived need or importance of change, and perceived
ability or self-efficacy for change. One way of operationalizing motivation
is as behavior probability. There is no scientific support whatsoever for
these perceptions that individuals with SUDs have a particular “addictive”
personality or exhibit high levels of immature defense mechanisms such
as denial. It is clear that low motivation is not an intrapersonal trait of
individuals with SUDs, and the attributions of low motivation to inter-
personal pathology are not empirically based. A patient’s motivation for
change is considered both an intrapersonal and interpersonal process and
is clearly influenced by an “empathic” approach by the practitioner. One
study found that the physician’s rates of dropout were predictable from
the physician’s “tone of voice” when talking about “alcoholic” patients: the
more anger in the physician’s voice, the higher the patient dropout rate
(Milmoe et al., 1967). The concern of significant others can also influ-
ence the change process negatively or positively. The socioenvironmental
context also considerably reinforces or deters change. For example, in a
randomized trial, patients were either encouraged to attend Alcoholics
Anonymous (AA) or were linked with an AA member who offered to take
them to a meeting. The corresponding percentages of patients attending a
first AA meeting were 0% and 100%.
Dimensions of Motivation
Five categories or dimensions of motivation were identified by Amrhein
et al. (2003), referred to with the acronym DARN/C:
1. Desire. Individuals use the language of “wanting” to change or
“wishing” to change; this reflects one’s level of desire for change.
2. Ability. This is the person’s perceived ability to change (self-efficacy;
Bandura, 1997), reflected in such language is “I can stop using” or “I
could stop using.”
3. Reasons. The person expresses the reasons to make or not make a
change. These reasons include the pros and cons of change and the
pros and cons of the status quo.
4. Need. The person verbalizes his or her level of need to change or not
change, reflected in such language as “I really should stop using” or
“I don’t have to stop using.” The language of need expresses some
degree of urgency.
5. Commitment language. Of all these dimensions, only committing
language is predictive of subsequent behavior change. Commitment is
the final pathway to change. Strengthening change talk (desire, ability,
reasons, and need) increases the likelihood of commitment language
and subsequent behavior change. Such language includes “I will go to
my therapy session”; “I know I will attend AA meetings”; “I intend
to stop smoking.” Behavior change also potentially occurs when the
 3 PSYCHOLOGICAL ASPECTS OF SUDS, TREATMENT, & RECOVERY 39

individual articulates a clear intention and a specific plan of action.

The commitment language is negotiated in the therapeutic encounter.
Ways to Influence Motivation
Multiple approaches in the treatment of SUDs have demonstrated no
beneficial effects on substance use behaviors, such as knowledge-based
education, insight-oriented persuasion, punishment, and confrontational
approaches. There is a strong scientific evidence for brief interventions,
motivational interviewing, and motivational incentives. In this chapter, we
address brief interventions and motivational interviewing (MI); motiva-
tional incentives.
Brief Interventions
Research also has shown that there is strong and consistent support for
the efficacy of brief interventions. Brief intervention is a form of treatment.
It usually compromises one to a few sessions, of a few minutes to an hour
long. What accounts for the impact of these interventions is not the duration
of the session. Brief interventions do not use education, confrontation, or
teaching of specific skills. The main goal of the brief interventions is to acti-
vate the patient’s own self-regulatory processes (Vohs & Baumeister, 2009).
Therefore, brief interventions can instigate behavior change in patients with
SUDs. The components of brief effective interventions for alcohol and drug
problems have been summarized using the mnemonic acronym FRAMES
(Miller & Sanchez, 1994):
• Feedback: This includes information about the individual’s drug or
alcohol use and problems from screening or assessment, information
about personal risks associated with current use, and general
information about the risks of continued use. If the patient’s presenting
problem is related to the substance use, it is important to provide
this link in feedback. Feedback often valuably contains comparisons
between the patient’s use and science, biology, and the problems
experienced by similar people in the population.
• Responsibility: A key factor in working with substance users is to
acknowledge that they are responsible for their own behavior and that
they can make choices about their substance use. Key phrases such as,
“What you decide about what to do with your substance use is up to
you” and “nobody can make you change or decide for you” help the
user retain personal control (or measure the lack of it) of his or her
behavior and responsibility for the consequences of that behavior.
• Advice: Individuals are often unaware of the link between their use and
the problems or harms associated to it. Providing clear advice that
cutting down or stopping substance use will reduce their risk for future
problems will increase their awareness of their personal risk while
maintaining their responsibility in doing so. Such clear advice is the
central component of therapeutic intervention with substance users.
• Menu of alternative change options: Providing a variety of possible
ways to achieve the sought changed behavior allows the patients to
choose which strategy is most suitable for their situation and which
they feel might be most helpful. Providing such choices reinforces the
sense of personal control and responsibility for making change while
40 Substance Use Disorders

simultaneously strengthening the individual’s motivation for change.

Some examples might be:
Keeping a diary or record of use (where, when, how much, why,
who with)
Helping patients design their own recovery plan
Identifying high-risk situations and ways to avoid them
Engaging in non–substance use activities with friends, support groups,
exercise, work, and so forth.
Providing information about self-help supports and connecting to them
Offering access to the therapist available if urgent need arises
• Empathy: An empathic approach is fundamental to the delivery of the
brief intervention.
• Self-efficacy (confidence): A reasonably reliable predictor of change
is self-efficacy. The final FRAMES component is to encourage the
patients’ confidence that they are able to make the sought changes in
their substance use. Those who believe they are able to use ways to
make a change are more successful.
Brief interventions can be implemented in diverse settings. A brief intervention
can be used as a single session or as an initial session, or it can be incorporated
within a particular treatment approach over a series of sessions. It can also
be used to strengthen adherence to treatment and used in combination with
pharmacotherapeutic interventions (Pettinati et al., 2004; Zweben, 2002).
Motivational Interviewing
MI is a person-centered, collaborative form of guiding the person to elicit
and strengthen motivation for change (Miller & Rollnick, 2002). The MI
approach facilitates change through exploring and resolving ambivalence,
which is the main motivational obstacle to seeking help. The outcome
literature for MI is growing, and the overwhelming evidence is in the areas
of addictions. MI has been conceptualized as having two major compo-
nents: a relational and a technical component (Miller & Rose, 2009). The
relational component focuses on the therapeutic alliance, with emphasis
on accurate empathy (Rogers, 1957). The technical component focuses
on eliciting change talk and strengthening commitment language (Glynn
& Moyers, 2010). The “spirit” of MI is defined by three components: col-
laboration, evocation, and supporting autonomy. Collaboration means
working together with the patient; evocation means calling forth the
patient’s strengths and motivations and intrinsic resources; and support-
ing autonomy means respecting the patient’s decisions, emphasizing the
importance of self-determination theory (Deci & Ryan, 2008). MI focuses
on evoking the patient’s motivational language (DARN) and ultimately a
commitment language. Instigation to change starts when the patient per-
ceives an inconsistency between his or her present state and his or her
desired own goals and values. Fundamental to the MI approach is the use
of micro skills that include open-ended questions, affirmation, reflective
listening, and summaries (OARS) to facilitate the change process. OARS
is a brief way to remember the basic approach. There is much more to
MI, and its effectiveness in gaining the involvement of the person in care
cannot be overstated. For more details on the MI approach, see www.
motivationalinterview.org and www.mitrip.org.
 3 PSYCHOLOGICAL ASPECTS OF SUDS, TREATMENT, & RECOVERY 41

Other Science-Based Treatments

Other evidenced-based practices have also been proved more effective
in treating drug abuse. Motivational incentives use strategies to encour-
age rapid and self-driven behavior change to stop drug use and help the
person enter and continue in treatment. Bus passes, coupons for food,
and even just participating in a patient fish-bowl lottery for home supplies
have been shown to be effective in initiating the motivation of a person
to try. When the incentive accomplishes its task of getting the person to
treatment, treatment can begin the process of building the motivation for
care and making it more internally rooted for the person. This practice has
been shown to be particularly effective in high-acuity, high-relapsing, and
financially challenged populations (Morgenstern et al., 2009). The “inter-
nalization” of treatment’s value is critical for sustained recovery and can
be evidenced when the patient declines the earned “incentive” or gives it
to another, more needy person.
More recently, cognitive behavioral therapy (CBT) is again emerging as
an effective practice to help patients recognize, avoid, and cope with the
situations in which they are most likely to abuse drugs. Historically seen
as an effective measure to prevent relapse (Daley & Marlatt, 1997), cogni-
tive therapy is now being used to reorient the person’s thinking from just
addressing the pathology to building constructive thinking in recovery. By
reframing the person’s thinking from past failures, from fear and “I can’t”
to “I’ll try,” “let’s do this,” and “here’s in someone who can help you with
your recovery,” the negative thinking is diminished, and positive thinking
can take hold to resist use (Beck, 2012; Flaherty, 2012) and build daily
recovery. In this sense CBT can strengthen the opportunity for recovery,
which itself strengthens the value of treatment by making treatment more
applicable to felt success.
Today the use of medication in treatment is more widely accepted and
a proven practice. Referred to as medication-assisted treatment (MAT) or,
by some in recovery, as medication-supported recovery (MSR), the use of
prescribed and monitored medications is generally accepted as another
valued and proven evidenced-based practice. The use of medication was
once viewed as failure or at best as a replacement for illicit use but not
recovery. Today, as noted in the above definitions paragraph, these medi-
cations are defined as “medicine” that, when managed properly, can help
the individual attain personal recovery whether continuing on the medica-
tion or not. A fuller definition of recovery will be discussed shortly, but
it is now defined by many factors in a person’s life—and not only use of
medication or not, or even complete abstinence or not. Examples of such
supportive medications might be the treatment of opiate dependence with
naltrexone, buprenorphine, ormethadone; co-occurring psychiatric disor-
ders with appropriate psychotropic medications; alcohol dependence with
antagonist or motivating medication, such as disulfiram, naltrexone, acam-
prosate, or topiramate; and smoking with nicotine replacement. Because
they work on different aspects of addiction, combinations of behavioral
therapies and medications generally appear to be more effective than
either approach used alone. Additionally, the recognition of the added
value of recovery supports and a recovery focus in care has provided
even more tools to improve outcomes and will be discussed momentarily.
42 Substance Use Disorders

In sum, three decades of scientific research and clinical practice have

yielded a variety of effective approaches in treatment. The previously noted
TTM of change, enhanced by the key evidenced-based practices, represents
one proven approach and practice. Other findings and practices also have
much to offer. These findings in aggregate have been integrated into an
overarching guide by the National Institute on Drug Abuse (NIDA) called
the “Principles of Drug Addiction Treatment—A Research-Based Guide”
(NIDA, 2009). These integrating principles are listed in Table 3.1.
Treatment programs should assess patients for the presence of HIV/
AIDS, hepatitis B and C, tuberculosis, and other infectious diseases as well
as provide targeted risk-reduction counseling to help patients change behav-
iors that place them at risk for contracting or spreading infectious diseases.

Table 3.1 Principles of Effective Treatment

1. Addiction is a complex but treatable disease that affects brain
function and behavior.
2. No single treatment is appropriate for everyone.
3. Treatment needs to be readily available.
4. Effective treatment attends to multiple needs of the individual, not
just his or her drug problem.
5. Remaining in treatment for an adequate period of time is critical.
6. Counseling, including individual and/or group and other behavioral
therapies, is the most commonly used form of drug abuse treatment.
7. Medications are an important element of treatment for many
patients, especially when combined with counseling and other
behavioral therapies.
8. An individual’s treatment and services plan must be assessed
continually and modified as necessary to ensure that it meets his
or her changing needs.
9. Many drug-addicted individuals also have other medical disorders.
10. Medically assisted detoxification is only the first stage of addiction
treatment and by itself does little to change long-term drug abuse.
11. Treatment does not have to be voluntary to be effective.
12. Drug abuse treatment must be monitored continuously because
lapses during treatment do occur.
From National Institute on Drug Abuse. (2009). Principles of drug addiction treatment: A research
based guide. Washington, DC: National Institute of Health, U.S. Department of Health and
Human Services.
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44 Substance Use Disorders

Psychology of Treatment
and Recovery
During this early phase of assessment and care, patients are often fright-
ened of both the physical complications of their illness (e.g., withdrawal,
cravings, potential seizures, possible arrest) and the stigma of being iden-
tified as an alcoholic or addict. Working privately with the person or
bringing in family or significant others to support care can be helpful but
is a decision the clinician must make in collaboration with the patient.
Research has proved the increased effectiveness of both bringing in
one’s family to support the individual (Rotgers, Morgenstern, & Walters,
2003) and using peers or recovery supports to augment care and reduce
stigma (White & Kurtz, 2006). In addressing the illness and its treatment,
investigators (Hser & Anglin, 2011; Moos, 2006; White, 2008, 2006) have
noted that on average it takes a person seven attempts in the current,
more acute model before attaining a1-year period of sustained abstinence.
Further research documents that in the current delivery model, nearly
80% of those completing formal treatment relapse with the first 90 days
if not receiving continuing or follow-up care (NIDA, 2009; White, 2008).
By connecting the patients to proven treatments at the right level of care
and with the added support of family, employer, and others in recovery,
the number of attempts can be significantly reduced while improving the
likelihood of achieved and sustained recovery (Humphreys, 1997, 1999;
Laudet, 2002; Moos, 2006, 2007; White, 2006).
A key in early treatment is to place the patient at the right level of
needed care. A placement at a level below medical necessity will likely
bring failure, increase patient despair, add medical morbidity, and possibly
lead to eventual mortality. A placement in too high a level of care can
result in a rejection of the appropriateness of care and the advancement of
the illness to that higher level. Precise placement at the right level of care
is key for optimal outcome. The American Society of Addiction Medicine
(ASAM) has published guiding Patient Placement Criteria for the Treatment
of Substance-Related Disorders (PPC-2R; Mee-Lee et al., 2001) with an
update planned for late 2013. These criteria are for both adult and ado-
lescent populations and include placement guidelines for people with
both single and co-occurring mental and substance use disorders. The
PPC assesses each patient along six clinical dimensions, matching those
individual dimensions to 15 potential levels if care. The six clinical dimen-
sions are as follows:
1. Acuity and/or withdrawal potential
2. Biomedical conditions and potential complications
3. Emotional, behavioral, or cognitive conditions and complications
4. Readiness to change
5. Relapse, continued use, or continued problem potential
6. Recovery environment
Based on these dimensions, the 15 potential levels of care are as follows:
1. Ambulatory detoxification without extended onsite monitoring: I-D
2. Ambulatory detoxification with extended onsite monitoring: II-D
3. Clinically managed residential detoxification: III.2-D
 3 PSYCHOLOGICAL ASPECTS OF SUDS, TREATMENT, & RECOVERY 45

4. Medically monitored inpatient detoxification: III.7-D

5. Medically managed inpatient detoxification: IV-D
6. Early intervention: 0.5
7. Outpatient services: I
8. Intensive outpatient: II.1
9. Partial hospitalization: II.5
10. Clinically managed low-intensity residential: III.1
11. Clinically managed medium-intensity residential: III.3
12. Clinically managed high-intensity residential: III.5
13. Medically monitored intensive inpatient: III.7
14. Medically managed intensive inpatient: IV
15. Opioid maintenance therapy: OMT
A fuller understanding of each level and what it provides is necessary
to properly use any PPC guide and achieve optimal patient outcome.
Individuals often move through levels from medical stabilization to reha-
bilitation and recovery as health improves. Also, detoxification, whether
I, II, III, or IV D, is seen only as achieving patient safety and/or medical
stabilization and, by itself, is not considered substance use treatment. The
following provides an example of using the adult ASAM criteria:
John, a divorced 34-year-old businessman, is assessed in your
outpatient practice as having severe alcohol dependence with
occasional marijuana use and the use of prescribed sedatives “to
sleep.” He also has had a history of heart problems for which
he receives treatment and is being monitored by his physician.
While having a 16-year history of progressive drinking, he has
not tried alcohol or drug treatment before but now must or
“lose his job.” He reports after a brief trial on his own that he
could not even go one day without drinking. You apply a Clinical
Institute Withdrawal Assessment for Alcohol Scale (CIWA-Ar)
and obtain a score of 14, indicating moderate to severe withdrawal
symptoms. In your assessment, you that conclude John needs a
fuller medical assessment, detox, and medical stabilization before
beginning actual alcohol recovery treatment. Given his length of
use, his current dependence (CIWA-Ar score), and his history of
heart problems, you do not see outpatient detox (ASAM level
1-D or II-D) as appropriate or safe. You recommend level IV-D,
medically managed inpatient detoxification, where John’s coronary
status can be monitored throughout the detoxification process
by medical staff, who are constantly present at this level of care.
After his detoxification is safely completed, you recommend he
consider going to a clinically managed medium-intensity residential
treatment program (level III.3) followed by an intensive outpatient
(level II.1) program in his local community before returning to you
for continuing and ongoing outpatient care (level I). The length
of time in each level will be determined by his progress and the
46 Substance Use Disorders

clinical judgment at each level in consultation with you. John resists

spending this much time off work for treatment, but after a brief
authorized discussion with his boss, he relents to “give it a try,”
given both the medical urgency and employer support. You also
contact his managed care organization to assist in their providing
authorization for the recommended treatment plan and related care
management.
In making the above patient placement, medical safety and stabilization
had to come first. After this was established, the central psychological
goal of this early period of assessment and treatment was the John’s
acceptance of his substance use problem and his motivation to change.
Many patients will minimize or “half-step” that understanding into a kind
of “compliance” to temporarily buy time and peace. Some will find other
problems or excuses and project the focused clinical attention elsewhere.
Changing this addictive thinking or what patients think about or how they
may minimize the consequences of their use (e.g., using CBT and insight
therapy or MI) can help them reframe their understanding of the true
personal impact of their use and increase their motivation and resolve to
quit. The patient’s true acceptance of the full problem is necessary, even
after abstinence, for recovery to begin. Such acceptance or “surrender” is
not easy, but achieving compliance or abstinence for the sake others is a
barrier to ultimate recovery. In the act of true acceptance, individuals see
or surrender to the problem honestly, accepting their role in the problem
and acknowledging the actions by which they will find a “sense of unity,
of ended struggles, of no longer divided inner counsel” (Tiebout, 1953).
Working with a therapist or peer can add to breaking down this denial,
minimization, and projection while forging an allied team to address the
problem and build recovery.
Beyond addressing personal denial or minimization, a psychological
assessment of other key clinical obstacles must also include determin-
ing whether the person’s emotions (e.g., fears, needs) are dominating the
person’s cognitive or personal regulatory control in any way or whether
these long and powerful conditioned impulses might need to be unlearned
or held in check. Here, responding to positive rewards or incentives
(e.g., MET), including the relationship with the therapist and peers, might
strengthen the motivation for treatment while diminishing less thought-
ful habitual acts (e.g., seeing bad people, going to bad places, or doing
bad things) and impulses. Assessing any other addictions is critical because
patients will often “cross” use to other substances (e.g., alcohol to seda-
tives) or behaviors (e.g., cocaine use to gambling) in their use and recov-
ery. Life trauma assessment is major. For many, the effects of drug use can
be a severe trauma that needs to be worked through in treatment. The
often-related drug lifestyle of violence, sex, or crime must eventually be
a topic of treatment if recovery is to be sustainable. Veterans and victims
of sexual assault and abuse and those suffering with post-traumatic stress
disorder or traumatic brain injury are a distinct group in whom the assess-
ment and treatment of the trauma is itself as critical as the effort to attain
abstinence and recovery. Left unchecked, it will undermine treatment.
 3 PSYCHOLOGICAL ASPECTS OF SUDS, TREATMENT, & RECOVERY 47

The rule is that in psychological treatment dealing with a traumatized

population and its high rate of suicide, “trauma trumps all,” lest we just
remove the individual’s coping mechanism (use) while opening the person
to re-experiencing that trauma outside a safe environment without any
coping mechanisms. Treating both the addiction and the trauma simulta-
neously and with great caution is the ideal path.
Co-occurring mental health issues also need to be assessed at intake
and once medical stability is attained. In early recovery, most individuals
will need to focus on their recovery from addiction; however, if other
mental health problems and psychological issues become evident, they
too must be clinically included lest they also undermine the person’s effort
at recovery. Some psychological issues may simply clear or recede once
recovery has progressed over 6 months or a year. Some, however, will
manifest more strongly as recovery progresses and may have been the
self-medicated target of the patient in his or her illicit use. The patient may
in fact be a person with mental illness who is abusing drugs. In some true
anxiety disorders, cautious use of mood-moderating medications can help
if closely monitored and not used in an attempt by the person to simply
sustain his or her physical addiction or potentiate the euphoric effect of
other use. Withdrawal itself causes anxiety, as do many life events aroused
by treatment. Differentiation of anxiety from addiction withdrawal is at
best a science in early development. Today, best clinical practice would
suggest to the clinician to expect and rule out co-occurring psychiatric
diagnoses and psychological issues in all clients. Additionally, when such
co-occurring diagnoses are found, they should be treated concurrently
with monitored, appropriate medication and psychotherapy as warranted.
SAMHSA’s Center for Substance Abuse Treatment TIP No. 42 (2008)
is an excellent guide to the assessment and treatment of co-occurring
disorders as well as an excellent reference for other scholarly works in
this area.
Because abstinence from the addictive or abused substance is often
essential for success, the psychological treatment of substance use has
emphasized more the resolution of current issues, conflicts, and barriers
than the dwelling on childhood experiences, developmental conflicts, and
fixations—often the focus of psychoanalysis or psychodynamic psycho-
therapy. Substance dependence will not disappear on its own through
understanding. Still, some patients may need and benefit from these
more in-depth processes after medical and chemical stabilization have
been achieved. In this chapter, however, we have outlined a treatment
approach based on the TTM of change, in which treatment helps the per-
son move along the stages of change to recovery. So often, the psychologi-
cal devastation and the physical domination of the addiction reduce the
person’s ability to simply halt use or the related pathology. By increasing
self-awareness and self-perception, we build the motivation of the person
to get well, and then, by connecting that motivation to an understanding of
the illness and others who have had it, we build an enormous new founda-
tion for the treatment of the illness and its pathological nature as well as
for remission and recovery. By building success, we reduce the odds of
the illness and add to the strengths of the person to sustain that success.
In short, we rebuild the capabilities and confidence of the person first.
48 Substance Use Disorders

After medical stabilization is achieved and compliance with treatment is

attained—and a recovery plan has been designed—the individual can state
that he or she is in early recovery. The role of treatment is to provide the
opportunity to attain wellness and the tools to sustain that wellness and
recovery over time. Although many more individuals achieve “recovery”
outside of formal treatment than within it, formal treatment is still neces-
sary for many, particularly those suffering from increased medical severity
of the illness, co-occurring psychiatric disorders, pregnancy, or other acute
or chronic medical conditions. Recall that only 11.2% of the 22.6 million
people who need substance abuse treatment receive such treatment in a
specialty facility (SAMHSA, 2007). Additionally, for those who do access
treatment, remission and recovery are rarely attained in a single episode
or as a linear event. The process to achieve remission or stabilization
of the illness and a quality of life measured by individual wellness and
attained management and/or recovery from illness is the goal of treat-
ment. Sustained recovery is a process focused more on the individual and
is often seen as a lifelong responsibility (like other chronic illnesses) that
may need further support professionally in both nonspecialty (e.g., physi-
cian, health center, medical home) and specialty medical settings, such as
those noted in the ASAM levels of care.
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50 Substance Use Disorders

Recovery
As the treatment goals take hold, recovery begins. As previously noted,
the ultimate goal for each individual is the attainment and sustainment
of wellness and personal recovery. Although treatment is often the plat-
form that makes recovery possible, it is rarely the place where sustained
recovery is born. Recovery is more than abstinence or remission of ill-
ness. Recovery is attained and sustained in the world of the person. Given
the chronic nature of addiction and its treatment, the very definition of
recovery from the illness has been expanded from simple abstinence and
improved health to the attainment of individual progress of recovery out-
come measures such as the following (White, 2008):
1. Reduced alcohol or drug (AOD) use and adverse consequences
2. Improved living environment
3. Improved physical health and reduced health care costs
4. Improved emotional health
5. Improved family relationships and family health
6. Citizenship (legal status, education, employment, community
participation, community service)
7. Quality of life (spirituality, life meaning, and purpose)
At this writing, there are two still evolving definitions of recovery:
1. Recovery is a voluntarily maintained lifestyle characterized by
sobriety, personal health, and citizenship (Betty Ford Institute
Consensus Panel, 2007)
2. Recovery from mental disorders and/or SUDs is a process of
change through which individuals improve health and wellness, live
self-directed life, and strive to reach their full potential. There are
four major dimensions that support a life in recovery (Substance
Abuse and Mental Health Services Administration, website, April
10, 2012):
• Health: overcoming or managing one’s disease(s) or symptoms—
for example, abstaining from use of alcohol, illicit drugs, and
nonprescribed medications if one has an addiction problem—and
for everyone in recovery, making informed, healthy choices that
support physical and emotional well-being
• Home: a stable and safe place to live
• Purpose: meaningful daily activities, such as a job, school,
volunteerism, family caretaking, or creative endeavors, and the
independence, income, and resources to participate in society
• Community: relationships and social networks that provide support,
friendship, love, and hope. White (2012) estimates that today
in America there are some 25 to 40 million (excluding those in
remission from nicotine dependence alone) adults in remission
from significant alcohol and drug problems. Of those, only 17.9%
retained the absence of clinical conditions through a strategy of
complete abstinence. Most recovery is reached through insight,
behavioral change, and attaining or building the previously noted
seven “improvements” in one’s life with less severe, less complex,
and less prolonged problems than those who actually enter
the treatment system. Recovery is a change in lifestyle, and for
 3 PSYCHOLOGICAL ASPECTS OF SUDS, TREATMENT, & RECOVERY 51

many whose illness is severe, treatment is necessary to attain it.

White further reports an attained average remission/recovery
rate at 5 years of about 46% to 50%, with about 30% maintaining
abstinence while others continue in life with some use—but at
subclinical levels.
In recovery-focused care, a key for the practitioner is to engage each indi-
vidual and family in a timely manner and at their precise level of need at
treatment entry, using the tools of exact screening and assessment, stages
of change (e.g., TTM), proper treatment matching or placement (ASAM
guidelines), and motivational interventions (e.g., cognitive therapy, CBT,
MAT, MET) to keep them working at their improved health. Treatment
and sustained recovery can often take years. Because of this, addiction
treatment outcomes too often become compromised by the lack of
ongoing care and support for sustained or long-term recovery. For most,
sustained recovery is generally achieved after three or four episodes of
care over multiple years (Anglin, Hser, & Grella, 1997; Dennis et al., 2005;
Grella & Joshi, 1999), often referred to an addiction career. More than half
of all post-treatment relapses occur within the 30 days of discharge from
treatment (80% within 90 days of discharge) (Hubbard, Flynn, Craddock, &
Fletcher, 2001). This reality has led to the perception that addiction treat-
ment is a “revolving door” whereby individuals are cycled through treat-
ment after treatment, criminal justice, and hospitals; 64% of those entering
treatment today have had prior treatments that did not work (DASIS,
2002). Worse, only one in five patients actually receives postdischarge
continuing care (Dennis, Scott, & Funk, 2003) to address this long-term
need related to a chronic condition.
In the psychology of building recovery, the client’s recovery capital
must be assessed. Recovery capital comprises all the personal, social, and
community resources that can be brought to bear on the initiation and
maintenance of an individual’s recovery (Granfield & Cloud, 1999). Each
person’s recovery capital is different. Although most patient placement
classification systems rely primarily on problem severity and pathology,
recovery capital brings the resources (if present) of the individual—and
of the community (community recovery capital)—into all decisions and
placement (see Table 3.2).
Using Table 3.2, an individual with high to moderate problem severity
might typically warrant inpatient placement of some duration. However,
if that person brings high levels of recovery capital, he or she may ini-
tiate and sustain recovery at much lower levels of care, or may stay
in inpatient or residential care for less time and need lower intensity
post-treatment monitoring. In contrast, an individual at early stages of
addiction with many vulnerability factors (e.g., present severity, family
history of substance use problems, early age of onset, traumatic victim-
ization) and extremely low personal recovery capital who also lives in a
community lacking significant recovery support resources may warrant
placement at a higher level of care and require higher intensity and longer
post-treatment care and support.
Once placed in treatment with a full assessment of both sever-
ity and recovery capital, recovery can be strengthened by continued
52 Substance Use Disorders

Table 3.2 Problem Severity/Recovery Capital Matrix

High recovery capital I High problem severity/complexity
I
I
Low problem severity/complexity I Low recovery capital
From White, W. (2008). Recovery management and recovery-oriented systems of care: Scientific
rationale and promising practice. Pittsburgh, Chicago, Philadelphia: Northeast Addiction
Technology Transfer Center, Great Lakes Addiction Technology Transfer Center, Philadelphia
Department of Behavioral Health and Intellectual disAbility Services.

post-treatment (recovery) check-ups (McKay, 2005; Scott & Dennis,

2011) and linkage of the individual and family from the very beginning
with recovery supports or peers who often have attained their own
recovery (Moos, 2011). This linkage is to those who can support the
individual’s (and family’s) attainment of recovery and is not to any par-
ticular fellowship or organization such as AA, Narcotics Anonymous,
Al-Anon, or S.O.S. WIR. This support person may be a recovery special-
ist or mentor, recovery school or dorm or roommate, recovery cen-
ter, family navigator, care manager, volunteer, or other nonclinician or
peer who is experientially familiar with the community’s services (e.g.,
transportation, employment, outreach, housing, relapse prevention, and
other support services) and who is able to be more assertive in helping
the individual during and after the acute phase of treatment. Recovery
support services are social vehicles for recovery that operate in conjunc-
tion with formal treatment or other existing mutual aid or fellowship
groups (CSAT, 2007), such as recovery centers, recovery dorms, recov-
ery employment centers, family recovery centers, and recovery men-
tors. Along with treatment management, recovery management is a new
philosophy of organizing treatment and recovery supports to enhance
early engagement, treatment compliance (if in treatment), recovery ini-
tiation and maintenance, and the quality of personal and family life over
the long term (White, 2011). Recovery-oriented systems of care are the
networks of indigenous and professional supports designed to initiate,
sustain, and enhance the quality of long-term addiction recovery for indi-
viduals and families and to create values and policies in the larger cultural
and policy environment that are supportive of these recovery processes
(White & Kelly, 2011). Such combined professional and experiential sup-
port is showing significant improvement in attained and sustained recov-
ery while being less costly both in the short and long term (Evans, 2011;
Kirk, 2011; Laudet, 2013).
In addressing substance use disorders in treatment, the patient would
be asked to design his or her own recovery plan to work alongside the
formal treatment plan. A recovery-focused treatment plan addresses
more than the elimination of symptoms from an unchanged life; it is about
regaining wholeness, connection to one’s community, and a purpose-filled
 3 PSYCHOLOGICAL ASPECTS OF SUDS, TREATMENT, & RECOVERY 53

life. What positive attainments can assist the person’s change and health?
Although most treatment addresses the illness, recovery-focused care
builds a pathway to recovery from the illness and wellness. As the positive
aspects of one’s life grow, the negative hold of the addictive life loosens.
As one example for treatment, Dr. Aaron Beck, a founder of Cognitive
Behavioral Therapy (CBT), is advancing recovery-oriented cognitive therapy
(CBT-R), in which he is applying the technology of cognitive therapy to
the negative moods and pathological thoughts of patients to address their
lack of motivation, unhealthy sociality, negative expectations, and illogical
thinking, with noted results of improved trust in treatment, empowerment
of the person, restoration of hope, increased motivation, improved social
integration, and overall satisfaction with treatment (Beck, 2012). These
early findings are confirmed in studies from six countries (including the
United States) using recovery-focused treatment that noted improved
outcomes and reduced costs by connecting the person to recovery sup-
ports, peer supports, fellowships, and the attainment of recovery goals.
This is particularly of value for an illness whose length of needed attention
may be longer than formal treatment and whose wellness is best attained
and sustained in the community where one lives.
Recovery does not always begin in a clinical or treatment setting. Most
recovery happens outside of and even without professional treatment
(DeLeon et al., 2006; Valliant, 1983; White, 2006). Such recovery achieved
without professional or mutual aid assistance is often referred to as solo
or natural recovery and is a viable pathway for shorter and less severe sub-
stance problems and for those with more stable social and occupational
supports (Larimer & Kilmer, 2000; Sobell et al., 1993; White, 2006). Natural
recovery or using one’s own intrapersonal and interpersonal resources
(family, knowledge, kinship, social networks, medical intervention) may be
the most common pathway to recovery. When professional treatment is
involved, it is referred to as treatment-assisted recovery; when mutual aid
or peers are involved, it is peer-assisted recovery. Styles of recovery are
not mutually exclusive. Surveys (White, 2006) have indicated that about
65% of those in AA have had some professional treatment before or
while in AA. In a 2001 national survey of people who self-identified as “in
recovery” or “formally addicted to” alcohol or other drugs, 25% reported
attaining and sustaining their recovery without ever receiving treatment
or mutual aid or fellowship support (Faces and Voices of Recovery, 2001).
Combining treatment of the illness while building wellness or recov-
ery in life has been suggested as the “new medical model” (Barber, 2012;
Flaherty, 2012). Recovery-oriented care parallels the move in other spe-
cialties toward person-centered care. Recovery may find remission of the
illness—cure; it may involve symptom control or long-term monitoring of
the illness by both doctor and patient—recovery with illness management;
or it may involve functioning at one’s best despite ongoing symptoms of
the illness—personal recovery. This is not a new philosophy and is the
same embraced by the disability rights movement, by cancer survivors,
and by people with mental illness (Deegan, 1993) and other chronic con-
ditions. In short, treatment today is optimal when it addresses both the
pathological nature of the illness and the strengths of those ways to attain
54 Substance Use Disorders

recovery from it. An example of using both professional treatment and

recovery-focused care follows:
Mary is a 42-year-old physician who comes to your practice (ASAM
level I) seeking help for what she describes as growing alcohol use.
In your assessment you determine she has had a chronic history of
recurrent depression, including six episodes of electroconvulsive
therapy and the ongoing support of a psychiatrist for medication and
therapy. She reveals that she is currently taking fluoxetine, 40mg
daily; naproxen, 500 mg twice a day as needed; ziprasidone, 160 mg
at night; clonazepam, 1 mg twice a day; bupropion SR, 200 mg daily;
alprazolam, 0.25 mg twice daily; and lamotrigine, 200 mg daily. She
described her alcohol use as one or two drinks daily after working a
long day in a local community health center. Her cognitive abilities
seem good, but she expresses concern that by seeking help she
may be jeopardizing her living. She is also concerned that altering
her medications might cause a reoccurrence of the depression.
Consultative reports from both her employer (also a physician) and
her treating psychiatrist indicate confidence in her patient practice
and judgment. Mary has a family history of alcoholism in both
parents and in a younger brother. She also evidences symptoms
of adult child of alcoholics syndrome (e.g., extreme caretaking,
selflessness) but of never having treatment for it despite having
several prior therapists. She asks you to evaluate her alcohol use
and suggest a plan for her to follow on an outpatient basis that
does not reignite her depression. Considering the multiple Axis
I diagnoses—ethanol dependence and historical recurrent bipolar
depression—and the medications in use and the delicate balance
of her depression, you suspect Mary may be self-medicating or
potentiating her sedative use through her drinking. You suggest
a hospital assessment with rehab to follow, but she declines. She
also declines AA for fear of being recognized and because of past
negative experiences with it. Using her caretaking motivation, you
suggest a week without drinking to assure you, her patients, and
herself that she has the “control” she professes to still maintain.
She agrees to try. You add that you would like her to speak
confidentially over coffee with another female physician (peer
support) who is in recovery over the week to “explain the ins and
outs unique to physicians in treatment and recovery.” Again, Mary
appeals not to do this for fear that person might overstate her
case and be reported to the state licensing board. She asks to try
just outpatient therapy with you. You assure her that this one visit
will not lead to being reported, especially if she isn’t drinking. With
3 PSYCHOLOGICAL ASPECTS OF SUDS, TREATMENT, & RECOVERY 55

Mary’s permission, you set up this meeting. You conclude by telling

Mary that if she cannot quit drinking, she should call you sooner.
You ask her husband to join your session and assist you and Mary in
this plan. He does.
One week later, Mary reports to you that she was able to quit
drinking entirely for 3 days but then returned to drinking even more
(two to four drinks daily) heavily over the weekend. She also added
that she took an old Vicodin to help sleep on Saturday and Sunday
evenings. She did meet with the female physician in recovery, and that
helped. On the admission of her expanded alcohol use, the added
opioid abuse, her own despair and multiple Axis I diagnoses, and
her patient care you insist on a hospital-based (ASAM levels IV and
III.5) evaluation and treatment. Over an extended session, she agrees
and ultimately expresses relief. She has in mind the same facility that
Dr. X, her peer-support coffee partner, went to because it seemed
to provide good medical care and could help manage her depression
while dealing with her substance dependence. Mary’s husband (family
support) concurs, her employer concurs, and her treating psychiatrist
concurs. Mary is relieved of her clinical duties immediately and enters
level IV detox and then level III.5 rehab 3 days later.
Six weeks later, Mary returns from the residential treatment
facility with all medications removed except ziprasidone at night
and lamotrigine each day. She has had no alcohol for the past
42 days and is off all sedatives. She had mild withdrawal, mostly
from the sedatives, but is coping and glad to be off them. She must
now recognize her psychological and social triggers and continue
in care regularly to sustain this recovery. She now agrees to go
to AA—“I need to.” She attended a meeting every day in rehab.
Dr. X. has offered to meet with her as a recovery support once
a week and serve as a temporary “sponsor,” taking her to some
meetings. Her employer has agreed to offer more supportive
oversight and to change Mary’s patient work to nonalcoholic and
nonaddicted persons “as best we can” over the next 6 months.
Mary’s own “recovery plan” calls for her to join Caduceus (society
of physicians caring for physicians) and to attend one meeting or
recovery-focused activity each day for 90 days. She must have
formal therapy at least weekly and participate online with a recovery
support network established by the rehab for 90 days. Mary is
relieved, and her depression is not reoccurring. She again feels like
a whole person and a doctor. She feels her family’s full support and
must now work at sustaining this recovery in her community, work,
and life.
56 Substance Use Disorders

Conclusion
The treatment of substance abuse and dependence remains one of society’s
most perplexing – and expensive - clinical challenges. In one moment, it
seems so simple to say, “just quit it” and follow the guide of others. In
the next moment, it opens up to all of the complexity of an ambivalent
society over use, pleasure, legality, medications, iatrogenic addiction, and
the equally strong complexities that each individual brings to that use and
their recovery. Treatment always reflects the values and knowledge of the
society at the time and, in the case of SUD treatment, the resources of that
society and of the individual, and the very payment methodology in place
(e.g., in-plan or not, fee for service or case rate, insurance or not, authorized
or not) to address the illness before us. No other health condition has so
many involved in determining care. The conscientious clinician must always
keep this in mind and work not only clinically but also in the realm of what
needs to and must be done to achieve medical safety, stabilization, and an
opportunity for attained wellness and recovery in each case.
Addiction or substance dependence is first addressed by establishing a
relationship with the patient that allows for truth, trust, and intervention
at the point at which the patient presents and with the knowledge of
what is needed to succeed. The person will almost always evidence some
degree of denial, minimization, rationalization, and resistance to whatever
is first presented, but that is where the work begins and the relationship
starts. Interestingly, the magnitude of these protestations often parallels
the severity of the illness.
Addressing the pathology alone, however, is not enough for treatment.
When hope is gone, victory cannot be had only by removing the symp-
toms. Building a solid treatment plan on a thorough assessment of the
person’s readiness to change stage and using the evidence-based prac-
tices proved to address the pathology are crucial—but only half of the
job. Adding to that plan the vision and hope of recovery connected to
the supports of one’s family, friends, community, and other attainments
strengthens the impact of treatment with each step of recovery. Recovery
is a change of lifestyle and may consume a lifetime.
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58 Substance Use Disorders

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 Chapter 4 63

Socioenvironmental
Aspects of Substance
Use Disorders
Marilyn Byrne and Laura Lander

Key Points 64
Impact of Substance Use Disorders on the Family
System and Members 66
Substance Use Disorder and Family Influence 68
Family and the Substance Use Disorder Development Stage 70
Family and Its Impact on Discontinuation of Use 72
Family and Its Impact on Treatment and Early Recovery 74
Family and Its Impact on Ongoing Recovery 76
Other System Influences on Substance Use Disorders:
Special Populations 78
Acknowledgment 88
References and Suggested Readings 90
64 Substance Use Disorders

Key Points
• A thorough evaluation for substance use disorders (SUDs) includes an
assessment of biological and environmental family history.
• Genetic makeup, environment, and the “addictiveness” of the drug
all influence the development of SUDs or provide protective factors
against the development of SUDs.
• Family and concerned significant other (CSO) involvement in
treatment should be incorporated in the individualized treatment plan.
• Family and CSOs should be encouraged to adapt their involvement
depending on the patient’s stage of change and recovery.
• Ethnic and racial groups have individualized risk and protective factors.
Substance use disorders (SUDs) take place in a context. In this chapter
we look at the varied sociocultural and familial systems that influence the
development of SUDs as well as their maintenance and treatment.
Urie Bronfenbrenner (1979) developed the concept of the social eco-
logical model. This model is a theoretical framework in which human
development is viewed as being influenced by external contexts in
the larger spheres of our social and cultural world. The relationship
between individuals and the contexts in which they live is reciprocal in
nature. These contexts influence individuals’ sense of self and place in
the world, and in turn individuals influence the contexts in which they
live. This theory divides the larger system in which we function in into
four parts known as contexts or environments: macro-, exo-, meso- and
micro-systems.
The macro-system refers to the global context in which we live.
Influences in this arena include our ethnic heritage, the cultural influences
in the country where we reside, technology, laws, the media, and political
and religious ideology. This context can be seen as a “societal blueprint” of
a particular culture. An example of macro-system influence is the French
tradition that wine is served as part of a meal, normalizing its use rather
than having it represent a mood changer.
The exo-system refers to the influences of the community in which we
live. This includes workplace influences and the culture and density of the
community in which we live, such as the impact of living in an urban versus
a rural setting. An example of exo-system influence is an urban environ-
ment in which there is high unemployment, furthering the use of illegal
behaviors for making a living.
The meso-system includes influences of the specific group, such as reli-
gious institutions, schools, neighborhoods, and sports teams with which
people are directly involved. An example of meso-system influence is a
religious tradition that teaches that drinking is wrong.
The micro-system influences are the family, teachers, coaches, friends,
personal biology, and personality. An example of micro-system influ-
ence is peers exposing others to experimentation with illegal drugs at
a young age.
Each of these spheres affects the expression and maintenance of SUDs.
Each layer of influence also holds information about what can positively
or negatively influence the success of treatment for SUDs. For example,
if an individual is addicted to carisoprodol (Soma) and finds that she can
 4 SOCIOENVIRONMENTAL ASPECTS OF SUDS 65

Macrosystem

Exosystem Na
ws
La m
e
es

Mesosystem
Ne

Parents
ity Servic

igh
bo
rh
Microsystem oo

Works
d
Commun

Ne
igh
bo

pace
ol

rh
ho

oo
Sc

Day Care

Individual
Child

Parents

Bronfenbrenner’s Culture Ecology Model

Macrosystem

History
Exosystem
Extended
Family
Laws
Microsystem

Individual Peers Parent’s

Family Work
Child Environ-
ment
School
Board Siblings
Mass
Media
Culture
Neighborhoods
Social
Conditions
Economic System
66 Substance Use Disorders

obtain this medication legally over the internet without a prescription,

this is an example of the macro-system affecting her SUD by increasing
the availability of her drug of choice. Alternately, if a young man grows up
attending a Pentecostal church and identifies as homosexual, he may expe-
rience stigma and rejection by the religious institution to which he belongs.
This affects him at the meso-system level. His response may be to engage
in alcohol abuse as a way to cope and feel accepted and part of a social
network that does not see him as a sinner. These influences can give the
clinicians insight into what kinds of interventions might be most successful.
A second theoretical model important to understanding how the socio-
environmental aspects of SUDs affect the individual is general systems
theory. The two theories are complimentary; Bronfenbrenner’s social
ecological model identifies the parts of the larger system in which we
all live, whereas general systems theory focuses on how the parts of the
system interact with one another. General systems theory had its origins
in biological science (Bertalanffy, 1968). Key concepts in this theory are
feedback and homeostasis. Feedback refers to the circular way in which
parts of a system communicate with each other. For example, in a fam-
ily system, the wife may identify that she drinks excessively because her
husband ignores her and she is depressed. The husband may in turn state
that he avoids his wife because she is always drinking and sad. Each per-
son’s behavior becomes reinforcing feedback for the other Homeostasis.
refers to the idea that it is the tendency of a system to seek stability and
equilibrium (Brown & Christensen, 1986). For example, a wife may cover
up her husband’s drinking by making excuses to friends and to his boss for
his moodiness and missed work days to try and prevent him from losing
his job because such a loss would significantly affect the stability of the
family. Her efforts enable his substance abuse to continue with limited
consequence, but keep the family system at relative equilibrium without
negative impact from the exo- and meso-systems.
Family systems theory is a specific example of a system that fits within
the framework of general systems theory. The primary understanding
of family systems theory holds that when treating an individual you are
actually working with that individual in the context of the family con-
stellation whether that individual is an adult or a child. Family systems
theory actually goes as far as saying that the individual presenting in
your office is merely the expression of the pathology found in the fam-
ily system. Family systems theory developed in the late 1960s and early
1970s. Salvadore Minuchin, Murray Bowen, Carl Witaker, and Nathan
Ackerman were highly influential figures in this movement and its appli-
cation to psychiatric treatment. The idea that individuals cannot be fully
understood or successfully treated without first understanding how they
function in their family system is central. Individuals who present in our
offices are seen as “symptomatic,” and in this theory their pathology
would be viewed as an attempt to adapt to their family of origin so as
to maintain homeostasis. Although that adaptation may keep the family
system in a state of equilibrium, as in the example of the wife covering
up her husband’s drinking, it maintains the problem. The idea of homeo-
stasis is key in that each family member must function in such a way that
keeps the whole system in balance even if it is not healthy for specific
individuals in the family.
 4 SOCIOENVIRONMENTAL ASPECTS OF SUDS 67

Impact of Substance Use

Disorders on the Family System
and Members
It is estimated that more than 8 million children younger than 18 years live
with at least one adult who has an SUD. This is more than 1 in 10 children.
Most of these children are under the age of 5 years (U.S. Department of
Health and Human Services [DHHS], 2009). Studies of families with SUDs
reveal patterns at the micro-system level that significantly influence the
development of personality and the likelihood that a child will develop an
SUD. In addition, we know that children of parents with SUDs are more
likely to have poor school performance, depression, and delinquency
(Gfroerer & De La Rosa, 1993; Gross & McCaul, 1991–1990; Johnson et al.,
1989; Moos & Billings, 1982; West & Prinz, 1987). The negative impacts of
parental SUDs on the family culture include disruption of rituals, roles,
routines, communication, social life, and finances. Families in which there
is a parental SUD often foster an environment that is characterized by
secrecy, loss, conflict, violence or abuse, role reversal, and fear.
Patients with SUDs cannot be understood and treated effectively
without consideration of the impact of the family. All persons influence
their social environment and in turn are influenced by it. Family systems
researchers have confirmed the reciprocal relationship between the dis-
order of SUD and the environment. Not only does an individual affect his
or her surrounding systems, but also individuals and their surrounding sys-
tems mutually influence each other (another example of feedback). The
family, representing the micro-system, consequently must be factored into
the understanding of the disorder development, maintenance, and efforts
necessary for successful ongoing recovery.
In this chapter we also address important considerations of family and
culture across stages of SUD. Identifying stages of the SUD and corre-
sponding family involvement demonstrates not only that the disorder
progresses but also that the family response has a predictable pattern in
that progression. Identifying this pattern is useful in formulating plans for
intervention. Starting with genetic influence and proceeding to stages of
experimentation, use, disorder emergence, recognition, and acceptance of
the disorder state, and finally through treatment and recovery, there are
considerations for the health practitioner at each stage.
Although much of the work around family and SUD has focused on the
role the family plays in the patient’s acceptance, treatment, and maintenance
of change, the impact of the SUD on the family members merits atten-
tion in and of itself. Each family member is uniquely affected by outcomes
including but not limited to difficult feelings related to the disorder process,
economic hardship, unmet developmental needs, and violence being perpe-
trated against each of them. For offspring there is also an increased risk for
becoming alcohol or drug abusers themselves. Thus, treating only the per-
son with the active SUD is limited in effectiveness. From a community health
standpoint, treating the individual only has limited impact in that much of
the devastation of the disorder of alcoholism is ignored. From an individual
health standpoint, treating the individual without the family limits the effec-
tiveness because it ignores the systemic supports for change or homeostasis.
68 Substance Use Disorders

Substance Use Disorder

and Family Influence
No single factor determines whether a person will develop an SUD;
rather, three broad risk factors contribute. Biology and genetic makeup,
the environment, and the addictive qualities of the drug, and the drug’s
route of administration constitute the three major risk factors contributing
to the development of an SUD (NIDA, 2007).
It is estimated that 40% to 60% of a person’s vulnerability to the disorder
is accounted for by genetics, suggesting that a family history of SUD is a
necessary element in patient evaluation (NIDA, 2007). Children of alco-
holics are between four and nine times as likely to develop alcohol use
disorders (Straussner & Fewell, 2006). In the assessment process, clinicians
should inquire about generational patterns of SUD and mental disorders.
In addition to the genetic component, the home environment influ-
ences the development of the disorder in multiple ways. Early exposure
to use by family members or others increases a child’s risk for problems
with SUD. Research shows that the earlier children use substances, the
more likely they are to progress to serious abuse or dependence (Lynskey
et al., 2003). Because the prefrontal cortex, the center of decision mak-
ing and emotional control in the brain, is still developing during adoles-
cence (Gotay et al., 2004), introducing drugs at this time has profound and
enduring consequences.
Apart from genetics and the physiological impact of early use, the family
environment provided by caretakers with SUDs provides unstable and
inconsistent living conditions, inadequate caretaking and supervision, and
exposure to violence. A chaotic home and the lack of emotional or physi-
cal supervision and abuse or violence increase the risk for early use of
substances by offspring. Children of alcoholics and drug addicts are also
at risk for other mental health problems, which in turn increases their risk
for development of SUDs. Peer and community attitudes coming from the
meso- and micro-system levels shape beliefs and patterns of experimenta-
tion and early use. On the other hand, a functioning family that offers a
secure, cohesive, mutually supportive environment with appropriate roles,
effective communication, family routines, and expression of positive affect
provide for protective factors against the development of addictive disor-
der (Straussner & Fewell, 2006).
In the evaluation process, it is important to assess both the risk factors
and the protective factors. For example, having a father who is an alcoholic
and is abusive toward his son introduces genetic and environmental risk
factors, while that same child may have protective factors such as strong
bond with a geographically close grandparent and regular involvement in a
church group with positive peers and routine positive adult modeling and
emotional connection.
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70 Substance Use Disorders

Family and the Substance Use

Disorder Development Stage
Much of the early literature (Brown & Lewis, 1999; Jackson, 1954; Steinglass
et al., 1987) regarding the process of family adjustment and coping with
an active SUD recognizes stages that speak to (1) recognition of disorder
development, (2) discontinuation of use, (3) treatment and early recovery,
and (4) ongoing recovery.
In the beginning family members often resist change in many ways.
There can be alternating recognition/labeling and resistance to recognition
of SUD-related behaviors. The family hopes that the escalating symptoms
are just a stage or a passing response to situational events. During this
phase the family members may try to cover up, knowingly or unknowingly
enabling and denying substance use as an issue. For example, a spouse may
at times experience anger and fear, attempt to stop use by a spouse or
child, and cover over problematic outcomes, while at other times believ-
ing that the use is not a problem. At times denial can be as strong within
the family as it is in the person with the SUD. Family members may accom-
modate substance use and its outcomes to the extent that they actually
inadvertently support use. The hope for normalcy allows the family to
ignore danger signs, defending themselves from fears and their loved one
from external judgments and consequences. These efforts are an example
of homeostasis in the family system.
When the family system has accommodated the SUD and its behaviors,
it becomes more rigid and closed. Counter-intuitively the preservation of
the unhealthy system supersedes the needs of the individual family mem-
bers, including children and adults (Steinglass et al., 1987). Having made a
series of adjustments to cope with the presence of an SUD in the family,
the family can demonstrate a high degree of stability. It is in this first stage
that we see the emergence of what is popularly known as enabling. Grasp
of this concept is essential to understanding the development of the disor-
der process. The word “enable” usually implies a helpful process, one that
suggests a relationship between an action and a positive outcome. In the
SUD process, enabling results in negative outcomes. Enabling is the inter-
ference with personal or societal consequences of the disorder of SUD,
which inadvertently contributes to its continued development. Examples
of enabling include providing money that might be used for alcohol or
drugs, paying fines related to use, bailing the family member out of trouble,
or keeping secrets regarding the scale of the use of alcohol or drugs.
Appreciation of the co-evolutionary nature of the system allows one to
see enabling and denial on the part of family members as adaptive and
protective of the family system, whereas denial on the part of the patient
is protective of the ongoing disorder process.
 4 SOCIOENVIRONMENTAL ASPECTS OF SUDS 71

Implications for the Clinician: Stage 1—Recognition

of Disorder Development
• Always assess the family history of SUD (alcohol or any drug
dependence).
• Include concerned significant others (CSOs) in the evaluation when
possible and assess the family member’s acceptance of disorder
state; elicit family members’ perceptions of the problem.
• Examine discrepancies between a patient’s and others’ perceptions
of the use and related problems.
• Inquire about age of initiation of use of alcohol and drugs.
• Educate the patient and CSOs about three major risk
factors: genetics, environment, and the drug of abuse and route of
administration.
• Educate specifically about drugs of abuse being prescribed and their
addictive potential.
• Educate CSOs about denial and enabling; avoid labeling when
discussing these concepts.
• Help CSOs articulate the impact of the patient’s use on them.
72 Substance Use Disorders

Family and Its Impact on

Discontinuation of Use
Change can occur when there is recognition by some part of the system
that there is a problem. Recognition and acceptance of the disorder and
its associated behaviors emerge when at least one person in the family
recognizes the problem and gives rise to a hope for change. At this stage,
there is instability in the family and disequilibrium in the system, which is
uncomfortable for individuals within the system but which increases the
possibility for change.
The transition from the active using and disorder development phase
to discontinuation of use is usually brought on by some negative event
or loss. Social consequences (job problems, illnesses, child problems, or
legal problems) can be significant motivators to treatment. It is when the
pattern of use and accommodation of use become destabilized by nega-
tive occurrences at the micro-, meso-, exo- or macro-system level (such
as threats of relationship loss, accidents and employer warnings or job
threats, police or legal involvement) that an individual or a family member
may reach out for help or be receptive to a clinician’s suggestion regarding
the need for treatment. If the person with the addictive disorder refuses
treatment, the family members nevertheless should be encouraged to
seek more information or treatment for themselves or attend family
self-help programs. Even if the person with the SUD refuses treatment
at this point, family members can be educated about their behaviors that
contribute to the stabilization of the disorder process. These behaviors
are often referred to as “enabling” and are best seen as learned patterns
intended to improve the situation and stabilize the family system while in
actuality allowing the disorder process to flourish.
Clinicians can be helpful at this stage even if the person with the addic-
tive disorder is not yet ready to engage in change. They can help fam-
ily members (1) recognize the impact of the disorder on each of them,
and (2) increase their awareness of enabling behaviors. In some instances
family members can be educated to take a very active position in con-
fronting the family member with the necessity of treatment. Originally
promulgated by the Johnson Institute (Johnson, 1998) and more recently
popularized by television, interventions by family members can be success-
ful in moving the alcoholic or addict to active treatment. An intervention
(a detailed accounting of the impact of the SUD with a proposed plan of
action regarding the need for treatment and stated consequences if the
person involved does not accept treatment) can effectively be used at this
stage to increase receptivity to treatment.
 4 SOCIOENVIRONMENTAL ASPECTS OF SUDS 73

Implications for the Clinician: Stage 2—

Discontinuation of Use
• Acknowledge, respect, and work with ambivalence regarding change.
• Use destabilizing events to motivate to treatment; support
recognition of disorder by individual or CSOs.
• Move quickly when treatment is wanted.
• Work with patient and CSOs to clearly articulate and specify impact
of addictive behaviors on individual and family.
• Formal interventions can be used to motivate to treatment but
require a thoughtful, compassionate, clear plan of action.
• Encourage CSO involvement in treatment and self-help regardless of
patient decision about treatment.
74 Substance Use Disorders

Family and Its Impact on Treatment

and Early Recovery
The transition from the discontinuing use stage to the engagement in
treatment stage is often accompanied by unexpected emotions (e.g., fear,
anger) as well as destabilizing roles in the family (often around issues
related to responsibility) and loss of homeostasis. For example, an ado-
lescent may begin using alcohol and drugs in response to a parent’s absti-
nence. A spouse may feel extreme anger rather than the expected relief
as the partner begins to get clean and sober.
Change for both the patient and the family is the most possible at the
time of destabilization. As the family seeks to regain homeostasis, change
can occur most effectively if both the person with the addictive disorder
and the family members are actively engaged in the process. Ideally the
patient will be involved in significant cognitive and behavioral changes.
Family members can also be encouraged at this time to learn about the
disorder and its impact on both the individual and the family. Learning
about kinds of treatment, length of treatment, the role of relapse in
chronic disorders, activities that support successful recovery, and appro-
priate roles and activities for family members and CSOs are all elements
of successful treatment support.
Early recovery is often not a time of the “family pulling together”
(Brown & Lewis, 1999). It is tempting for clinicians to attempt at this time
to immediately restabilize the family. It is better, however, to encourage
a focus on individual recovery for each patient and family that in turn
supports foundational building blocks for the development of a healthy
system. Encouraging individual responsibility for new recovery behaviors
interrupts old enabling patterns that allowed the disorder to flourish with-
out apparent consequences. For example, parents may be encouraged to
see that their adolescent son should be responsible for a debt related to
past use rather than restoring harmony to the family and relief to the son
immediately by paying the debt. A family member may be encouraged to
abandon previous rituals that contributed to use or abuse.
In this time of dramatic changes, it is best if family members are involved
in the change process. Both family systems theory and the social ecological
model suggest that change is best initiated and supported when the whole
family is involved in treatment. Involving families in family therapy when
treating SUDs has been associated with better retention and completion of
treatment, reduced substance abuse (Liddle et al., 2001; Stanton & Shadish,
1997; Williams et al., 2000), reduced problem behaviors (Szapocznik et al.,
2003), and improved academic performance (Williams et al., 2000).
 4 SOCIOENVIRONMENTAL ASPECTS OF SUDS 75

Implications for the Clinician: Stage 3—Treatment and

Early Recovery
• Length of treatment is a factor in successful outcomes; encourage
involvement in treatment at different levels of care (inpatient,
outpatient, IOP, residential, self help).
• Teach about the SUD as a progressive disorder with potential for
recovery and relapse.
• Use evidence-based treatments for both the patient and CSOs.
• Support cognitive and behavioral changes.
• Provide, facilitate, and refer to family education and treatment
groups.
• Refer to self-help groups for both patient and family.
76 Substance Use Disorders

Family and Its Impact on Ongoing

Recovery
In ongoing recovery, abstinent behaviors and supports for those behav-
iors have been developed and solidified. However, the family educated
about SUD recognizes that relapse is a factor in any chronic illness. The
development of new interests and a support network that is consistent
with recovery marks change for the whole family. This change may include
not associating with friends who have SUDs of their own. New individual
behaviors and patterns that support ongoing recovery are built into the
family rituals and roles. One common change is for families to establish
new ways to celebrate that do not involve drinking or drug use. The
strong foundation in individual recovery and behavioral patterns support-
ing ongoing recovery give space for increasing focus on healthy relation-
ship patterns that include flexibility, open communication, respect for the
individual, and intimacy.

Implications for the Clinician: Stage 4—Ongoing Recovery

• Continue support and inquiry regarding abstinence and recovery
with individual and family and CSOs.
• Help family develop a plan in case of relapse.
• Support lifestyle changes in the individual and family that sustain
recovery.
• Support identification and expression of feelings that were masked
or made unsafe by the presence of the SUD.
• Assess cohesiveness, problem-solving capacities, routines and rituals
that support recovery, and individual and family identity.
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78 Substance Use Disorders

Other System Influences on

Substance Use Disorders: Special
Populations
Societal and cultural factors associated with age, gender, class, ethnicity,
and other subgroup populations significantly affect the development of
SUDs in the individual at the macro-system and exo-system levels. These
effects are not only geographic and cultural but also ideological. The
culture with which an individual is affiliated provides one more channel
through which norms and values are conveyed and behaviors are viewed.
It is important for the clinician to know both cultural differences in values
and norms as well as his or her own biases toward these different groups
when working with families or individuals from a population that is differ-
ent from the clinician’s own race or culture.
In general, racial and ethnic minorities receive inferior heath care
and have worse health outcomes in the United States than whites. This
includes their access and utilization of substance abuse treatment (Schmidt
& Mulia, 2009). Understanding differences in racial and ethnic minorities
will increase appreciation for variation in treatment needs. For example,
differences in SUDs by ethnicity exist. A variety of factors have been
indentified to serve as an explanation as to why. These include cultures
and norms favorable to use, availability of drugs, and neighborhood pov-
erty (Wallace, 1999). In addition, the understanding of the effects of immi-
gration on various ethnic minorities is essential for understanding their
cultural values (CSAT, 2004).
Ethnic minority groups studied are generally broken down into black/
African American, American Indian/Alaska Native, Asian, mixed race of two
or more races, and Hispanic/Latino. There is great diversity among indi-
viduals of the same race sometimes based on geographic locations, accul-
turation, and other factors. Consequently the descriptions listed below are
generalizations and should be understood as such. What is most important
is to solicit the specific stories of the patient in front of you so as to offer
the most effective treatment that will be consistent with the patient’s val-
ues and cultural beliefs. Acculturation is key with regard to assessment
and to having a sense of how strong the cultural influence might be in
terms of the patient’s worldview. The more acculturated patient is more
Americanized, and his or her ethnicity might play a less prominent role.
Examples of SUD differences in ethnicities can be seen in many ways.
For example, the National Survey on Drug Use and Health (NSDUH)
reports that in 2010, among persons aged 12 years or older, rates of sub-
stance dependence or abuse were lower among Asians (4.1%) than among
other racial/ethnic groups, including American Indians/Alaska Natives
(16%), persons reporting two or more races (9.7%), Hispanics (9.7%),
whites (8.9%), and African Americans (8.2%) (U.S. DHHS, 2010b).
African Americans
African Americans are the second largest minority and represent 12.6%
of the U.S. population. Generally African Americans share some common
 4 SOCIOENVIRONMENTAL ASPECTS OF SUDS 79

Implications for the Clinician

• Being treated with respect is a core value and essential for
engagement.
• Personal connection between clinician and patient may be the most
important element in treatment (CSAT, 2004).
• African American patients can be highly sensitive to an authoritarian
or patronizing approach (Boyd-Franklin, 1989).
• Immediate and/or extended family members should be included
whenever possible.

cultural themes: They are bonded by their racial and cultural heritage, have
a strong sense of spirituality, and are shaped by a history of social injustice
and inequality. Community and family are strongly valued, including the
importance of elders in the family. Contrary to popular belief, black youths
who remain in school are less likely than their same-age white, Latino,
or American Indian peers to engage in substance abuse (NRC, 2009).
However, living in an urban environment where they may be exposed to
substance use regularly and where there are limited employment oppor-
tunities creates risk at the meso- and exo-system levels. Disproportionate
numbers of African Americans live in urban settings and in poverty. These
meso-system factors heavily influence substance use. Assertiveness and
standing up for one’s rights are valued. The church is often a core influ-
ence at the exo-system level.
Hispanics
Hispanic/Latinos are the largest and fastest growing minority in the United
States, representing 16.3% of the population. This group is composed
of a variety of racial and ethnic groups with different cultures, including
Mexican, Puerto Rican, Cuban, South American, Dominican, and Spanish.
A disproportionate number of Hispanics live in urban settings and in pov-
erty. The experience of specific groups of Hispanics often has to do with
the original reasons for the group’s immigration to the United States. For
example, Cuban Americans have been granted more governmental sup-
port as a result of fleeing an oppressive communist government compared
with Mexican Americans (NRC, 2009). Understanding a patient’s immigra-
tion history is essential.
In general, Latinos have strong traditional family values. Respect, posi-
tive social relationships, and a cultural emphasis on politeness prevail.
Assertiveness and confrontation are frowned on. There is a patriarchal
hierarchy in the family system (NRC, 2009). The family is most often an
extended family unit, including cousins, aunts and uncles, and godparents
with whom there are very close ties (CSAT, 2004).
More acculturated individuals show higher rates of substance abuse.
For example, English-speaking Mexican Americans are eight times more
likely to smoke marijuana than Spanish-speaking peers. Similar trends exist
among Puerto Ricans as well (Cuadrado & Lieberman, 1998).
80 Substance Use Disorders

Implications for the Clinician

• Family therapy can often be an effective intervention because it is
consistent with the core values around the importance of the family
system.
• Hispanic families often resolve conflict differently than Western
families. Children are not encouraged to speak their mind because
the family system is hierarchical and respecting elders is paramount
(Santisteban & Mena, 2009).
• Be sure to ask about immigration history.
• Various ethnic subgroups may have a more permissive attitude
toward substance abuse.
• Solicit feelings in a subtle and indirect way– don’t be business-like.
• Discuss spiritual views and beliefs.

American Indian/Native Alaskan

American Indian/Native Alaskans are 0.9% of the U.S. population. Less than
one-third of American Indians live on reservations, and the majority live in
urban settings. They are the most impoverished ethnic group in the United
States, with a history of oppression and discrimination connected to their
removal from their traditional lands. This group has a strong sense of spiri-
tuality, and elders hold a high position and a strong sense of community
and family. Values include sharing, cooperation, harmony with nature, and
orientation in the present (Sue & Sue 1999). There is a high incidence of
inhalant use and alcohol use among this group (NRC, 2009). Youths have
higher rates of substance abuse compared with other ethnic groups. This
may be due in part to failure to rebuild a sense of culture after the oppres-
sion they have experienced as well as permissive attitudes among adults.
The NSDUH study, sponsored by the Substance Abuse and Mental
Health Services Administration (SAMHSA), also shows that American
Indian or Native Alaskan adults have a rate of past-month binge alcohol
drinking (i.e., five or more drinks on the same occasion—on at least 1 day
in the past 30 days) well above the national average (30.6% vs. 24.5%) (U.S.
DHHS, 2010b). The level of past-month illicit drug use was also found
to be higher among American Indian or Native Alaskan adults than the
overall adult population (11.2% vs. 7.9%).

Implications for the Clinician

• Include immediate and/or extended family members whenever
possible.
• Depending on the tribe, families can be matriarchal or patriarchal,
but usually there is one prominent male or female leader in a family.
Gaining a family’s trust is essential (McGoldrick, 1982).
• Clinical interventions consistent with Native American culture, such
as storytelling, metaphor, and paradoxical interventions, can be
effective (Sutton & Broken Nose, 1996).
• With regard to communication style, listening and observing can be
more important than verbal communications (Paniagua, 1998).
 4 SOCIOENVIRONMENTAL ASPECTS OF SUDS 81

Asians
Asians represent 4.8% of the U.S population. There are 60 racial/eth-
nic subgroups in this classification falling into three main categories—
Pacific Islanders (Hawaiians, Samoans, Guamanians), Southeast Asians
(Vietnamese, Thai, Cambodian, Laos, Burmese, and Phillipino), and East
Asians (Chinese, Japanese, Korean) (CSAP, 1997). Each group has a varied
history, culture, language, and religion. Most Asians in the United States
live in urban areas. In general, Asians have a very negative view of sub-
stance abuse and may engage in secret keeping and denial. Asians have
a nationalistic culture with an emphasis on harmony, working together,
and mutual interdependence. Concepts of time and communication are
quite different than those of Western culture. Time is considered a healer.
Communication is in large part nonverbal, but the nonverbal cues have
different meanings than Western nonverbal cues (NRC, 2009).
In general, Asians have the lowest rates of SUDs among the main ethnic
minorities. There is a strong emphasis on education and academic achieve-
ment in the culture. The expectation of children is that they should be
quiet and obedient. Values of moderation and restraint may help explain
lower incidence of substance abuse. Genetic predisposition to “flushing”
when drinking alcohol may reduce incidence of heavy drinking. Second-
and third-generation Asian Americans are at higher risk for substance
abuse (Mercado, 2000) than first-generation Asian Americans (Mercado,
2000). As with other cultures, as individuals become more acculturated to
the United States, their incidence of substance abuse increases.
Age, gender, and sexual orientation can affect the development,
maintenance, and treatment of SUDs from a biological standpoint at
the micro-system level as well as socioculturally at the meso-, exo- and
macro-system levels. Specific influences on these special populations
will vary by region but most often include ostracism or marginalization
by the mainstream culture. This can drive individuals from these special
populations to seek comfort in substance use or to have their use go
undetected.

Implications for the Clinician

• Deference to authority, emotional inhibition, hierarchical families,
and gender-specific roles are all characteristics of Asian culture that
may affect treatment.
• Asian families are patriarchal. The family patriarch may need to be
involved to help facilitate change.
• Asians are often reluctant to admit to having a substance abuse
problem, believing that it may be shaming to the family.
• Family members may participate in enabling, keeping the problem
hidden (Chang, 2000).
• Asians generally are uncomfortable with confrontation. Their culture
places high value on “saving face” and avoiding shame or humiliation.
The very act of engaging in treatment and discussing family issues
with a stranger can be seen as weak (Lee, 1996; Paniagua, 1998).
82 Substance Use Disorders

Elderly
SUDs affect 17% of adults older than 60 years. There are both biological
and psychosocial issues that make elderly adults more susceptible to sub-
stance use problems. Older adults are often more sensitive to alcohol and
medications on a biological level, and their bodies do not process these
substances as efficiently as younger adults, thereby increasing the effect.
Only recently has the extent of the problem received attention in the sub-
stance abuse and gerontology literature. Diagnosis can be difficult because
the symptoms of common problems in elderly people, such as dementia
and depression, are similar to the signs of SUDs (CSAT, 1998). The extent
of the substance abuse problem can often go undetected among older
adults because they are no longer in the workforce, can be socially iso-
lated, and drive less, which reduces the likelihood that a problem would
be recognized.
There are generally two patterns of abuse among older adults: a chronic
lifelong pattern of use or a recent pattern of misuse in response to a life
transition such as retirement, death of a loved one, or physical illness.
Physiological changes associated with aging, including a decrease in water
content in the body, can result in reduced tolerance (Dufour & Fuller,
1995). In addition, early onset of dementia can cloud accurate diagnosis
because drug or alcohol intoxication can sometimes be misdiagnosed as
dementia. Studies have shown that ageism contributes to the underdetec-
tion of substance abuse in older adults (Ivey et al., 2000).
Prescription drug abuse and misuse are also common among older
adults. More than 36% of individuals older than 60 years use five or more
prescription drugs monthly (Gu et al., 2010). For some individuals, the
misuse of prescription drugs is accidental and is a result of confusion;
others may overmedicate purposely to achieve an altered state or may
even be selling medications to supplement their income. The incidence of
depression is higher among older adults, which puts them at higher risk for
abusing substances in an effort to self-medicate mood disorders. Medical
comorbidities can complicate the diagnostic picture.

Implications for the Clinician

• Treatment is more effective and the prognosis better in individuals
who have only recently developed a pattern of abuse or dependence
on substances (CSAT, 2004).
• Gathering an accurate substance abuse history is important.
• Involving family members of the older adult in treatment can
increase both effectiveness and retention in treatment.
• Family members can often be helpful in providing transportation and
in reminding patients of appointments.
• Because of high rates of comorbidity, collateral contact with
physicians or nursing staff treating other medical or psychiatric
illnesses is important.
• Patients may be struggling with end-of-life issues such as death of a
loved one or fears of their own death, which may contribute to their
substance use.
 4 SOCIOENVIRONMENTAL ASPECTS OF SUDS 83

Gay/Lesbian/Bisexual/Transgender
There is some evidence to suggest that substance abuse rates among the
gay/lesbian/bisexual/transgender (GLBT) population are greater than that
of the population as a whole, but currently no large-scale national studies
have been done (Rosario, Hunter, & Gwadz, 1997; U.S. DHHS, 2010a).
It is hypothesized that these individuals use substances to cope with the
social stigma of their sexual orientation. Interestingly, gay men and lesbians
report alcohol problems nearly twice as often as heterosexuals, but their
drinking patterns differ minimally (McKirnan & Peterson, 1989). A factor
to consider when working with this population is that they have likely
experienced different forms of harassment with regard to their sexual
orientation as well as possible physical or sexual assault.
Women
According to the 2010 NSDUH (U.S. DHHS, 2010b), the rate of current
illicit drug use among persons aged 12 years or older was higher for males
(11.2%) than for females (6.8%). Males were more likely than females to be
current users of several different illicit drugs, including marijuana (9.1% vs.
4.7%), nonmedical use of psychotherapeutic drugs (3% vs. 2.5%), cocaine
(0.8% vs. 0.4%), and hallucinogens (0.6$ vs. 0.3%). Despite lower rates of
substance abuse among women than men, the consequences for women
are significant. Studies show that women begin using substances for differ-
ent reasons than men. For example, the death of a loved one or divorce
(Brady & Randall, 1999) is more likely to present with women as a reason
underlying the increasing use. Women also have barriers to treatment,
such as child care responsibilities and a stigma associated with female sub-
stance abuse. Women often develop more severe substance abuse prob-
lems in a shorter time than men and use lesser amounts but with greater
negative consequences. This is known as the telescoping effect (Diehl et al.,
2007). Women with SUD have a high incidence of interpersonal violence
and sexual assault (Covington, 1999; Lincoln et al., 2006).
Pregnant Women
According to the NSDUH 2010 (U.S. DHHS, 2010b), 4.4% of pregnant
women aged 15 to 44 years were engaged in current illicit drug use based
on data averaged across 2009 and 2010. This was lower than the rate
among women in this age group who were not pregnant (10.9%). The

Implications for the Clinician

• GLBT patients may present as “out” with their sexual orientation
or as “closeted,” meaning they keep their sexual orientation hidden,
which can affect their substance use.
• When initiating treatment, you may or may not know an individual’s
sexual orientation, so it is important to be sensitive to this fact.
• If a GLBT person is closeted to their family, familial involvement
should proceed cautiously.
• Involvement of same-sex partners in treatment can be very effective.
84 Substance Use Disorders

rate of current illicit drug use was 16.2% among pregnant women aged
15 to 17 years, 7.4% among pregnant women aged 18 to 25 years, and
1.9% among pregnant women aged 26 to 44 years. This places teenage
mothers and their unborn children at an even higher risk given the high
rates of substance abuse. Pregnant women with SUD are at higher risk
for anemia, gestational diabetes, hepatitis C, sexually transmitted disor-
ders, poor oral hygiene, cystitis, and depression and anxiety. Obstetric
complications that are commonly associated with pregnant women with
SUDs are placental abruption, intrauterine growth restriction, spontaneous
abortion, premature rupture of the membranes, preeclampsia, intrauterine
fetal death, and premature labor and delivery (Helmbrecht & Thiagarajah,
2008). Babies born to mothers with SUDs are at increased risk for neonatal
abstinence syndrome, sudden infant death syndrome, low birth weight, and
early childhood cognitive and behavioral problems (Jones et al., 2010; Little
et al., 2003).
Pregnant women frequently express reluctance to seek treatment for
SUDs because of fear of being judged by health care providers and being
reported to child protective services. Research suggests that coordina-
tion of care can improve clinical outcomes for both the baby and mother
(Bahl et al., 2010; Wong et al., 2011). Specifically, the integration of care
between substance abuse treatment, pediatrics, and obstetrics is essential.
Babies born to mothers with SUDs frequently need neonatal intensive
care unit care. Often, these different disciplines do not have an apprecia-
tion for what the others do, so as part of integration, education across
disciplines is essential and will help retain pregnant mothers in treatment
for SUDs even after they give birth.

Implications for the Clinician

• Women often come into treatment sicker than men because they
often wait longer than men do to seek treatment.
• Women may be reluctant to be entirely truthful about their history
of use because of fears of Child Protective Services involvement and
the removal of their children.
• Issues particularly relevant to women include shame, stigma, trauma,
and loss of control.
• Women tend to hide their substance abuse more than men due to
the shame.
• It is critical to address environmental safety issues such as assessing
risk for domestic violence or having a partner with an active SUD.
• History of trauma should be assessed when treating women because
the incidence is high among women with SUD and unresolved
trauma issues can present barriers to successful treatment.
 4 SOCIOENVIRONMENTAL ASPECTS OF SUDS 85

Case Vignette 1
Sarah is a 42-year-old divorced woman seeking help from her family
physician for symptoms of depression. She is irritable, has crying spells,
and has limited social outlets. She is the mother of three children, ages
22, 18, and 12 years. Two children still live in the home. She works at
a minimum-wage job and has health benefits. Her religious beliefs are
important to her, but work and family leave her little time for church
involvement or recreational outlets. She has been divorced for 10 years
from her alcoholic husband who provides periodic financial support for
the youngest child.
Sarah went to Al-Anon when her husband first went to treatment.
She remembers that an alcohol use disorder is a medical disorder and
clearly sees the pattern in both her family and his. She recalls that her
husband relapsed despite her involvement with his treatment. Josh, her
22-year-old son, is on probation for possession of drugs. He has not kept
a job for more than 3 weeks in the past 2½ years, and Sarah worries
that he has friends who are bad influences. Sarah frequently helps him
with his rent and is too exhausted to participate in his mandated treat-
ment program despite a recommended family component. She is angry
that SUD has again emerged in her life. She asks you for help with Josh.
• What treatments would you consider for Sarah?
• What recommendations would you make regarding Josh?
• What micro- and meso-system level considerations are important in
the understanding of this case?
Answers to Case Vignette 1
Educate Sarah about SUDs, including their genetic and familial compo-
nents. Help her to identify the need to address her own depressive
symptoms. Teach about enabling and help her identify those behaviors
that contribute to the interruption of the consequences of her son’s
use. Help her identify and cope with the feelings associated with this
loss. Encourage her attendance at the family program and at Al-Anon.
Encourage Sarah to assist with an evaluation for her son Josh. In your
work with Sarah, it is appropriate to meet with her son Josh. However,
an evaluation of him would be best done by a referral to another clini-
cian. Your work with Sarah needs to have continued emphasis on her
well-being regardless of Josh’s engagement in treatment.
On a micro-system level, Josh has been affected by both his father’s
SUD and his mother’s enabling. His biology has exposed him to the
genetic influence of addictive disorders. He most likely saw substance
use at a very early age. Appropriate supervision of him may have been
interrupted by a focus on his father or by beliefs influenced by the fact
that heavy use was normalized in his family life.
On a meso-system level, he and his family may have been isolated
from important religious traditions and community functions because of
his father’s alcoholism and the family response to it.
86 Substance Use Disorders

Case Vignette 2
Randall, a 48-year-old African American environmental services worker
from the local University Hospital is referred to you from the hospital
Employee Assistance Program (EAP) services. Recently he was caught by
hospital security selling marijuana to another employee. EAP sends you a
urine drug screen, which is positive for cannabis and opioids. A Board of
Pharmacy report indicates he has no active prescription for pain medica-
tion. Randall is being required by his employer to attend treatment in
order to retain his job.
Randall denies regular use or sale of drugs and says it was just a
“one-time thing.” He reports no history of any legal problems in the past
and has a good work record. He has never been treated for substance
abuse or mental health issues, nor does he think he needs treatment.
However, he is willing to come and see you because he does not want
to lose his job.
Randall is divorced and has two teenage children from whom he is
estranged. He currently lives with his mother. His father is deceased. He
is the youngest of three siblings, who all live locally.
• Who should you consider involving in treatment?
• What stage of his SUD development do you think Randall is in?
• How will you attempt to reduce Randall’s ambivalence about
engaging in treatment?
• What meso-, exo-, and macro-system level influences are important
to understanding this case?

Answers to Case Vignette 2

Ideally, Randall’s mother should be included in treatment because he
lives with her. Including her in treatment will better help you to under-
stand the micro-system influences on Randall’s SUD. In the long term,
including Randall’s children in treatment as Randall enters into recovery
would be beneficial because his estrangement from them might be a
source of loss that could be fueling his substance use.
Randall has not yet entered into stage 1, recognition of disorder devel-
opment. He is still in denial that he has a problem, as evidenced by his
denial of regular use and statement that selling was a “one-time thing.”
Developing rapport and a nonjudgmental stance toward Randall will
be very important. The use of the skills and strategies of motivational
interviewing can be helpful to engage him in treatment and explore and
resolve his ambivalence about change.
Important micro-system considerations are how his mother, imme-
diate family members, or friends have influenced or been affected by
his SUD. It will be important to assess for substance abuse problems
and attitudes toward substance use in the extended family. Important
meso-system considerations would be the neighborhood Randall lives in
as well as his work environment. Assessing any race or ethnicity issues
could be important.
SUDs affect the entire family. The effects will differ depending on the
different characteristics and structure of the family. Age, gender, class,
 4 SOCIOENVIRONMENTAL ASPECTS OF SUDS 87

and ethnicity also affect the development, maintenance, and treatment

of SUD in the individual at the macro-system and exo-system levels.
When treating an individual who you know has an SUD, your assess-
ment should include an examination of the culture, community, and
neighborhood in which he lives as well as the ones in which he was
raised. Understanding these ecological contexts can make the difference
between successful and unsuccessful treatment. Whenever possible,
family members should be included in treatment. If they cannot be seen
in person, collateral phone contact can be useful. Part of any interven-
tion with family members would be educating them about SUDs and
helping to connect them to community resources, such as mutual sup-
port groups like Al-Anon and Nar-Anon.
88 Substance Use Disorders

Acknowledgment
The preparation of this chapter was supported in part by the National
Institute on Drug Abuse grant #5U10DA020036-08.
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90 Substance Use Disorders

References and Suggested Readings

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Hispanic youth. Journal of Addictive Diseases, 12(2), 87–107.
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mapping of human cortical development during childhood through early adulthood. Proceedings
of the National Academy of Science U. S. A., 101, 8174–8179.
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 Chapter 5 93

Substances of Abuse and

Their Clinical Implications
James H. Berry, Carl R. Sullivan, Julie Kmiec,
and Antoine Douaihy

Key Points 94
Basic Principles of Pharmacology 96
Specific Clinical Syndromes 98
Acknowledgment 133
References and Suggested Readings 134
94 Substance Use Disorders

Key Points
• Knowledge of the principles of pharmacokinetics and
pharmacodynamics is crucial to the understanding of substances
of abuse.
• Detoxification does not constitute treatment for substance
dependence but is one part of a continuum of care for
substance-related disorders.
• Detoxification is defined as a set of interventions aimed at managing
acute intoxication and withdrawal.
• The appropriateness of the use of medication and protocols in the
management of an individual in a specific substance withdrawal state
is critical to help minimize the serious complications of withdrawal
syndromes.
Pharmacokinetics is defined as the study of the quantitative relationship
between administered doses of a drug and the observed plasma/blood
or tissue concentrations. The field of pharmacokinetics addresses drug
absorption, distribution, biotransformation, and excretion or elimination.
These processes, in addition to the dose, determine the concentration of
drug at the active site and, therefore, the intensity and duration of the drug
effect. Through the consideration of pharmacokinetics, physicians are able
to determine the drug of choice, dose, route, frequency of administration,
and duration of therapy in order to achieve a specific therapeutic objective
when prescribing medications. A knowledge of pharmacokinetics will help
a physician understand why particular drugs are abused and factors that
affect their potential for abuse.
Pharmacodynamics is the study of the physiological and biochemical
mechanisms by which a drug exerts its effects in living organisms. An effect
is initiated by the drug binding to receptor sites on a cell’s membrane, set-
ting in motion a series of molecular and cellular reactions that culminate
in some physiological (e.g., opioid-induced analgesia) or behavioral (e.g.,
alcohol-induced impairment such as ataxia) effect. Drugs typically have
multiple effects. Knowledge of both pharmacokinetics and pharmacody-
namics is central to an understanding of drug abuse. Simply put, pharma-
cokinetics is what the body does to the drug, and pharmacodynamics is
what the drug does to the body.
This chapter is a concise overview of the specific pharmacokinetics and
pharmacodynamics of some common drugs of abuse. The clinical effects
of these drugs are described in terms of intoxication and withdrawal syn-
dromes. Detoxification treatments for alcohol, benzodiazepines, and opi-
oids are also discussed within a framework aimed at providing practical
approaches to treatment.
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96 Substance Use Disorders

Basic Principles of Pharmacology

Pharmacokinetics Pharmacodynamics
DRUG Concentration EFFECT

Pharmacokinetics: What the body does to the drug

• Absorption
• Process in which drug goes from site of administration (e.g., oral
[PO], intravenous [IV], intramuscular [IM], topical, inhaled) to site of
measurement in body (usually plasma)
• Affected by many factors, including:
• For oral administration:
• Dosage form (capsule, tablet, oral disintegrating tablet [ODT],
solution, suspension)
• pH of stomach
• pH of small intestine
• Presence of food in GI tract
• Post gastric surgical changes
• Solubility of the drug
• H-binding
• Ionization of functional groups of drug
• Permeability of drug to biological membranes
• Bioavailability: percentage of drug administered to body that
reaches systemic circulation intact; in other words, how much of a
drug reaches the biological fluid where it can exert its mechanism
of action
• This is affected by absorption and first-pass metabolism.
• Intravenous administration is 100% bioavailable.
• Oral drugs range from 5% to less than 100% bioavailable.
• Drugs of abuse are often smoked, insufflated, and injected, resulting
in high bioavailability.
• Distribution
• Process of drug being transferred from site of measurement to
peripheral body tissues
• Depends on:
• Blood flow to tissues
• Permeability to tissues
• Degree of binding of drug in blood (proteins: albumin, alpha-1
glycoprotein)
• Degree of binding of drug to tissues
• Volume of distribution (Vd): measurement of volume where drug
distributes into body at equilibrium
• Metabolism
• How the body breaks down the drug through physiological
processes
• Drugs can pass through the body without being metabolized
(i.e., excreted unchanged), being partially metabolized, or being
metabolized completely
• Primary means of metabolism are phase 1 and 2 metabolism in the
liver. Phase 1 metabolism is primarily through oxidative reactions
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 97

with the CYP450 enzymes that alter drug to various metabolites,

active or inactive. Phase 2 metabolism occurs primarily in the
liver but can also occur at other sites like the kidney, intestine,
and lungs. Phase 2 reactions are conjugation reactions that are
primarily completed through methylation, sulphation, acetylation, or
glucuronidation by enzymes in the body
• Elimination/excretion
• How the body gets rid of the drug and its metabolites
• Drugs can be excreted in two primary ways: through urine by renal
excretion or through feces by biliary excretion
Therapeutic window: optimal range of doses, where a dose exerts a
therapeutic effect while causing minimal adverse effects
Therapeutic index: the ratio of the dose of a drug that causes a toxic
response in 50% of the population (TD50) to the dose of the drug that is
therapeutically effective in 50% of the population (ED50; TI = TD50/ED50).
Drugs with a high therapeutic index need a large dose to cause a toxic
response and a small dose to be effective.
• High therapeutic index: Minor increase of a dose will not greatly
increase the risk of adverse effects (e.g., TI of sufentanil = 25,000).
• Low therapeutic index: Minor increase of a dose will greatly increase
risk of adverse effects (e.g., TI of methadone = 10).
Pharmacodynamics: What the drug does to the body
• Mechanism of action, therapeutic effect
• Drug interacting with receptor and eliciting a response
• Adverse effects, toxicities
98 Substance Use Disorders

Specific Clinical Syndromes

Alcohol
People use alcohol for a number of different reasons. Some people state
that it helps them relax at the end of a long day, others find it helps them
in social situations, it helps others to fall asleep, it decreases anxiety, and
others state that they drink just because they like the taste.
The alcohol content in beer typically ranges from 3% to 10%, whereas
the alcohol content of wine ranges from 8% to 20%, and the alcohol con-
tent of spirits can range from 20% to 70%.
Pharmacology of Alcohol
Absorption: Alcohol is absorbed in the stomach (70%), duodenum (25%),
and remaining bowel (5%). The rate of absorption depends on gastric
emptying time and can be delayed by food in the small intestine.
Distribution: Alcohol is water soluble, and once in the bloodstream, it
is distributed throughout the body, gaining access to all tissues, including
the brain and the fetus in pregnant women.
Metabolism: Alcohol is metabolized by alcohol dehydrogenase, which
occurs in the stomach and gastric mucosa, to acetaldehyde. Acetaldehyde
is a toxic chemical that is thought to be responsible for symptoms of
a hangover, and repeated exposure to acetaldehyde can result in alco-
holic hepatitis. Acetaldehyde is metabolized by aldehyde dehydrogenase
to acetic acid.
Elimination: Alcohol exhibits zero-order kinetics and is eliminated at a
constant rate regardless of how much alcohol is in the system. Typically,
unhabituated drinkers clear 15 to 20 mg/dL/hr, whereas people who drink
daily clear 25 to 35 mg/dL/hr.
Mechanism of Action: Alcohol acts as a central nervous system depres-
sant, enhancing gamma-aminobutyric acid (GABA) and glycine receptor
function, and antagonizing N-methyl-D-aspartate (NMDA) receptor func-
tioning. Alcohol likely affects other neurotransmitter systems in the brain
owing to its widespread reach.
Alcohol Intoxication
Most of us have seen someone under the influence of alcohol before ever
becoming physicians. Common symptoms such as slurred speech, ataxia,
and memory impairment are well-known symptoms of alcohol intoxica-
tion. Symptoms include the following:
• Slurred speech
• Uncoordination
• Unsteady gait
• Nystagmus
• Impaired attention or memory
• Stupor or coma
The behavioral or clinical effects increase with the blood alcohol concen-
tration. Table 5.1 lists the typical clinical effects at a given breath alco-
hol concentration. Individuals with a high tolerance to alcohol may show
fewer effects at higher concentrations.
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 99

Table 5.1 Typical Clinical Effects at a Given Breath Alcohol

Concentration
Breath Alcohol Clinical Effects
Concentration
0.01–0.1 Euphoria, mild deficits in coordination, attention,
cognition
0.1–0.2 Increased deficits in coordination and
psychomotor skills, decreased attention, ataxia,
impaired judgment, slurred speech, and mood
variability
0.2–0.3 Lack of coordination, incoherent thoughts,
confusion, nausea, and vomiting
0.30 Stupor, loss of consciousness
0.4 Possible death
>0.55 Death

Alcohol Withdrawal
People who have been drinking regularly over a period of time may expe-
rience alcohol withdrawal if they suddenly stop drinking. Table 5.2 shows
common symptoms of alcohol withdrawal and when they typically appear.
In patients who have high tolerance to alcohol, signs of alcohol withdrawal
can appear even before blood alcohol level has reached zero.
Alcohol Detoxification
To avoid complications of alcohol withdrawal, people who experience
symptoms of withdrawal when they try to stop drinking should undergo
supervised detoxification. Alcohol detoxification can be done in either
inpatient or outpatient settings. For many patients, it is possible to safely
detoxify them as an outpatient if they are generally healthy, have no his-
tory of complicated withdrawal, and have a stable home environment.
Other patients who have a history of complicated withdrawal or extenuat-
ing medical, psychiatric, or social factors warrant inpatient detoxification.
Adolescents may undergo outpatient detoxification; however, if their
motivation to quit using is largely external (i.e., due to parental pressure),
inpatient detoxification may be more appropriate because the adolescent
may continue to use outside of a controlled environment.
Healthy geriatric patients have successfully undergone outpatient
detoxification. Careful consideration of medical comorbidities, possible
medication interactions, and social support must be given before starting
an outpatient detoxification for an elderly individual.
Goals of Detoxification
• Decrease withdrawal symptoms
• Prevent more serious withdrawal symptoms from occurring
• Treat any medical or psychiatric comorbid disorders
• Prepare the patient for long-term recovery
100 Substance Use Disorders

Table 5.2 Common Symptoms of Alcohol Withdrawal

Onset Symptoms
6–24 hr after Anxiety
last drink Insomnia
Nausea and vomiting
Headache
Tremor
Diaphoresis
Psychomotor agitation
Tachycardia
Elevated blood pressure
Elevated temperature
24–48 hr after Tactile hallucinations (from pins-and-needles
last drink sensation to formication)
Visual hallucinations
Auditory hallucinations
8–24 hr after Withdrawal seizure, typically grand mal
last drink
72–96 hr after Withdrawal delirium or delirium tremens (autonomic
last drink hyperactivity, tremor, confusion, disorientation,
hallucinations without insight, psychomotor agitation,
disruption of sleep–wake cycle)

Alcohol Withdrawal Assessment Scales

To adequately treat alcohol withdrawal, standardized scales composed of
common withdrawal symptoms have been developed. These scales are
meant to help guide treatment of alcohol withdrawal and should not be
used as a substitution for clinical judgment. Two alcohol withdrawal scales
will be discussed here: the Withdrawal Assessment Scale (WAS) developed
by Foy, March, and Drinkwater (1988), and the Clinical Institute Withdrawal
Assessment of Alcohol Scale, Revised (CIWA-Ar; Sullivan et al., 1989).
The WAS, like the CIWA-Ar, is used to assess the severity of a patient’s
withdrawal from alcohol. Unlike the CIWA-Ar, it takes a patient’s vital signs
into account in its scoring system. Because autonomic hyperactivity is a key
feature of alcohol withdrawal, we believe it is important to include a patient’s
vital signs in the withdrawal score and therefore use the WAS at our (JK
and AD) institution. The WAS consists of 19 items, and scores can range
from 0 to 98. A score of greater than 15 indicates significantly increased risk
for severe alcohol withdrawal if untreated. The WAS is shown in Table 5.3.
The CIWA-Ar (Sullivan et al., 1989) is the other instrument commonly
used to measure severity of alcohol withdrawal. It is a 10-item scale, and
items are scored from 0 to 7, with the total score ranging from 0 to 67.
Items include nausea and vomiting, tremor, paroxysmal sweats, anxiety,
agitation, tactile disturbances, auditory disturbances, visual disturbances,
headache or fullness in the head, and orientation (Table 5.4).
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 101

Table 5.3 Withdrawal Assessment Scale

Temperature Auditory Disturbances
(Loud Noises, Hearing Voices)
1 = 37˚–37.5˚ C 0 = Not present
2 = 37.6˚–38˚ C 2 = Mild harshness or ability to
3 = >38˚ C frighten (increased sensitivity)
4 = Intermittent auditory
hallucinations (appears to hear
things you cannot)
6 = Continue auditory hallucinations
(shouting, talking to unseen persons)
Pulse (beats/min) Hallucinations
1 = 90– 95 0 = None
2 = 96–100 1 = Auditory, tactile, or visual only
3 = 101–105 2 = Nonfused auditory or visual
4 = 106–110 3 = Fused auditory and visual
5 = 111–120
6 = >120
Respiration Rate Clouding of Sensorium
(What day is this? What is this place?)
1 = 20 – 24 0 = Oriented
2 = >24 2 = Disoriented for date by no more
than 2 days
3 = Disoriented for date
4 = Disoriented for place (reorient if
necessary)
Blood Pressure Quality of Contact
(diastolic, mm Hg)
1 = 95–100 0 = In contact with examiner
2 = 101–103 2 = Seems in contact, but is oblivious
3 = 104–106 to environment
4 = 107–109 4 = Periodically becomes detached
5 = 110–112 6 = Makes no contact with examiner
6 = >112
Nausea and Vomiting Anxiety (Do you feel nervous?)
(Do you feel sick, have (Observation)
you vomited?)
0 = None 0 = No anxiety, at ease
2 = Nausea, no vomiting 2 = Appears anxious
4 = Intermittent nausea with 4 = Moderately anxious
dry heaves 6 = Overt anxiety (equal to panic)
6 = Nausea, dry heaves,
vomiting

(continued)
102 Substance Use Disorders

Table 5.3 (Continued)

Tremor (Arms extended, Agitation (Observation)

fingers spread)
0 = No tremor 0 = Normal activity
2 = Not visible, can be felt 2 = Somewhat more than normal
fingertip to fingertip activity
4 = Moderate with arms 4 = Moderately fidgety and restless
extended 6 = Pacing, or thrashing about
6 = Severe, even when arms constantly
not extended
Sweating (Observation) Thought Disturbance (Flight of ideas)
0 = No sweat visible 0 = No disturbance
2 = Barely perceptible, palms 2 = Does not have much control over
moist nature of thoughts
4 = Beads of sweat visible 4 = Plagued by unpleasant thoughts
6 = Drenching sweats constantly
6 = Thoughts come quickly and in a
disconnected fashion
Tactile Disturbances Convulsions (Seizures or fits
of any kind)
0 = None 0 = No
2 = Mild itching or pins and 6 = Yes
needles or numbness
4 = Intermittent tactile
hallucinations (e.g., bugs
crawling)
6 = Continuous tactile
hallucinations (feeling things
constantly)
Visual Disturbances Headaches
(Photophobia, seeing things)
0 = Not present (Does it feel like a band around your
2 = Mild sensitivity (bothered head?)
by light) 0 = Not present
4 = Intermittent visual 2 = Mild
hallucinations (occasionally 4 = Moderately severe
sees things you cannot) 6 = Severe
6 = Continuous visual
hallucinations (seeing things
constantly)
Flushing of the Face Total =
0 = None
1= Mild (Maximum score = 98)
2 = Severe
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 103

Table 5.4 Clinical Institute Withdrawal Assessment of Alcohol

Scale, Revised
Item Score
Nausea and vomiting:
Ask, “Do you feel sick to your stomach? Have you
vomited?”
Observation.
0 No nausea or vomiting
1 Mild nausea with no vomiting
4 Intermittent nausea with dry heaves
7 Constant nausea, frequent dry heaves and vomiting
Tactile disturbances:
Ask, “Have you any itching, pins-and-needles sensations,
any burning, any numbness, or do you feel bugs crawling
on or under your skin?”
Observation.
0 None
1 Very mild itching, pins and needles, burning or numbness
2 Mild itching, pins and needles, burning or numbness
3 Moderate itching, pins and needles, burning or numbness
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations
Tremor:
Arms extended and fingers spread apart. Observation.
0 No tremor
1 Not visible, but can be felt fingertip to fingertip
2
3
4 Moderate with patient’s arms extended
5
6
7 Severe, even with arms not extended
Auditory disturbances:
Ask, “Are you more aware of sounds around you? Are
they harsh? Do they frighten you? Are you hearing
anything that is disturbing to you? Are you hearing things
that are not there?”
Observation.
0 Not present
1 Very mild harshness or ability to frighten
2 Mild harshness or ability to frighten
3 Moderate harshness or ability to frighten
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations

(continued)
104 Substance Use Disorders

Table 5.4 (Continued)

Item Score
Paroxysmal sweats:
Observation.
0 No sweat visible.
1 Barely perceptible sweating, palms moist
2
3
4 Beads of sweat obvious on forehead
5
6
7 Drenching sweats
Visual disturbances:
Ask, “Does the light appear to be too bright? Is its color
different? Does it hurt your eyes? Are you seeing anything
that is disturbing to you? Are you seeing things that you
know are not there?
Observation.
0 Not present
1 Very mild sensitivity
2 Mild sensitivity
3 Moderate sensitivity
4 Moderately severe hallucinations
5 Severe hallucinations
6 Extremely severe hallucinations
7 Continuous hallucinations
Anxiety:
Ask, “Do you feel nervous?”
Observation.
0 No anxiety, at ease
1 Mild anxiety
2
3
4 Moderately anxious, or guarded, so anxiety is inferred
5
6
7 Equivalent to acute panic states as seen in severe
delirium or acute schizophrenic reactions
Headache, fullness in head:
Ask, “Does your head feel different? Does it feel like there
is a band around your head?” Do not rate for dizziness or
lightheadedness. Otherwise, rate severity.
0 Not present
1 Very mild
2 Mild
3 Moderate
4 Moderately severe
5 Severe
6 Very severe
7 Extremely severe
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 105

Table 5.4 (Continued)

Item Score
Agitation:
Observation.
0 Normal activity
1 Somewhat more than normal activity
2
3
4 Moderately fidgety and restless
5
6
7 Paces back and forth during most of the interview, or
constantly thrashes about
Orientation and clouding of sensorium:
Ask, “What day is this? Where are you? Who am I?”
0 Oriented and can do serial additions
1 Cannot do serial additions or is uncertain about date
2 Disoriented for date by no more than 2 calendar days
3 Disoriented for date by more than 2 calendar days
4 Disoriented for place and/or person
SCORE =
(Maximum score = 67)

CIWA-Ar Scores
• <8: mild withdrawal
• 9–15: moderate withdrawal
• >16: severe withdrawal
Medications Used for Alcohol Detoxification
Benzodiazepines
Since the 1970s, benzodiazepines have been accepted as the treatment
of choice for alcohol detoxification because of their cross-tolerance with
alcohol, increased safety profile compared with barbiturates, and abil-
ity to prevent withdrawal seizures and delirium tremens. It appears that
all benzodiazepines are capable of suppressing the signs and symptoms
of withdrawal. No single benzodiazepine or detoxification protocol has
emerged as the consistent choice for treating withdrawal. However, the
four benzodiazepines typically used in alcohol withdrawal are lorazepam,
oxazepam, diazepam, and chlordiazepoxide. The choice of which benzo-
diazepine to use is a clinical one, based on detoxification setting, desired
onset of action, a patient’s age and comorbid medical conditions, and
preferred route of administration. Clinician familiarity and preference for
specific benzodiazepines also is important. Potential benefits and draw-
backs to using lorazepam, oxazepam, diazepam, and chlordiazepoxide for
alcohol detoxification are discussed in Table 5.5.
There are three general approaches to using benzodiazepines for alco-
hol withdrawal:
106 Substance Use Disorders

Table 5.5 Comparison of Common Benzodiazepines Used for Alcohol

Detoxification
Medication Important Considerations
Lorazepam Routes of administration available = PO, SL, IM, IV
Half-life = 14 hr
Onset of action = PO intermediate; SL, IM, IV rapid
Metabolism = only undergoes Phase II metabolism
(glucuronidation) by liver, so may be preferable in
elderly patients and those with significant liver disease
Oxazepam Routes of administration available = PO
Half-life = 8.2 hr
Onset of action = slow
Metabolism = only undergoes Phase II metabolism
(glucuronidation) by liver, so may be preferable in
elderly patients and those with significant liver disease
Diazepam Routes of administration available = PO, IM, IV
(IM absorption is erratic)
Half-life = 30–60 hr
Onset of action = all routes rapid
Metabolism = undergoes oxidation and
glucuronidation by liver
Chlordiazepoxide Routes of administration available = PO
Half-life = 30 hr, active metabolites = 200 hr
Onset of action = intermediate
Metabolism = undergoes oxidation and
glucuronidation by liver
Onset of action: rapid, within 15 min; intermediate, 15–30 min; slow, 30–60 min.

• Symptom-Triggered Dosing—In this approach, the patient is

typically given benzodiazepines when scoring above 10 on the WAS
or CIWA-Ar. The WAS or CIWA-Ar is repeated 1 hour after
every dose to assess the need for medication. The advantages of
symptom-triggered therapy are that the patient usually receives
a smaller amount of medication than a patient on a fixed dosing
schedule, the detoxification process takes less time, and therefore the
cost of detoxification is lower.
• Fixed Dosing—Some facilities may give a patient the same dose of a
benzodiazepine for several days to treat withdrawal. It is important
that patients on fixed dosing schedules are monitored for withdrawal
symptoms using the WAS or CIWA-Ar between medication
administration intervals in case they have withdrawal symptoms that
are not adequately treated by the fixed dosing schedule. They will then
receive medication if scoring above a certain threshold on the WAS or
CIWA-Ar, which is usually 10.
• Tapered Dosing—Some facilities develop a tapering protocol for
alcohol detoxification, giving the patient a tapering dose of a particular
benzodiazepine over several days. As with patients on a fixed
dosing schedule, it is important that patients on a tapering dose of
benzodiazepine are monitored for withdrawal symptoms using the
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 107

WAS or CIWA-Ar between medication administration intervals in

case they have withdrawal symptoms that are not adequately treated
by the taper schedule. They will then receive medication if they
score above a certain threshold on the WAS or CIWA-Ar, which is
usually 10.
Anticonvulsants
Although never used as commonly as benzodiazepines, there is a significant
literature on the usage of antiepileptic drugs (AEDs) in the treatment of mild
to moderate alcohol withdrawal. Gabapentin, carbamazepine, and valproic
acid are comparable to benzodiazepines in symptom reduction. Furthermore,
in outpatient detoxification, these agents avoid the abuse potential of ben-
zodiazepines. Interestingly, gabapentin, carbamazepine, and valproic acid
have also been reported to reduce the level of postdetoxification drinking.
Currently, there are no accepted standard detoxification protocols.
It was once thought that adding an anticonvulsant, such as phenytoin, to
benzodiazepine treatment reduced the risk for alcohol withdrawal seizures.
However, more recent studies have found that when patients are properly
treated with benzodiazepines for alcohol withdrawal, the addition of phe-
nytoin does not lead to an improved outcome (Rathlev et al., 1994).
Beta-Adrenergic Antagonists and Alpha-Adrenergic Agonists
Agents such as atenolol and clonidine have been shown to ameliorate
the autonomic symptoms of mild to moderate alcohol withdrawal. These
agents, however, do not have any known anticonvulsant activity. In addi-
tion, beta-blockers may contribute to delirium. Use of these agents may
mask other autonomic symptoms of withdrawal and therefore make it
difficult to use withdrawal scales to guide treatment. Hence their use
is adjunctive and is recommended only if needed to control persistent
hypertension or tachycardia.
Thiamine and Magnesium
To avoid the risk of developing Wernicke encephalopathy (confusion,
ataxia, ophthalmoplegia/nystagmus) and Wernicke-Korsakoff syndrome
(Wernicke encephalopathy with memory loss and confabulation), all
patients in alcohol withdrawal should receive thiamine (100 mg PO/IM/
IV). Patients who have symptoms of Wernicke encephalopathy, those at
high risk for malnutrition, and those who are to receive intravenous fluids
containing glucose should receive a parenteral dose of thiamine.
Total body magnesium is usually decreased in alcoholic patients in with-
drawal. Magnesium replacement has not been shown to affect the severity
of withdrawal symptoms, and it is unclear whether magnesium supplemen-
tation decreases the incidence of seizures. Therefore, although magnesium
replacement carries little risk, there is no evidence that supplementation
should be routinely used.
Antipsychotics
There is no evidence that antipsychotic medications are useful as primary
detoxification agents in alcohol withdrawal. Their use is limited to those
patients who have hallucinations or agitation. Haloperidol has been most
extensively used, and the recommended dose is 2 mg to 5 mg IM/PO
every 2 hours as needed for agitation.
108 Substance Use Disorders

Barbiturates
Benzodiazepines have almost completely replaced barbiturates as agents
used for alcohol detoxification because of their increased safety profile.
Phenobarbital is still used by some programs because it has a long half-life,
anticonvulsant activity, and low abuse liability, and it is inexpensive. It is
strongly recommended that use of barbiturates in detoxification only
occur in a hospital setting by experienced physicians.
Benzodiazepines
Benzodiazepines are primarily prescribed for anxiety and insomnia. They
are also used to treat seizures muscle spasms, and to induce anesthesia.
The first benzodiazepine, chlordiazepoxide, was manufactured in 1957.
Soon after, diazepam, also known as “Mother’s little helper,” was devel-
oped and became the top-selling drug in the United States for several
years. Diazepam was marketed as nonaddictive, much like heroin and
morphine had been in the early 1900s when they were first manufactured.
Properties that lend a benzodiazepine to having a higher abuse liability
are a faster onset of action, higher lipid solubility, and shorter half-life, all
characteristics of alprazolam, for example.
Pharmacology of Benzodiazepines
Absorption
Benzodiazepines can be given orally, intramuscularly, intravenously, and
even rectally (e.g., Diastat). Some people who abuse these medications
use them intranasally. Oral absorption depends on the medication but
typically is 90% or greater. Diazepam can be given intramuscularly but has
erratic absorption, whereas intramuscular lorazepam has high intramus-
cular absorption.
Distribution
These medications are highly protein bound and widely distributed. They
enter the brain quickly and are also distributed to the plasma, lungs, liver,
and adipose tissue, and cross the placenta.
Metabolism
CYP3A4 is responsible for oxidation of alprazolam, clonazepam, chlor-
diazepoxide, and diazepam (phase I metabolism). Metabolites may be
active and have long half-lives (e.g., diazepam). Lorazepam, oxazepam, and
temazepam undergo phase II metabolism, that is, glucuronidation only.
The half-life ranges from 5 to 60 hours depending on the benzodiazepine.
Elimination
These medications are largely excreted by the kidney.
Mechanism of Action
Benzodiazepines potentiate GABA, the major inhibitory neurotransmitter
of the brain, at the postsynaptic GABAA receptor. The GABAA subunit
mediates anticonvulsant, anxiolytic, amnestic, and sedative effects.
Symptoms of Benzodiazepine Intoxication
Patients intoxicated with benzodiazepines or nonbenzodiazepine omega-1
agonists (e.g., zolpidem, zaleplon, eszopiclone) often look very much
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 109

like someone who is intoxicated on alcohol. The symptoms include the

following:
• Drowsiness
• Unsteady gait
• Slurred speech
• Poor coordination
It is extremely unlikely that death will occur in a patient who overdoses on
benzodiazepines alone. However, it is important to note that very often
benzodiazepines are found as part of polypharmacy ingestion that includes
alcohol and opioids. It is well known that the combination of two or more
sedatives amplifies the likelihood of dying from overdose.
Benzodiazepine Withdrawal Symptoms
When considering the severity of impending withdrawal, it is helpful to
know how long the patient has been on benzodiazepines and at what
dosage. There is little chance of withdrawal in patients who have been
on benzodiazepines for 2 weeks or less. However, greater than 90% of
long-term users (e.g., 8 months to 1 year), even at therapeutic doses, have
withdrawal symptoms. Patients taking short-acting compounds or high
doses have most severe withdrawal. The presence or absence of other
drugs, including alcohol, must also be taken into consideration. The with-
drawal syndrome from benzodiazepines is similar to that seen for alcohol
and includes the following:
• Tachycardia
• Hypertension
• Agitation
• Anxiety and panic
• Irritability
• Insomnia
• Tremors
• Tinnitus
• Nausea and anorexia
• Sensory disturbances—distortions in taste and smell
• Hallucinations
• Seizures
• Delirium—sometimes in the absence of autonomic hyperactivity
Withdrawal severity can be measured using the WAS or CIWA-Ar (see
earlier section, “Alcohol Withdrawal”), and as in alcohol withdrawal, the
withdrawal score can be used to guide treatment.
Detoxification from Benzodiazepines
There are three strategies for the safe discontinuation of benzodiazepines
in a patient who is physically dependent on them. A gradual taper, outpa-
tient detoxification, or inpatient detoxification can be performed depend-
ing on clinical characteristics.
1. Gradual Taper—If a patient is taking a therapeutic dose and there
is no concern that he or she is abusing the medication, a gradual
taper of the benzodiazepine can be performed. A Cochrane review
(Denis et al., 2006), found that a gradual taper over 10 weeks led to
a higher completion rate and was judged more favorably than abrupt
discontinuation. Lader et al. (2009) propose an 8- to 12-week taper
110 Substance Use Disorders

and suggest that if the taper is much longer, the withdrawal becomes
“the focus of the patient’s existence.” Conventional wisdom is to
change patients to a benzodiazepine with a longer half-life before
the taper, but the Cochrane review (2006), which only included
one study, did not find much support for this practice (Murphy
et al., 1991).
2. Outpatient Detoxification—This is for patients who need to be
detoxified from benzodiazepines in a safe and efficient manner,
such as patients who are using illicitly obtained benzodiazepines or
patients who are abusing their prescription. Unlike a gradual taper,
detoxification is completed over 4 to 7 days.
a. As with alcohol withdrawal, patients may undergo outpatient
detoxification if they are generally healthy, have no history of
complicated withdrawal, and are in a stable environment.
b. Patients are medicated with benzodiazepines as for alcohol
withdrawal (i.e., lorazepam, oxazepam, diazepam, or
chlordiazepoxide) using a fixed dose, taper, or symptom-triggered
dosing regimen (see earlier section, “Alcohol Withdrawal,” for
explanation of these terms).
c. Detoxification from benzodiazepines is similar to detoxification
from alcohol, with symptom severity measured by the WAS or
CIWA-Ar.
3. Inpatient Detoxification—This is for patients who have a history of
complicated withdrawal or extenuating medical, psychiatric, or social
factors and need to be detoxified from benzodiazepines in a safe and
efficient manner in a medically monitored setting.
a. Patients are medicated with benzodiazepines as for alcohol
withdrawal (i.e., lorazepam, oxazepam, diazepam, or
chlordiazepoxide) using a fixed dose, taper, or symptom-triggered
dosing regimen (see earlier section, “Alcohol Withdrawal,” for
explanation of these terms).
b. Detoxification from benzodiazepines is similar to detoxification
from alcohol, with symptom severity measured by the WAS or
CIWA-Ar.
Several adjunctive medications have been studied for patients undergoing
benzodiazepine withdrawal and appear in Table 5.6.
Protracted Withdrawal of Benzodiazepines
A protracted withdrawal syndrome has been proposed for some patients
who have been on long-term benzodiazepine therapy. These patients
complain of prolonged neuropsychiatric symptoms after cessation of ben-
zodiazepines, including anxiety, insomnia, depression, paresthesia, tinnitus,
and perceptual and motor symptoms (Ashton, 1995). These symptoms
may make it difficult for a patient to remain abstinent from benzodiaz-
epines if he or she is very uncomfortable. Therefore, it is important to
address these complaints and treat the symptoms with nonaddictive medi-
cations, such as those listed below, or selective serotonin reuptake inhibi-
tors (SSRIs), in addition to supportive therapy.
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 111

Table 5.6 Studies on Adjunctive Medications for Patients Undergoing

Benzodiazepine Withdrawal
Medication Effect of Medication Study
Propranolol Patients taking propranolol had Hallstrom et al.,
a lower resting pulse and not as 1988
great an increase in anxiety during
benzodiazepine taper compared with
those taking placebo.
Hydroxyzine Patients taking 25–50 mg had Lemoine et al.,
a decrease in anxiety during a 1997
benzodiazepine taper compared with
those taking placebo.
Carbamazepine When given during and after a Schweizer et al.,
benzodiazepine taper, it may reduce 1991
withdrawal symptoms and promote
abstinence compared with placebo.
Trazodone A significantly higher percentage of Rickels et al.,
patients taking trazodone during a 1999
benzodiazepine taper were abstinent
from benzodiazepines 5 weeks after
taper compared with patients taking
placebo
Sodium A significantly higher percentage Rickels et al.,
valproate of patients taking sodium valproate 1999
during a benzodiazepine taper were
abstinent from benzodiazepines 5
weeks after taper compared with
patients taking placebo.
Imipramine Pretreatment and use of imipramine Rickels et al.,
during benzodiazepine taper 2000
increased taper success rate, and
a significantly higher percentage of
patients taking imipramine were
abstinent from benzodiazepines
12 weeks after taper compared with
those taking placebo.

Opioids
Opioids are prescribed for the treatment of pain. The term opioid refers
to all natural and synthetic compounds related to opium. The term opiate
refers to drugs that are made from opium or thebaine, such as heroin,
codeine, and morphine.
Heroin was first manufactured by Bayer Corporation in 1898 as a pain and
cough remedy. Like other opioids in the 19th century, it was thought to be
nonaddictive. It gained widespread use by the medical profession in the early
20th century. In 1913, Bayer stopped manufacturing and selling heroin, and
112 Substance Use Disorders

in 1924, the United States banned the production and sale of heroin. Now
heroin is imported to the United States primarily from Mexico and Asia.
Prescription opioids are available orally, transdermally, intravenously
(and even transmucosally and intranasally for breakthrough cancer pain).
Since 1991, there has been a significant increase in the number of pre-
scriptions of opioids in the United States. Some patients with opioid
dependence are prescribed opioid pain medications, while others take
medications prescribed to family members or friends, or buy pills off
the street. To prevent abuse of prescription opioids, manufacturers are
developing pills that are crush proof or adding naloxone to make a per-
son go into opioid withdrawal if the pill is dissolved and injected. Some
states have prescription drug monitoring programs and “doctor shop-
ping” laws to try to curb the prescription drug abuse epidemic.
People who abuse opioids often use them for their analgesic, seda-
tive, and euphoric effects. Abused pill opioids are taken in a variety of
ways—swallowed whole, chewed and swallowed, crushed and insuf-
flated, dissolved and injected, or heated up while inhaling the fumes
(i.e., “freebased or smoked”). Some patients with opioid dependence
will chew on fentanyl patches to get the drug’s effects much more
quickly. People who use heroin most often will insufflate it or inject it
into their veins. Other times, they may inject it just under the skin (i.e.,
“skin popping”) or into their muscles or heat it up and smoke the fumes
(i.e., “chasing the dragon”).
Pharmacology of Heroin (Diacetylmorphine)
Absorption
Heroin is not typically taken orally. About 50% of the heroin dose
is bioavailable when it is smoked, compared with 100% when it is
injected intravenously. Heroin is rapidly absorbed through the mucous
membranes because of its lipophilicity, so when heroin is insufflated,
it is highly absorbed owing to good perfusion in the nasal mucous
membranes.
Distribution
Heroin is lipid soluble and can cross the blood–brain barrier. Heroin’s bio-
logically active metabolite, 6-mono-acetylmorphine (6-MAM), enters the
brain. Heroin’s other active metabolite, morphine, is widely distributed to
the liver, lung, kidneys, and brain.
Metabolism
Heroin is a prodrug, which undergoes almost spontaneous hydrolysis/
deacetylation to 6-MAM in the serum and then undergoes further deacet-
ylation to become morphine. Both 6-MAM and morphine are active drugs.
Morphine undergoes glucuronidation in the liver and kidneys to an inactive
metabolite, morphine-3-glucuronide, and an active metabolite, morphine
6-glucuronide. The half-life of heroin is about 3.5 minutes, and the half-life
of its metabolites is about 4 hours.
Elimination
About 90% of morphine (and thereby heroin) is excreted in the urine, and
less than 10% is excreted in the feces.
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 113

Mechanism of Action
Opioids bind to the mu opioid receptor in the brain. Opioids exert most
of their reinforcing actions through binding at the mu opioid receptor in
the brain.
Signs and Symptoms of Opioid Intoxication
• Bradycardia
• Hypotension
• Hypothermia
• Sedation
• Head nodding
• Constricted pupils
• Slurred speech
• Euphoria
• Analgesia
Signs and Symptoms of Opioid Withdrawal
Patients who become physically dependent on opioids are trapped in a
cycle of having to use to avoid opioid withdrawal (i.e., negative reinforce-
ment). Some patients report they no longer get high from using, they just
use to avoid getting sick.
It is often said that the symptoms of opioid withdrawal closely mimic
those of influenza. In fact some patients will report that they have the “flu”
to their family, friends, or physician. Although patients often report feel-
ing like they are dying from opioid withdrawal, it is rarely fatal. Common
symptoms include the following:
• Tachycardia
• Hypertension
• Hyperthermia
• Increased respiratory rate
• Insomnia
• Dilated pupils
• Diaphoresis
• Rhinorrhea
• Lacrimation
• Yawning
• Muscle spasms
• Body aches
• Restlessness
• Abdominal cramps
• Nausea and vomiting
• Diarrhea
• Tremor
• Anxiety
• Piloerection
Clinical Opioid Withdrawal Scale
The Clinical Opioid Withdrawal Scale (COWS; Wesson et al., 1999) is
a useful, clinician-administered 11-item scale that measures opioid with-
drawal symptoms (Table 5.7). The COWS was initially used as a way of
measuring opioid withdrawal associated with initiation of buprenorphine
treatment. It typically takes 2 to 4 minutes to administer by a trained
114 Substance Use Disorders

Table 5.7 Clinical Opioid Withdrawal Scale

Item Score
Resting pulse rate (record beats per minute):
Measured after patient is sitting or lying for one minute
0 Pulse rate 80 or below
1 Pulse rate 81–100
2 Pulse rate 101–120
4 Pulse rate >120
Sweating:
Over past ½ hour not accounted for by room temperature or
patient activity
0 No report of chills or flushing
1 Subjective report of chills or flushing
2 Flushed or observable moistness on face
3 Beads of sweat on brow or face
4 Sweat streaming off face
Restlessness:
Observation during assessment
0 Able to sit still
1 Reports difficulty sitting still, but is able to do so
3 Frequent shifting or extraneous movements of legs/arms
5 Unable to sit still for more than a few seconds
Pupil size:
0 Pupils pinned or normal size for room light
1 Pupils possibly larger than normal for room light
2 Pupils moderately dilated
5 Pupils so dilated that only the rim of the iris is visible
Bone or joint aches:
If patient was having pain previously, only the additional
component attributed to opiate withdrawal is scored
0 Not present
1 Mild diffuse discomfort
2 Patient reports severe diffuse aching of joints/muscles
4 Patient is rubbing joints or muscles and is unable to sit still
because of discomfort
Runny nose or tearing:
Not accounted for by cold symptoms or allergies
0 Not present
1 Nasal stuffiness or unusually moist eyes
2 Nose running or tearing
4 Nose constantly running or tears streaming down cheeks
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 115

Table 5.7 (Continued)

Item Score
GI upset:
Over last ½ hour
0 No GI symptoms
1 Stomach cramps
2 Nausea or loose stool
3 Vomiting or diarrhea
5 Multiple episodes of diarrhea or vomiting
Tremor:
Observation of outstretched hands
0 No tremor
1 Tremor can be felt, but not observed
2 Slight tremor observable
4 Gross tremor or muscle twitching
Yawning:
Observation during assessment
0 No yawning
1 Yawning once or twice during assessment
2 Yawning three or more times during assessment
4 Yawning several times/minute
Anxiety or irritability:
0 None
1 Patient reports increasing irritability or anxiousness
2 Patient obviously irritable anxious
4 Patient so irritable or anxious that participation in the
assessment is difficult
Gooseflesh skin:
0 Skin is smooth
3 Piloerection of skin can be felt or hairs standing up on
arms
5 Prominent piloerection
SCORE =
(Maximum score = 47)

clinician and can easily be done in the office or hospital. The COWS score
can be used to guide treatment of opioid withdrawal (see below), for
buprenorphine induction, or to guide dose increases for methadone main-
tenance (see chapter 7).
Total scores range from 0 to 47, and withdrawal has been classified as
follows:
• Mild (5–12)
• Moderate (13–24)
• Moderately severe (25–36)
• Severe (>36)
116 Substance Use Disorders

Patients with moderately severe to severe withdrawal may need inpatient

detoxification. The COWS score can also be used to guide buprenorphine
induction in order to avoid precipitated withdrawal (see later section,
“Buprenorphine,” and chapter 7).
Clinical Institute Narcotic Assessment
The Clinical Institute Narcotic Assessment (CINA) was developed by
Peachey and Lei in 1988 to assess opioid withdrawal symptoms (Table 5.8).
It measures 11 symptoms: 4 based on patient self-report and 7 based on
clinician observation. Self-report items include abdominal changes, changes
in temperature, nausea and vomiting, and muscle aches. Parameters based
on observation are gooseflesh, nasal congestion, restlessness, tremor, lacri-
mation, sweating, and yawning. The total maximum score is 31, with higher
scores indicating more severe withdrawal. The CINA was used to validate
the COWS for assessing opioid withdrawal (Tompkins et al., 2009).
Pregnancy
It is generally recommended that pregnant women not be detoxified
from opioids. Detoxification is stressful for the embryo or fetus and
may lead to miscarriage. Furthermore, many women, once detoxified,
do not maintain abstinence for the duration of the pregnancy, and the
fetus is subject to periods of opioid exposure and withdrawal and often
has poor prenatal care. Rather than detoxify from opioids, it is recom-
mended that pregnant women start on methadone or buprenorphine
maintenance. See chapter 7 for further discussion of opioid agonist
treatments.
Opioid Detoxification
The symptoms of opioid withdrawal are often extremely uncomfortable
for the patient who is dependent on opioids and trying to stop using.
Without medication-assisted detoxification, the patient is often intensely
driven to obtain opioids to relieve the withdrawal symptoms. In order to
break this addictive cycle, physicians must be able to provide some relief
options when a patient presents in withdrawal or indicates a desire to stop
using. There are several approaches to opioid detoxification, although the
clinician may be limited by local resources and what may be reimbursed by
third-party payers. Both inpatient and outpatient opioid detoxification are
possible. The following section describes pharmacological options com-
monly used for opioid detoxification and alleviation of opioid withdrawal
symptoms.
Clonidine
For three decades, the alpha-2 agonist, clonidine, has been used off
label to help ameliorate the symptoms of opioid withdrawal. During
opioid withdrawal, it is thought that some of the symptoms are second-
ary to noradrenergic hyperactivity in the locus ceruleus. Clonidine may
decrease some of the opioid withdrawal symptoms, including lacrima-
tion, rhinorrhea, myalgia, joint pain, restlessness, and gastrointestinal
symptoms (Gold et al., 1978). Although clonidine will not alleviate
all symptoms of withdrawal, for many patients, it will make it more
tolerable.
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 117

Table 5.8 Clinical Institute Narcotic Assessment

Parameters Findings
Parameters based on questions and observation:
Abdominal changes: 0 No abdominal complaints; normal bowel
Do you have any pains in sounds
your abdomen? 1 Reports waves of crampy abdominal pain
2 Crampy abdominal pain; diarrhea; active
bowel sounds
Changes in temperature: 0 None reported
Do you feel hot or cold? 1 Reports feeling cold; hands cold and
clammy to touch
2 Uncontrolled shivering
Nausea and vomiting: 0 No nausea or vomiting
Do you feel sick to your 2 Mild nausea; no retching or vomiting
stomach? Have you 4 Intermittent nausea with dry heaves
vomited? 6 Constant nausea; frequent dry heaves
and/or vomiting
Muscle aches: 0 No muscle aching reported; arm and neck
Do you have any muscle muscles soft at rest
cramps? 1 Mild muscle pains
3 Reports severe muscle pains; muscles in
legs, arms, or neck in constant state of
contraction
Parameters based on observation alone:
Gooseflesh: 0 None visible
1 Occasional goose flesh but not elicited by
touch, not permanent
2 Prominent goose flesh in waves and
elicited by touch
3 Constant goose flesh over face and arms
Nasal congestion: 0 No nasal congestion or sniffling
1 Frequent sniffling
2 Constant sniffling, watery discharge
Restlessness: 0 Normal activity
1 Somewhat more than normal activity; moves
legs up and down; shifts position occasionally
2 Moderately fidgety and restless; shifting
position frequently
3 Gross movement most of the time or
constantly thrashes about
Tremor: 0 None
1 Not visible but can be felt fingertip to
fingertip
2 Moderate with patient’s arm extended
3 Severe even if arms not extended

(continued)
118 Substance Use Disorders

Table 5.8 (Continued)

Parameters Findings
Lacrimation: 0 None
1 Eyes watering; tears at corners of eyes
2 Profuse tearing from eyes over face
Sweating: 0 No sweat visible
1 Barely perceptible sweating; palms moist
2 Beads of sweat obvious on forehead
3 Drenching sweats over face and chest
Yawning: 0 None
1 Frequent yawning
2 Constant uncontrolled yawning
SCORE =
(Maximum score = 31)

On the first day of detoxification, the patient is usually prescribed cloni-

dine 0.1 mg, one tablet every 4 to 6 hours as needed for opioid withdrawal,
and 0.1 to 0.2 mg every 4 to 6 hours as needed on subsequent days, up
to 1.2 mg daily. Dosing is limited by a patient’s blood pressure. Patients
who are undergoing outpatient detoxification should be instructed to hold
doses if they feel lightheaded. Patients should be instructed to drink plenty
of fluids and change positions slowly to avoid orthostatic hypotension.
Because the medication may also cause sedation, patients should not drive
or operate machinery while taking it. If patients are undergoing inpatient
detoxification, blood pressure and pulse should be taken before adminis-
tering each dose of medication, and the medication should be held if the
blood pressure is less than 85/55 mmHg. Toward the end of the detoxifi-
cation, the clonidine dose should be tapered by 0.1 to 0.2 mg daily to avoid
rebound hypertension.
Occasionally, clonidine patches (0.1 mg) will be prescribed for treat-
ment of opioid withdrawal. The patch, once placed, works for 7 days.
Steady state is not reached for 24 to 48 hours after starting the patch, so
oral clonidine will have to be given additionally for the first 2 days. The
advantage of using the patch is that the patient receives a constant dose of
clonidine without the peaks and troughs a patient taking clonidine tablets
experiences.
Typical adverse effects of clonidine include dry mouth, sedation, low
blood pressure, dizziness, and anergia.
Other adjunctive medications can be given with clonidine to help treat
other symptoms of opioid withdrawal (Table 5.9). Medications used vary
from institution to institution based largely on a clinician’s experience and
reading of the literature because there are no evidence-based guidelines
on which medications to use with an alpha-2 agonist. Generally, benzo-
diazepines are not recommended for outpatient detoxification unless a
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 119

Table 5.9 Adjunctive Medications Used with Clonidine to Treat

Symptoms of Opioid Withdrawal
Symptom Medication Used Typical Doses
Anxiety Hydroxyzine pamoate 25–50 mg PO q4hr PRN
anxiety
Insomnia Trazodone 50–150 mg PO QHS PRN
insomnia
Quetiapine 50–100 mg PO QHS PRN
insomnia
Nausea/ Prochlorperazine 5–10 mg PO q6–8hr PRN N/V
vomiting (N/V) maleate
Promethazine 12.5–25 mg PO q4–6hr PRN
N/V
Trimethobenzamide 300 mg PO q6–8hr PRN N/V
Ondansetron 4–8 mg PO q8hr PRN N/V
Diarrhea Loperamide 2 mg PO after each loose
stool (up to 16 mg daily)
Diphenoxylate/atropine 1–2 tabs PO q6hr PRN
diarrhea (up to 8 tabs daily)
Myalgia Ibuprofen 600 mg PO q6hr PRN pain
Naproxen 500 mg PO q12hr PRN pain

patient is also withdrawing from benzodiazepines or alcohol, owing to

their abuse potential and risk of diversion.
Lofexidine
Of note, another alpha-2 adrenergic agonist, lofexidine, which has been
used in the United Kingdom for opiate withdrawal for 13 years, has under-
gone Phase 3 clinical trials in the United States for treatment of opioid
withdrawal. The pharmaceutical company, US WorldMeds, reported
that they received a $3 million grant from the National Institute on Drug
Abuse (NIDA) to develop lofexidine in February 2011. If approved by the
U.S. Food and Drug Administration (FDA), lofexidine may become more
popular than clonidine because it is expected to have less of an effect on
blood pressure.
Guanfacine
Guanfacine, an alpha-2 adrenergic agonist like clonidine and lofexidine, has
been used in studies on treatment of opioid withdrawal (Gowing et al.,
2009), but to a lesser extent than clonidine. Because there is a larger
evidence base for clonidine, it is typically used in opioid withdrawal rather
than guanfacine.
Methadone
Methadone is a long-acting mu-opioid agonist that has been used success-
fully for more than 40 years for opioid detoxification. Its use is limited
120 Substance Use Disorders

to facilities that are licensed to prescribe methadone for the treatment

of opioid dependence. Prescribers must have a Drug Enforcement
Administration (DEA) registration number to prescribe methadone in one
of these facilities.
If a patient is admitted to an inpatient facility for methadone detoxifi-
cation from opiates, methadone is given in 5- to 10-mg increments until
physical signs of opioid withdrawal abate, usually up to a total of 10 to
20 mg in the first 24 hours. A higher dose of methadone, for example,
30 mg, may be required for a patient who uses a larger amount of opi-
oids daily or perhaps heroin of higher purity. Once a stabilizing dose is
reached, the dose is tapered by 20% daily, which can result in a 1- to
2-week procedure.
Patients who have been maintained on methadone for treatment of opi-
oid dependence (see chapter 7 for further details on methadone mainte-
nance) and want to taper off of the medication can do so at their own rate
under most circumstances (exceptions are patients who are administra-
tively discharged because of violence or nonadherence to program rules,
or because they are in arrears at the clinic and no arrangements can be
made to correct this). Studies have been conducted to determine the opti-
mal rate of taper for outpatients at methadone clinics. Senay et al. (1977)
conducted a double-blind study of methadone maintenance patients and
found that patients tapered from methadone by 3% of initial dose per
week did better than those tapered by 10% of their initial dose per week,
as determined by dropout rates, requests to stop the study, illicit drug use,
and withdrawal symptom scores.
Buprenorphine
In 2002, the FDA approved buprenorphine as the first office-based treat-
ment for opioid dependence. Clinicians must have a DATA (Drug Abuse
Treatment Act 2000) waiver and “X” DEA number to prescribe buprenor-
phine for the treatment of opioid dependence or withdrawal. To receive a
DATA waiver, physicians must go through an 8-hour buprenorphine train-
ing session. These trainings are offered at annual meetings of the American
Academy of Addiction Psychiatry, American Society of Addiction Medicine
(ASAM), and American Osteopathic Academy of Addiction Medicine. The
American Academy of Addiction Psychiatry and American Osteopathic
Academy of Addiction Medicine regularly offer webinars and trainings,
which can be accessed on PCSSB.org.
Buprenorphine is a partial opioid agonist that partially binds to the
mu-opioid receptor, and it is also an antagonist at the kappa receptor. It
has a very high affinity for the mu receptor and exhibits slow dissocia-
tion from it. Buprenorphine, even at low doses, may precipitate opioid
withdrawal in patients who have opioids in their system. Buprenorphine
comes with or without naloxone. When it is mixed with naloxone, it is
combined in a 4 to 1. Recently generic buprenorphine/naloxone sublin-
gual tablets have become available and Suboxone itself is only available as
a film. Except for pregnant women and in controlled settings, buprenor-
phine should almost always be prescribed in the buprenorphine-naloxone
formulation to prevent misuse. See chapter 7 for further discussion of
studies of the buprenorphine-naloxone combination.
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 121

Because of the risk of precipitating withdrawal, when starting a patient

on a buprenorphine-naloxone taper for opioid detoxification, the patient
should be in visible opioid withdrawal (i.e., have objective signs of with-
drawal as measured on the COWS). Typically, this means a COWS score
of 12 or greater. Tapering schedules (doses and lengths of taper) vary by
institution, and only physicians with DATA waivers are allowed to prescribe
buprenorphine-naloxone. Two examples of buprenorphine-naloxone
tapers are given in Table 5.10.
If a longer period of time for detoxification is available, such as in an
outpatient setting, the buprenorphine dose could be tapered by 2 mg
every 5 days.
A Cochrane review (Gowing & White, 2009) found that that for simi-
lar withdrawal severity, withdrawal symptoms may resolve more quickly
with buprenorphine compared with methadone. Patients treated with
buprenorphine are more likely to complete the detoxification phase of
treatment than those treated with clonidine and lofexidine.
In an NIDA study of predictors of outcome for short-term medically
supervised opioid withdrawal, medication type was the single best pre-
dictor of retention in treatment and successful detoxification, with a
higher percentage of patients randomized to buprenorphine-naloxone
staying in treatment longer and completing detoxification (Ziedonis
et al., 2009).
For the patient who has been on buprenorphine-naloxone maintenance
treatment and wishes to taper off of the medication, a slow taper is rec-
ommended to ensure that the patient remains comfortable and abstinent
from illicit opioids. While definitive research is lacking, this typically would
be accomplished by decreasing the dose by 2 to 4 mg of buprenorphine
every 1 to 2 months. If the patient starts having cravings or urges to use
opioids, the taper should be discontinued to prevent relapse.
Tramadol
Tramadol is a centrally acting synthetic weak opioid agonist that is used for
analgesia. Its parent compound and M1 metabolite are thought to bind to

Table 5.10 Two Sample 5-Day Buprenorphine-Naloxone Tapers

Day Taper 1 Taper 2
1 2/0.5 mg q4hr PRN withdrawal (up to 8/2 mg once
12/3 mg in 24 hr)
2 2/0.5 mg q6hr PRN withdrawal (up to 6/1.5 mg once
8/2 mg in 24 hr)
3 2/0.5 mg q8hr PRN withdrawal (up to 4/1 mg once
6/1.5 mg in 24 hr)
4 2/0.5 mg q12hr PRN withdrawal (up to 2/0.5 mg once
4/1 mg in 24 hr)
5 2/0.5 mg once PRN withdrawal (up to 2/0.5 mg once
2/0.5 mg in 24 hr)
122 Substance Use Disorders

mu-opioid receptors and also inhibit norepinephrine and serotonin reup-

take. Tramadol, if taken regularly, has a withdrawal syndrome similar to
opioid withdrawal syndrome. It is currently not a scheduled medication by
the DEA; however, some states have recognized this medication’s abuse
potential and classified it as a Schedule IV drug.
Some studies have investigated tramadol as an agent for opioid detoxi-
fication. An early retrospective chart review study that compared 59
patients detoxified with tramadol with 85 patients detoxified with cloni-
dine found that patients taking tramadol had a 23% lower chance of leaving
against medical advice than those detoxified with clonidine (Sobey et al.,
2003). A retrospective cohort control study done by Tamaskar and col-
leagues (2003) compared tramadol to buprenorphine for its effectiveness
in heroin detoxification. Sixty-four patients were enrolled in the study, and
patients on both detoxification regimens had comparable lengths of stay
and CINA scores. A recent prospective study in India found that tramadol
was more effective than clonidine in treating symptoms of heroin with-
drawal (Chattopadhyay et al., 2010).
Tramadol’s use is limited by its potential to cause seizures at doses above
400 mg daily. At this time there is a larger evidence base for using clonidine,
buprenorphine, and methadone for opioid withdrawal than tramadol.
Rapid and Ultra Rapid Detoxification
Most patients want to be detoxified from opioids as rapidly and painlessly
as possible. At the center of all rapid detoxification treatment is the use
of an opioid antagonist such as naltrexone or naloxone. The idea is to
displace the opioid agonist from receptor sites as quickly as possible. This
invariably will precipitate a severe withdrawal in patients who are opioid
dependent.
In the 1980s, a procedure was developed whereby patients were given
an increasing dose of naltrexone with a combination of clonidine, non-
steroidal anti-inflammatory drugs, and benzodiazepines to help ease the
discomfort of withdrawal (Riordan & Kleber, 1980).
In the 1990s, an ultrarapid detoxification procedure was developed by
anesthesiologists that involves placing patients under sedation or gen-
eral anesthesia before giving them naloxone. The patients are sedated
for several hours, and the opioid antagonist is switched to naltrexone.
Before leaving the facility, patients are typically given a naltrexone
implant (which is not an FDA-approved route of administration for nal-
trexone). This procedure is costly, $7,500 to $10,000, and deaths follow-
ing the procedure due to complications have been reported (Hamilton
et al., 2002). A Cochrane review by Gowing and colleagues (2010) ana-
lyzed nine studies, eight of which were randomized controlled studies
that involved a total of 1,109 subjects. These investigators found that
antagonist-induced withdrawal is more intense but less prolonged than
withdrawal managed with a tapering dose of methadone. They also
found that naltrexone induction could be performed more quickly with
antagonist-induced withdrawal than withdrawal managed with clonidine.
There was a higher risk of adverse events with heavy versus light seda-
tion and with the antagonist approach overall compared with other
forms of detoxification.
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 123

Stimulants
Stimulants are drugs that act on the central nervous system to inhibit
sedation, increase energy, and decrease appetite. The primary stimulants
of abuse in the United States are cocaine and the amphetamine deriva-
tive, methamphetamine. Recently popular drugs of abuse are “bath salts”
or “plant food,” which are synthetic cathinones with the chemical names
methylenedioxypyrovalerone (MDPV), methylone, and mephedrone.
Some drugs in this class are Schedule I drugs, whereas others are pre-
scribed for the treatment of attention deficit hyperactivity disorder or
narcolepsy, and others are prescription weight-loss medications.
Pharmacology of Stimulants
Absorption
Cocaine is used in different ways. Its absorption orally (chewed) takes 1
hour, with 75% metabolized in the liver on first pass and only 25% reaching
the brain. Intranasally, only about 20% to 30% is absorbed, with peak levels
within 30 to 60 minutes. When cocaine is smoked (i.e., crack cocaine),
the absorption is rapid and complete with onset of effects in seconds.
Intravenous use bypasses all barriers to absorption and places the drug
immediately into the bloodstream, with onset of effects within 30 to 60
seconds. The oral absorption of amphetamines occurs within 1 hour,
whereas intravenous and intranasal absorption occur within seconds. The
bioavailability of insufflated methamphetamine is about 79%. The use of
“ice” or “crystal meth” (freebase methamphetamine) is similar to use of
crack cocaine, with almost immediate absorption. Bioavailability of smoked
methamphetamine ranges from 67% to 90%, and this is in part based on the
technique of the smoker. MDPV, methylone, or mephedrone (chemicals
found in “bath salts” preparations) are swallowed, snorted, smoked, or
injected. Their pharmacokinetic properties are not known.
Distribution
Cocaine crosses the blood–brain barrier easily, and the initial concentra-
tion in brain is greater than plasma concentration. After cocaine leaves the
brain, it redistributes to other body tissues because it is water soluble. It
easily passes the placental barrier. Amphetamines are highly lipid soluble
and are widely distributed but have highest concentrations in the kidneys,
lungs, stomach, pancreas, spleen, heart, and brain.
Metabolism
Cocaine is metabolized extensively by liver and plasma enzymes and
is removed more slowly from brain than from body tissues. Cocaine is
metabolized to its major metabolites benzoylecgonine and ecgonine methyl
ester. The half-life of cocaine is 30 to 90 minutes. Methamphetamine is
metabolized by the liver by different processes, including N-demethylation
to produce amphetamine, hydroxylation through cytochrome P450 2D6
to produce 4-hydroxymethamphetamine, and beta-hydroxylation to pro-
duce norephedrine. The half-life of methamphetamine is about 12 hours.
Elimination
Cocaine’s metabolites, benzoylecgonine and ecgonine methyl ester, are
excreted in the urine. Methamphetamine and its metabolites are excreted
124 Substance Use Disorders

in the urine. It is estimated that 30% to 50% of methamphetamine is

excreted unchanged.
Mechanism of Action
Cocaine is a major dopamine (DA) agonist. It blocks the reuptake of DA
and increases DA activity, especially in nucleus accumbens. Cocaine can
also directly affect postsynaptic membranes of neurons, and the end result
is a decrease in discharge rate of neurons of the nucleus accumbens and of
ventral-tegmental pathway. Cocaine is also a major serotonin (5-HT) and
norepinephrine (NE) agonist and blocks the reuptake transporter protein
for 5-HT and for NE. Amphetamines are NE, epinephrine, and DA ago-
nists. They increase the release of NE and DA from presynaptic neurons
in central nervous system. They also increase the release of DA in meso-
limbic pathway. The release of DA in basal ganglia leads to stereotypic
behavior called “punding” or “tweaking.” MDPV is thought to function as
a DA and NE reuptake inhibitor.
Symptoms of Stimulant Intoxication
Stimulant use is likely to be in a binge pattern rather than consistent, daily
use. Often, the user will go on “runs” of heavy use that may last a few days.
Symptoms of stimulant intoxication include the following:
• Agitation/Irritability
• Insomnia
• Pressured speech
• Anxiety
• Transient paranoia
• Hypersexuality
• Paranoid delusions
• Hallucinations: auditory > visual > tactile (“cocaine bugs”)
• Decreased appetite
• Increased physical activity
• Stereotyped behaviors, such as skin picking
• Dilated pupils
• Bruxism
• Increased blood pressure
• Cardiac arrhythmias
• Chest pain
• Nausea, vomiting, diarrhea
• Increased body temperature
• Violence
• Seizures
Symptoms of Stimulant Withdrawal
The binge is followed by a period in which there is little or no use, and
the patient is in stimulant withdrawal; this often referred to as the “crash.”
The symptoms of stimulant withdrawal are very different from what is
seen with alcohol, sedative-hypnotic, or opioid withdrawal and do not
typically require medical monitoring. Many of the symptoms are essentially
opposite of those seen during intoxication. These symptoms will typically
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 125

last a few days but may persist for weeks in some individuals and include
the following:
• Depression
• Hypersomnia
• Fatigue
• Anxiety
• Irritability
• Poor concentration
• Psychomotor retardation
• Increased appetite
• Paranoia
• Drug craving
Cannabis
Cannabis is a drug that is currently highly debated. It is classified as a Schedule
I drug by the DEA, meaning that it has no current accepted medical use and
high potential for abuse. However, 18 states plus Washington, DC, allow for
the use of “medical marijuana,” and marijuana has been used to treat condi-
tions from anxiety to spasticity from multiple sclerosis. At the time of this writ-
ing, there are no major medical associations that support “medical marijuana”
legislation. See the ASAM policy statement at http://www.asam.org/advocacy/
find-a-policy-statement/view-policy-statement/public-policy-statements/2011/
12/15/medical-marijuana for a summary of concerns about medical marijuana.
In addition to “medical marijuana,” two states, Colorado and Washington,
legalized marijuana for recreational use in 2012.
Of note, “spice” or “K2” and other synthetic cannabinoids have grown
in popularity over the past 3 years and can produce symptoms of intoxica-
tion similar to cannabis intoxication. However, they have produced other
symptoms that have prompted calls to 911, poison control centers, and
visits to the emergency department and admissions to hospitals. People
who have used these substances have had seizures, severe panic attacks,
tachycardia, hypertension, nausea and vomiting, psychosis, and altered
mental status. In 2009, poison control centers received 14 calls about
synthetic cannabinoids, and in 2010, the number of calls about these sub-
stances grew to 2,874. On March 1, 2011, the DEA made the synthetic
cannabinoids a Schedule I drug. Previously available in convenience stores
and “head shops,” these synthetic drugs are now banned in 41 states but
are still available for purchase on the Internet.
Pharmacology of Cannabis
Absorption
Cannabis is typically inhaled or taken orally in some sort of food (e.g.,
brownie). Oral absorption is about 90% to 95%, but oral bioavailability
has been reported to be 10% to 20%. Bioavailability through inhalation of
smoked cannabis has been reported to be 2% to 56%.
Distribution
Delta-9-tetrahydrocannabinol (THC) is rapidly distributed into the tissues.
It is highly lipophilic. It has a large volume of distribution and is slowly
eliminated from body stores.
126 Substance Use Disorders

Metabolism
THC is largely metabolized by the liver through Phase I and II metabolism.
The brain, lung, and intestines may also contribute to metabolism. The
half-life of THC is about 3 to 4 days.
Elimination
Within about 5 days, about 80% to 90% of the THC is eliminated, with
65% of it being excreted in the feces, and 20% of it being excreted in
the urine.
Mechanism of Action
Cannabis exerts its effects by binding to the CB1 receptor in the brain.
Symptoms of Cannabis Intoxication
Typically, when someone thinks of a person with cannabis intoxication,
they think of the stereotypical experience of a relaxed person with blood-
shot eyes and the “munchies.” Not everyone has this type of experience;
some people experience paranoia or become psychotic with the use of
cannabis. Below are possible symptoms of cannabis intoxication.
• Euphoria
• Hunger
• Relaxation
• Anxiety
• Panic
• Paranoia
• Nausea
• Impaired short-term memory
• Pupillary constriction
• Conjunctival injection
• Headache
• Mild tachypnea
• Orthostatic hypotension
• Impaired motor coordination
• Slowed reaction time
• Slowed information processing
Symptoms of Cannabis Withdrawal
It is clear that many users do not experience a significant withdrawal syn-
drome, and until recently, most people did not think there was a with-
drawal syndrome from cannabis. Over the past several years, researchers
have defined a cannabis withdrawal syndrome that starts within about 24
hours after a patent stops using cannabis. It appears to be more common
in frequent, heavy users of cannabis. Symptoms are not life threatening but
can cause a patient to resume use of cannabis through negative reinforce-
ment. Typical symptoms of withdrawal are listed below.
• Anxiety
• Restlessness
• Irritability
• Insomnia
• Decreased appetite
• Anger or aggression
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 127

• Depressed mood
• Tremor
• Sweating
• Fever, chills
• Stomach pain
• Nausea
• Headache
There is no treatment for cannabis withdrawal. Withdrawal symptoms
are usually time limited, although on occasion nonaddictive medications
may be used to treat symptoms such as depression, insomnia, and anxiety.
Hallucinogens
Hallucinogens are also referred to as psychedelics or psychomimetics.
They are taken orally and alter sensory experiences, may produce hallu-
cinations, and often have adrenergic effects. This class of drugs includes a
diverse class of substances, including mescaline, lysergic acid diethylamide
(LSD), ecstasy (3,4-methylenedioxy-N-methylamphetamine; MDMA), and
psilocybin (“shrooms”).
Pharmacology of LSD
LSD is reviewed here because it is the best studied.
Absorption
LSD is rapidly absorbed from the small intestine.
Distribution
LSD is more than 80% protein bound and enters the brain, liver, spleen,
and lungs.
Metabolism
LSD is metabolized by the liver. Its metabolite, 2-oxy-lysergic acid diethyl-
amide is inactive. The half-life of LSD is about 3 hours.
Elimination
About 80% of LSD is eliminated through biliary excretion, and it is also
excreted in the urine.
Mechanism of Action
Hallucinogens are 5-HT2A receptor agonists or partial agonists.
Symptoms of Hallucinogen Intoxication
• Euphoria
• Spiritual insight
• Intensified or distorted perception
• Depersonalization
• Agitation
• Paresthesia
• Headache
• Piloerection
• Diaphoresis
• Tachycardia
• Hypertension
128 Substance Use Disorders

• Depression
• Confusion
• Hallucinations
• Anxiety
• Paranoia
• Nausea, vomiting
• Tremor
• Hyperreflexia
• Seizures
• Urinary retention
• Dizziness
Symptoms of Hallucinogen Withdrawal
There is no evidence for a clinically significant withdrawal syndrome from
hallucinogens. Regular users of hallucinogens may experience fatigue,
anhedonia, and irritability when they become abstinent from one of these
substances, and this is usually time limited.
Hallucinogen Persisting Perception Disorder
Some patients will complain of “flashbacks” from prior episodes of halluci-
nogen intoxication. They may complain of perceptual symptoms that were
experienced during previous “trips,” such as geometric hallucinations, false
perceptions of movement in the periphery, flashes of color, halos around
objects, and intensified colors.
Dissociative Drugs
The dissociative class of drugs includes phencyclidine (PCP), ketamine,
and dextromethorphan. When abused, these drugs cause experiences of
depersonalization and derealization. Those who use these drugs may also
experience hallucinations.
PCP was originally marketed as a schedule IV anesthetic but was taken
off the market in 1965 because of a high rate of complications including
postoperative delirium and psychosis. It continued to be marketed for
veterinary use until 1978. As a drug of abuse, PCP is taken orally or intra-
nasally, and is injected or smoked.
Ketamine is still used for anesthesia. As a drug of abuse, it is used orally,
intranasally, and by injection. Dextromethorphan is a cough medication
that suppresses the medullary cough center. In high quantities (up to 1,500
mg), it causes dissociative effects when taken orally.
Use of dextromethorphan (“DXM,” “robotripping”) is typically by adoles-
cents because this medication is available over the counter. Dextromethorphan
is used in cold preparations, often combined with other medications, includ-
ing acetaminophen. Therefore, those using these medications regularly to get
high may be inadvertently using high doses of acetaminophen. The clinician
should be certain to ask which type of medication the patient is using and
conduct appropriate tests when the patient presents for evaluation (e.g., acet-
aminophen level if clinically intoxicated and using a preparation containing
acetaminophen, as well as transaminase levels).
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 129

Pharmacology of PCP and Ketamine

Absorption
PCP is rapidly absorbed from the small intestine. Ketamine is poorly
absorbed when taken orally and undergoes first-pass metabolism to its
active metabolite, norketamine.
Distribution
PCP and ketamine have a high volume of distribution. They are lipid soluble
and are rapidly distributed to the brain and accumulate in the adipose tissue.
Metabolism
PCP is metabolized by the liver through oxidative hydroxylation. Ketamine
is metabolized by the liver by CYP3A4, 2B6, and 2C9 isoenzymes to its
active metabolite, norketamine.
Elimination
Less than 10% of PCP and less than 4% of ketamine are excreted
unchanged by the kidneys. The half-life of PCP ranges from 7 to 46 hours
(average of 21).
Mechanism of Action
Dissociative drugs are N-methyl-D -aspartate (NMDA) receptor antago-
nists. NMDA receptors normally bind glutamate, the major excitatory
neurotransmitter in the brain.
Symptoms of Dissociative Drug Intoxication
• Horizontal/vertical nystagmus
• Tachycardia
• Hypertension
• Ataxia
• Dysarthria
• Numbness
• Hyperreflexia
• Sialorrhea
• Stage II or III anesthesia
• Stroke
• Heart failure
• Seizures
• Rhabdomyolysis
• Acute renal failure
• Coma
• Death
Symptoms of Dissociative Drug Withdrawal
There is no recognized withdrawal syndrome for dissociative drugs.
Tennant and colleagues found that daily chronic (>3 months) users who
stop using phencyclidine may experience depression, anxiety, restless-
ness, irritability, low energy, sleep disturbance, and craving (1981). Regular
heavy users of dextromethorphan who discontinue use may experience
dysphoria, insomnia, and cravings for the drug (Miller, 2005).
The following two cases synthesize the concepts presented in the chap-
ter and allow you to develop treatment recommendations.
130 Substance Use Disorders

Case Vignette 1
Frank, a 36-year-old single African American male, presents to the emer-
gency department requesting detoxification. The patient reports he has
been drinking a fifth of vodka daily for the last year and before that he
was drinking a case of beer daily since he was 24 years old. He denies
any significant period of abstinence from alcohol. He denies the use of
other drugs but does smoke 1 pack of cigarettes daily. He has never
tried to stop drinking before, so he states he has no history of with-
drawal seizures or delirium tremens. Frank denies any significant medical
and psychiatric history, but states he hasn’t been to a doctor in years. He
is homeless and has been staying in a shelter or on the street for the past
3 months. On examination, you notice flushed facies, beads of sweat on
his forehead, impaired concentration, slightly dysarthric speech, and a
notable postural tremor. He states his last drink was about 4 hours ago.
Vital signs show blood pressure 145/100 mm Hg, pulse 109 beats/min-
ute, respiratory rate 16 breaths/minute, temperature 98.6˚ F. A breatha-
lyzer reading is 0.289. His WAS score is 16.
• What would be your treatment recommendation for Frank?
• What medication would you use for detoxification?
• Would you favor giving Frank a benzodiazepine taper or
symptom-triggered schedule of medication for alcohol withdrawal?
Answers to Case Vignette 1
What would be your treatment recommendation for Frank?
Based on Frank’s withdrawal symptoms while still having a very high
breathalyzer reading, Frank will probably need inpatient detoxification.
Additionally, Frank is homeless, and it would be best if he had a sup-
portive environment in which to stay during the detoxification. A physi-
cal examination and basic laboratory tests, including a complete blood
count, comprehensive metabolic panel, and serum magnesium level,
should be drawn.
Frank’s laboratory test results come back and show the following:

Total protein 5.3

Albumin 3.9
Total bilirubin 0.7
Direct bilirubin 0.3
ALT 257
AST 363
Alkaline phosphatase 89

What medication would you use for detoxification?

Based on Frank’s elevated liver enzymes, oxazepam or lorazepam would
be the recommended agent. The choice between these two medica-
tions would depend on whether you want a medication with fast or
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 131

intermediate onset of action and also on the route of administration you

need. Typically, oral route of delivery is adequate; however, if a patient
is not taking anything by mouth or if the withdrawal becomes more
severe, you may need to switch to an intravenous route of delivery,
which would favor lorazepam.
There is no indication to use a beta-blocker, alpha-2 agonist, or
anticonvulsant.
Would you favor giving Frank a benzodiazepine taper or symptom-triggered
schedule of medication for alcohol withdrawal?
Because Frank has never gone through detoxification before, it is hard
to predict what his withdrawal will be like. Fixed dose schedules lead
to more sedation and longer detoxification episodes and are thereby
more expensive. Symptom-triggered dosing requires more frequent
nursing assessments but leads to less sedation and shorter detoxifica-
tion episodes.
If Frank is going to a detoxification unit, you may wish to start him on
a symptom-triggered schedule. If he is going to a medical-surgical unit,
where things are chaotic and frequent nursing assessments may not be
practical, it may be best to start him on a fixed dose or taper dosing
schedule to ensure that he gets the medication of a regular basis.

Case Vignette 2
Cindy is a 33-year-old single white woman who presented to the emer-
gency department seeking detoxification from heroin. She started
using pill opioids recreationally at 21 years of age with her boyfriend.
At first she started with Vicodin and Percocet, swallowing the pills
whole. Eventually, she started buying oxycodone tablets and using them
intranasally. About 9 months later, she started using heroin intranasally
because it was much less expensive than the pills she was buying off
the street. Soon she was using 20 bags of heroin intranasally daily, so
she started injecting the heroin. She is currently injecting 25 bags daily.
She has gone through detoxification before and has been to several
rehabilitation facilities. Her longest period of abstinence is 6 months,
which she achieved after completing a 28-day residential rehabilitation
program, living in a three-quarter house, and participating in Narcotics
Anonymous meetings.
Cindy denies the use of alcohol and other drugs. She smokes 1 pack
per day of cigarettes. She recently lost her job as a server at a restaurant
for coming to work late and calling off due to being in withdrawal and
having to find heroin to avoid being “dope sick.” She is about to be
evicted from her apartment because of nonpayment of her rent.
Cindy has hepatitis C but is otherwise healthy. She denies any psychi-
atric symptoms, including suicidal and homicidal ideation.
Cindy’s last use of heroin was about 8 hours ago. She is currently
complaining of myalgia, anxiety, restlessness, hot and cold flashes, irri-
tability, and leg cramps. On interview, you notice that she is yawning,
132 Substance Use Disorders

her eyes are moist, she is sniffling, and she has psychomotor agitation.
Her vital signs are as follows: blood pressure 119/84 mm Hg, pulse 88
beats/minute, temperature 98.3˚ F, respirations 16 breaths/minute, and
COWS score of 8.
• What is your next step?
• While Cindy is in the detox program, it is important to focus
on what?
Answers to Case Vignette 2
What is your next step?
Because Cindy is of childbearing age, you should get a pregnancy test
to be sure she isn’t pregnant. Although women may undergo medically
supervised opioid withdrawal during pregnancy, it is not recommended.
Evidence shows that pregnant women maintained on methadone do
better than women who undergo detoxification (see chapter 7).
After pregnancy is ruled out, and Cindy elects detoxification and not main-
tenance treatment, what options would be appropriate?
Cindy can be referred to an inpatient or outpatient detoxification cen-
ter. The detoxification protocol used will likely be clonidine in addition
to other medications for symptom management or a buprenorphine/
naloxone taper.
While Cindy is in the detox program, it is important to focus on what?
During detoxification, it is important to focus on aftercare planning.
Detoxification is not a treatment in itself but rather is a portal to treat-
ment. If Cindy is not interested in an opioid maintenance treatment,
such as buprenorphine-naloxone or methadone maintenance, naltrex-
one tablets and extended-release injection should be discussed with
her and incorporated with psychosocial treatment into her recovery
plan. Before starting naltrexone, baseline liver function tests should be
obtained.
 5 SUBSTANCES OF ABUSE AND THEIR CLINICAL IMPLICATIONS 133

Acknowledgment
The preparation of this chapter was supported in part by the National
Institute on Drug Abuse grant #5U10DA020036-08.
134 Substance Use Disorders

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 Chapter 6 137

Screening, Diagnostic
Approaches, and Essential
Elements of Treatment
for Substance Use
Disorders
Thomas M. Kelly and Antoine Douaihy

Key Points 138

Therapeutic Alliance 139
Establishing Safety and Confidentiality 140
Opening of the Assessment Process 142
Strategies for Facilitating Sharing 143
Maintaining an Empathic Approach 144
Transparency 146
Validity of Self-Reports on Drug and Alcohol Use 148
Importance of Valid Screenings for Substance Use
Disorders 150
Screening for Substance Use Disorders 152
Screening Tools and Instruments 154
Assessment of Substance Use Disorders 157
Assessment Domains 158
Diagnostic Approaches 160
Interview Scenarios, Problems, and Resolutions 162
Acknowledgment 165
References and Suggested Readings 166
138 Substance Use Disorders

Key Points
• Empathy is one of the strongest predictors of a practitioner’s
effectiveness in treating substance use disorders (SUDs).
• The therapeutic alliance is as important as the type of treatment you
provide.
• Important areas of ethical and professional responsibilities include
confidentiality, professional honesty and transparency, duty to protect,
maintaining practice within the boundaries of expertise, and utilizing
evidence-based approaches.
• The validity of substance use self-reports varies according to interview
setting, clinical population, and patient motivation.
• Most screening instruments for substance abuse are too long to be
used in clinical practice.
• Brief Screens are used to detect the possible presence of substance
use at levels that require an assessment to determine the need for
treatment.
• They are adaptable to clinical interviews, but no one instrument works
well with all clinical populations.
• Urine drug testing is a fundamental clinical tool that can be used as
more than just a verification of the presence of drug.
• Assessment is a multidimensional process that helps formulate a
comprehensive treatment plan and objectives for change. This covers
all domains of functioning.
• Diagnosis determines whether a patient meets specific criteria
for a particular SUD but does not alone determine the process of
treatment.
• The most important element of determining the existence of a
“disorder” is whether substance use is causing subjective distress or
objective impairment.
People with substance use disorders (SUDs) and their significant others
are frequently seen in diverse clinical settings, including physician offices,
emergency rooms, and behavioral health programs. In this chapter, we
first address the basic principles that govern the therapeutic encoun-
ter focusing on engagement strategies. We then discuss evidence-based
practices on how to screen for substance use problems and perform
a comprehensive assessment of patients with SUDs. The last section
addresses varying perspectives and approaches to diagnosis and treat-
ment of SUDs.
 6 SCREENING, DIAGNOSTIC APPROACHES, & TREATMENT FOR SUDS 139

Therapeutic Alliance
Establishing the therapeutic alliance with the patient is considered the prac-
titioner’s most fundamental tool. The best way to enhance engagement in
the therapeutic encounter is to develop an relationship that engenders
collaboration. This begins by interacting with the patient in ways that maxi-
mizes the potential for the patient to see the practitioner as someone who
is open-minded, flexible, honest, non-judgmental, motivated by a desire to
work with him or her, and curious to learn more about his or her needs.
Patients with SUDs have experienced significant disruptions of their moral
and value systems and exploration of values is a crucial component of
the therapeutic encounter. The practitioner’s approach is an important
catalyst to this process. Practitioners who hold an attitude of therapeutic
nihilism about the potential for change in substance abuse behavior will
likely convey this to their patients and reduce the prospects for a positive
therapeutic alliance. Similarly, overidentification with a patient’s feelings of
paralysis, helplessness, or poor sense of self often leads to poor treatment
outcomes. Practitioners must be well-informed and trained regarding the
effect of substance use on patients and be able to control their own per-
sonal reactions. Relating to patients in this way strengthens the therapeu-
tic alliance and facilitates treatment.
Patient collaboration and openness can be enhanced by (1) establishing
a safe atmosphere in which the patient can achieve growth through shar-
ing and processing; (2) promoting “safety” by assuring patients that what
they share with the practitioner remains confidential (while also inform-
ing them of any limits of confidentiality); (3) maintaining an empathetic
approach; and (4) being “transparent,” or otherwise openly discussing
with patients what is being done (asked) and why it is important to the
therapeutic process.
140 Substance Use Disorders

Establishing Safety and

Confidentiality
Establishing safety is primarily related to ensuring that a patient’s health
care information is kept confidential. This means that patients must be
interviewed in private, and it is the practitioner’s responsibility to estab-
lish a safe environment for the patient. This also involves taking steps to
educate patients about not discussing their drug use or any other medical
matters in public areas.
After the setting where the evaluation will take place is established, the
practitioner should first explain what will happen during the time that will
be spent with the patient. Asking if the patient has questions at this point
is not an efficient use of time, but often patients want to discuss something
about their experiences before their arrival, and if necessary, practitioners
should allow this for no more than several minutes. It is important not to
show annoyance. Rather, it is best to remain empathetic, continue engag-
ing the patient, and address any questions or concerns. How the first few
minutes of the evaluation are handled and the nonverbal behavior of the
practitioner either greatly enhances or detracts from the therapeutic alli-
ance. This was noted decades ago by one of the most well-known students
of the interpersonal experience in psychiatry (Sullivan, 1954). Occasionally
a patient clearly wants to take more time to share than is possible before
starting the evaluation. In these cases the practitioner can tactfully reas-
sure the patient that there will be time to discuss such things later but that
it is also necessary to start the formal evaluation at this time.
The next part of the evaluation process extends the issue of establishing
safety: practitioners should explain that patient-related information will
not be revealed to anyone unless the patient requests it in writing. Even
the fact that a person is receiving treatment is confidential. Practical, com-
monsense behaviors include closing the door whenever you are discuss-
ing private information with patients or colleagues and never discussing
patients in public places. Because patients with SUDs may feel particularly
stigmatized, there are extra measures in place to protect confidentiality.
A U.S. federal regulation (42 Code of Federal Regulations (CFR), part 2)
provides special protection of the confidentiality for patients seeking an
evaluation for SUDs.. This regulation applies to any treatment programs
receiving direct federal funding or tax-exempt status. It requires that any
substance-related information is kept separate from other health care
information and protected from subpoena or warrant if the records are
requested. Even deceased patients are afforded the protection of confi-
dentiality. Nor can next of kin authorize release of records; in such cases,
42 CFR, part 2 protects patient records.
Most important, patients must be informed about any exceptions to
confidentiality. First, practitioners should be well informed about regional
laws. Health care professionals are expected to reveal to authorities any
threats that are imminent, foreseeable, and dangerous, such as suicidal
or homicidal behaviors or major bodily harm to others. In addition, pro-
fessionals have a duty to warn an intended victim or the police when a
patient discloses intent to harm. Child or elder abuse is another exception
 6 SCREENING, DIAGNOSTIC APPROACHES, & TREATMENT FOR SUDS 141

to confidentiality and must be reported to the proper authorities. Even

in these situations, the practitioner is not obligated to disclose that the
patient has an SUD or is in treatment for an SUD. In this way patients
are protected from themselves and society is protected from patients.
Furthermore, disclosing information to collaborating health care practi-
tioners is sometimes necessary to reveal whatever is required in order
for the patient to receive quality care. However, any information that is
to be divulged must be discussed with the patient before its release, and
the patient must sign an accepted form documenting that he or she is
requesting its release. Finally, it is not appropriate to report a pregnant
patient with an SUD to child protective services based solely on her use
of drugs. However, other factors may weigh on this decision. Practitoners
must know their agency policies and state laws and decide the best course
of action on a case by case basis.
Patients should be informed that what they reveal about their drug
use will not be shared with anyone, including family. This is particu-
larly relevant when patients are being pressured by family to receive
an evaluation. In such instances patients may fear that practitioners
will collude with family and inform family about their substance use.
Practitioners must first and foremost maintain a therapeutic alliance
with the identified patient. Therefore, it is very important to explain
the standards of confidentiality to the patient and family in the first
therapeutic encounter.
However, this process is not designed to promote family secrets.
Patients need the support of concerned family members and so practitio-
ners should encourage patients to be open and honest about their sub-
stance use with their significant others and supportive family members.
Emphasizing that the patient is responsible for initiating such discussions
and that such openness is therapeutic promotes patient responsibility for
their recovery. . . . Furthermore, such openness improves the potential for
the patient to receive the necessary social and emotional support to facili-
tate change during treatment.
142 Substance Use Disorders

Opening of the Assessment Process

No topic other than what motivated the patient to seek help or what
transpires between the patient and practitioner should be discussed.
Questioning about demographic information or issues related to pay-
ment or insurance should not be conducted unless the patient brings
them up in relation to the evaluation. When practitioners bring such top-
ics up as part of the evaluation, they are tacitly suggesting that such topics
are more important than the patient’s concerns and struggles. Similarly,
it is important to remain focused throughout the therapeutic encounter
and avoid “chat” that is unrelated to the patient’s treatment needs. In one
study the amount of informal chat was inversely related to the patient’s
motivation for change and retention in addiction treatment (Banmatter
et al., 2010).
Although it may seem elementary to state it outright, it is important
not to be interrupted during evaluations, except in dire emergencies.
Practitioner and patient telephones should be turned off and no attendion
should be paid to the computer or other distractions. It is best to refrain
from note taking because this can potentially reduces eye contact and
other attending behaviors and puts too much emphasis on the clinical
nature of the assessment. Practitioners should train their memories so
that they can conduct an hour-long interview without the need for note
taking.
There are ways to improve memory for these purposes. This is done
primarily by using summary statements of three types: collecting, linking,
or transitional summaries. Collecting summaries synopsize what is known
to a particular point and usually happen in the midst of the session.
Linking summaries connect what the patient shared at the moment and
what they mentioned earlier in the encounter, and transitional summaries
are used at the end of the encounter, or to shift the focus of the session.
Every 10 to 15 minutes, practitioners should stop and summarize what
has been discussed in order to maintain a sense of organization to the
assessment process. This practice reminds the patient and practitioner of
the discussion content, and encourages the patient to correct, clarify and
elaborate on his or her experiences.
 6 SCREENING, DIAGNOSTIC APPROACHES, & TREATMENT FOR SUDS 143

Strategies for Facilitating Sharing

Consistent with a motivational interviewing (Miller & Rollnick, 2002) par-
adigm, it is best to start the assessment process by asking patients an
open-ended question. An opening such as, “I don’t know much about you,
please share with me why you decided to see me today” is an appropriate
way to begin. In specialized settings such as mental health or addiction
clinics, this is always best practice because the “meta-message” is that
patients are not being told they “have a problem” with substances. Rather,
they are given the opportunity to share what they believe their problem
to be. If questioned by patients in a “So what do you want to know?” man-
ner, practitioners should say that they want to understand the patient’s
perspective of why they decided to seek treatment, or what he or she
believes are the concerns or problems. By communicating this verbally, as
well as nonverbally, patients are given the message that the practitioner
has no preconceived ideas or “agenda.” This style of interviewing reduces
defensiveness and enhances the therapeutic relationship. Often patients
become willing to discuss their perspectives about how substance use
affects their lives, even if they started sharing about how substances are
not the problem.
144 Substance Use Disorders

Maintaining an Empathic Approach

One of the most powerful predictors of positive outcomes in treating
SUDs is practitioner empathy. Carl Rogers (1965) identified “accurate
empathy” as one of the three important conditions that a practitioner or
counselor must provide to promote change in patients. The other two
conditions are unconditional positive regard and genuineness. These con-
ditions can be associated with the particular practitioner’s approach. What
Rogers defined as “empathy” is the ability to listen to patients and accu-
rately reflect back the core meaning of what they have stated; this is called
reflective listening. Reflective listening clearly helps the patients better
understand their internal processes and experiences in a nonjudgmental
atmosphere. The critical issue is to put the focus on patient behaviors
and experiences that they discuss as the source of their problems. This
approach encourages patients to explore their past and to do so with
someone who listens with unconditional interest and accepts their experi-
ences in a non-judgmental manner.
Questions should be formed and statements made that do not suggest
the practitioner believes that the patient “has a problem” with substance
use. Even validated screening instruments sometimes contain items that
equate substance “use” with “abuse” during screening. For example, the
Drug Abuse Screening Test (Yudko et al., 2007) contains several questions
that use the term “abuse” when the neutral term “use” would be a better
choice. Patients are often very sensitive to this issue and may react very
differently to the question, “Do you ever feel bad or guilty about your
drug abuse?” versus “Do you ever feel bad or guilty about your drug use?”
One form of the question implies that the practitioner assumes the patient
is abusing substances, whereas the other does not. An important point in
this context is that patients often do not necessarily think of themselves as
“having a problem” with substance use if they have not yet suffered major
consequences from it.
Similarly, patients may respond with irritation and possibly anger to
terms and labels such as “alcoholic” or “addict.” Practitioners should avoid
trying to impose these diagnostic labels. Classic addiction treatment sug-
gests that use of such labels helps patients “accept their illness.” However,
applying them often creates resistance and impedes establishing the thera-
peutic alliance. Practitoners are sometimes asked what they think about
use of such terms. The best response to avoid argumentation is to state
that it is not necessarily warranted or helpful to apply labels and that
the focus should be on behaviors and experiences the patient brings up
in relation to their substance use. Some patients do actually think it is
helpful if they can “accept” that they are an addict or have an addiction.
This attitude can indicate that they accept the need for treatment, and
practitioners should take the stance that this is fine, if the patient finds
it helpful. However, research shows no evidence that accepting labels is
a prerequisite to change. Within the 12-step philosophy, it is up to the
individual to decide whether adopting the identity as an “alcoholic” helps
him or her with their recovery. The overarching issue is that it is best to
leave the decision of labeling up to the patients. With this approach, even
patients who are not initially open in the interview often become more
 6 SCREENING, DIAGNOSTIC APPROACHES, & TREATMENT FOR SUDS 145

engaged. Patients who are closed or guarded initially misrepresent their

substance use because they expect practitioners to judge them. Patients
are more inclined to be objective when they realize that the practitioner
is willing to accept their perspectives and is not interested in imposing his
or her perspective on them. An atmosphere of trust is established, and
patients are often relieved to find that the practitioner is accepting of
them “where they are.”
146 Substance Use Disorders

Transparency
Of course, occasionally patients are reluctant to be open about their sub-
stance use despite practitioner efforts to promote engagement. Different
options often lead to either a continuation of the conversation or a ter-
mination of the assessment by the patient. Any problems that may reduce
collaboration can often be decreased by lessening the professional distance
that is a usual part of the “doctor–patient” relationship. First, the approach
should be one of informality. In most cases a substance use assessment
does not involve touching the patient, as is done during a physical exami-
nation. Furthermore, substance abuse assessments can be conduced with-
out useof written self-reports or cformal psychological tests. Therefore,
informality can be communicated to the patient by indicating that the only
thing that is expected from the patient is to talk with the practitioner dur-
ing the therapeutic encounter. The practitioner will then formulate his or
her evaluation and, possibly, provide some recommendations.
This approach provides the patient with a view of what to expect and
often reduces the patient’s level of anxiety. If the practitioner asks about
something that the patient indicates he or she does not feel comfortable
discussing, it should be made clear that this will be respected. A response
such as the following works well: “I respect your decision not to discuss
it with me. I am asking about it because we know from research and clini-
cal work that ______________. can sometimes be an important area to
explore, given what led you to come in. However, it is entirely up to you
to decide whether or not you want to discuss it.”
This statement includes a very important clause that essentially tells
the patient that your recommendation, as a professional who has exper-
tise in treatment of SUD, is to discuss a particular area of inquiry. What
is not said, but is tacitly indicated, is that the patient is taking responsibil-
ity for avoiding something a professional believes should be assessed.
Implied here also is that exploring the subject could possibly result in
avoiding future problems. However, it is best not to discuss this last
point explicitly because pointing it out to the patient may sound argu-
mentative and could be taken as a confrontation that may promote dis-
cord in the relationship.
The foundation of this approach is that ending an assessment simply
because the patient is reluctant to discuss what the practitioner wants
explore is not therapeutic. Ending an assessment because the patient is
unwilling to follow the practitioner’s agenda indicates that the practitioner
is unwilling to do exactly what is expected of the patient, that is to is,
explore alternatives, be flexible, negotiate and consider change. Simply
recognizing that the conversation does not have to be about substance
use and suggesting that the patient talk about whatever he or she wants
can keep the discussion going and strengthen the therapeutic alliance.
This approach often works with adolescents because of their ambiva-
lence related to feeling controlled. Adolescents often want to assert
their independence and, in their view, this precludes considering different
perspectives as methods for working through problems, e.g., substance
induced impairment, problems in relationships with parents or legal prob-
lems. However, adolescents are often willing to negotiate, if they view
 6 SCREENING, DIAGNOSTIC APPROACHES, & TREATMENT FOR SUDS 147

the practitioner as someone who will be open and fair with them. When
a practitioner allows the patient to set the agenda he/she models that
flexibility is accepted, even encouraged. This technique can decrease anxi-
ety and otherwise tip the scale for the patient to become more engaged
and reveal more about himself or herself as a result of increased trust in
the practitioner. Another helpful strategy is to ask patients about what
they liked and did not like about their past treatment and invite them to
explore these experiences. In this way the practitioner can emphasize how
he/she works differently, which may make the treatment experience more
fulfilling and beneficial to the patient.
Transparency includes being clear about why the practitioner is will-
ing to be flexible in working with the patient. This involves practitioners
clearly stating their belief and experience that they can work with patients
to achieve their goals when the relationship is based on openness and
honesty. Finally, however, practitioners must also make it clear that they
do not “take it personally” if the patient decides to terminate the relation-
ship. Many things can affect such a decision and it is sometimes better for
the patient to refer him or her on to a colleague. This attitude is best com-
municated by stating that self-determination is valued above all because it
is the patient who will experience either the benefits or consequences of
their decisions.
Patients with antisocial personality disorder often minimize or lie about
their substance use in an attempt to manipulate practitioners into get-
ting something from the “system.” This can include medications from the
health care system or monetary benefits from social welfare programs.
With the exception of medications, practitioners conducting drug and
alcohol evaluations rarely have any direct control over benefits from the
health care and social welfare system, although patients may perceive
things differently. Practitioners who believe that a patient is attempting to
manipulate them should be very open about the fact that they do not have
the influence the patient believes they do in determining whether a person
is eligible for welfare or disability payments. In the case of patients seeking
medications that are not safely and clinically indicated, this should also be
met with honesty that ethical practitioners will not prescribe medications
in ways that may potentially harm patients, for example, when medications
are being sought for illicit use to further drug dependence. Discussions
such as these should be closely followed by the statement that the practi-
tioner’s mission is to help people stop abusing substances and that he or
she will assist the patient to obtain treatment for substance dependence,
if he or she is willing to make that their goal.
148 Substance Use Disorders

Validity of Self-Reports on Drug

and Alcohol Use
Research on the validity of drug use self-reports is contradictory. Some
investigators have found support for the validity of patient self-report in
comparison with toxicology screenings while others have not. For exam-
ple, patients who are in emergency departments for an injury and have
been using alcohol are likely to be honest about such use because the
alcohol use is apparent to medical staff. They may be less forthcoming
about use of other drugs if they believe that the medical staff will not
detect them. Blood screenings, of course, are often used to determine
the validity of self-reports. Veterans seeking treatment for post-traumatic
stress disorder (PTSD) have been found to be honest about their drug
use because they do not expect it to interfere with their request for
psychiatric treatment. However, high school students have been found
to be dishonest about drug use on written surveys because they can-
not be convinced that the person obtaining the information won’t use it
against them. Other motivations can affect veracity, for example, pregnant
women may underreport certain drug use–related behaviors because
admitting to them during pregnancy may cause guilt or shame. In particu-
lar settings such as criminal justice systems and child protection agencies,
additional problems interfere with honesty on self-report, such as fear of
being incarcerated or losing parental custody. The primary inference to be
drawn from this research is that the interview setting, clinical population,
and motivations are the most important variables affecting the validity of
patient self-report.
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150 Substance Use Disorders

Importance of Valid Screenings

for Substance Use Disorders
A valid screening for substances of abuse is the most important objec-
tive during the first interview with patients who may be abusing drugs
because of the effects substance use could have on other psychiatric and
medical conditions. Valid screenings for substance abuse is vital in some
circumstances because it can protect patients from harm that can occur
as a result of drug withdrawal syndrome. For example, withdrawal from
alcohol and benzodiazepines can be lethal, and patients must be informed
about that in order for them to appreciate the significance of being honest
during assessment.
The SUDs most often encountered include (1) intoxication, (2) with-
drawal (3) abuse, and (4) dependence. However, epidemiologic evidence
suggests that the rate of SUDs with other non–substance-related con-
ditions, known as dual or co-occurring disorders, is quite high (Kessler
et al., 2005). Effective treatment must be based on treatment planning
that takes all available clinical data into account. Therefore, patients who
report symptoms of depression or anxiety without alluding to their use
of substances should be asked directly about substance use. For example,
major depression commonly coexists with SUDs. These conditions can
have different etiologies and often require different treatments. However,
substance-induced mood, anxiety, and psychotic disorders, which com-
monly occur within a month of substance intoxication or withdrawal, will
require a different approach because an SUD is the only cause for the
disorder.
Medical or psychological problems are often associated with SUDs. For
example, further exploration of substance use should be pursued with
patients who report having gastrointestinal problems. Short-term prob-
lems with other drugs can include psychological blackouts or flashbacks.
Long-term problems can include an “amotivational syndrome” often asso-
ciated with cannabis dependence (Schwartz, 1987). Patients with amotiva-
tional syndrome often report that they are depressed and have low energy
and motivation but do not associate the syndrome with cannabis use.
In clinical settings where active treatment is occurring, such as in pain clinics
where opiates are commonly prescribed, it is important to engage patients
so that they feel comfortable to openly disclose any use of other central ner-
vous system depressants, such as alcohol. It is vital to make these patients
aware of the risk for overdose and death if they use a combination of central
nervous system depressants. Similarly, patients taking amphetamine-based
medications for treatment of Attention Deficit Hyperactivity Disorder
should not be using any other drugs but should especially avoid ones that
may interact with the stimulating effects of amphetamines. Finally, patients
who are being treated for co-occurring conditions such as drug dependence
and major depression should be informed that the antidepressant effect of
any medication they are prescribed could be potentially compromised or
nullified if they continue to overuse other drugs.
Combining biological measures such as laboratory tests with self-reports
will, of course, enhance accuracy of screening data, particularly when
 6 SCREENING, DIAGNOSTIC APPROACHES, & TREATMENT FOR SUDS 151

doubt about self-report is an issue. Individuals are more likely to reveal

accurate information about their drug and alcohol use if they believe that
the information will be corroborated by other tests. This is commonly
referred to as the “bogus pipeline” because patients will be honest if they
believe any lies will ultimately be revealed.
When choosing a biological test, it is important to consider factors such
as the nature of the substance, half-life of the tested substance, biotrans-
formation and metabolism of the substance, sensitivity and specificity of
the test, and purpose and cost of the test. Biological tests will be dis-
cussed more in detail in the next section, “Screening for Substance Use
Disorders.”
152 Substance Use Disorders

Screening for Substance

Use Disorders
Screening is neither a formal evaluation nor a diagnosis. Screening tools
are meant to detect the possible presence of a particular problem that
requires an additional evaluation. When considering use of a screening
test, it is important to know the cutoff point of that test, the score at
which defines the optimal balance between the sensitivity and specificity of
the test. Expressed in percentages, sensitivity refers to the score at which
an instrument will detect a substance use disorder, with the understand-
ing that some non-disorders will be detected (false-positives). Specificity
refers to the score at which the test will detect a non-disorder, with
the understanding that some disorders will be missed (false-negatives).
For example, research on the Alcohol Use Disorders Identification Test
(AUDIT) among a sample of ambulatory patients found that scores of 8 or
above (range 0–40) is the cut point at which 95% of subjects with alcohol
related impairment later in life were identified (sensitivity). Scores of 7 or
below identified 85% of patients without alcohol-related impairment later
in life (specificity) (Conigrave et al, 1995).
Before using screening tools in any clinical setting, it is important to
discuss with the patient the rationale for its use. It is important to explain
that it is a standard procedure used with all patients, give clear instructions
on how to complete it, and review confidentiality related to the results.
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154 Substance Use Disorders

Screening Tools and Instruments

Screening tools are divided into three categories: particular clinical ques-
tions, instruments, and biological measures.
Clinical Questions
The one-question screen developed by the National Institute on Alcohol
Abuse and Alcoholism (NIAAA, 2007) may be useful to identify heavy
drinking. This single question identified 86% of individuals who had an
alcohol use disorder. The question is:
- For men: How many times in the past year have you had 5 or more
drinks a day?
- For women: How many times in the past year have you had 4 or
more drinks a day?
For patients with an SUD in the primary care setting, the simple question
asked is: How many times in the past year have you used an illegal drug or
used a prescription medication for nonmedical reasons?
Instruments
Brief scales for determining drug use disorders employ simple scoring sys-
tems so that they can be used in busy clinical environments where the
need is to diagnose the disorder with the expectation that patient will
receive follow-up care in another clinic:
1. The best-known and most widely used is the CAGE (http://jama.
ama-assn.org/content/300/17/2054.full) for alcohol abuse, as
self-administered, which is a mnemonic for answering questions on
(1) feeling the need to Cut down on drinking; (2) feeling Annoyed
when others comment on use; (3) feeling Guilty about use; and
(4) needing an Eye-opener—or drinking in the morning—which is an
indirect affirmation of using to avoid withdrawal. It is scored on a 0 to
4 scale, and scoring even 1 may be indicative of “problem drinking.”
Most studies have found that positive scores on the CAGE correlate
with alcohol dependence and that it works well with adults but is
much less valid with adolescents (Chung et al., 2000).
2. The best-known screening instrument for alcohol abuse is the
Alcohol Use Disorders Identification Test (AUDIT). The AUDIT
was developed by the World Health Organization (WHO) and
has gained widespread acceptance. However, the AUDIT is still
too lengthy to be easily used in open clinical interviews because it
comprises 10 items and is scored on a 0 to 40 to scale. A score of
0 to 7 is indicative of low problem severity, whereas a score of 8 or
above is suggestive of high problem severity. A parallel version for
screening for drug use, the DUDIT, has been developed. The DUDIT
comprises of 11 items and is scored on a scale of 0 to 44 (Voluse
et al., 2012).
3. The Michigan Alcoholism Screening Test (MAST) is a
self-administered test of 25 questions. The short version (SMAST) is
a 13-item scale that correlated 0.90 with the MAST. This test screens
for the major psychological, social, and physiological consequences of
alcoholism.
 6 SCREENING, DIAGNOSTIC APPROACHES, & TREATMENT FOR SUDS 155

4. The National Institute on Drug Abuse (NIDA) promotes screening

and brief intervention in general medical settings and suggests the
use of the Modified Alcohol, Smoking, and Substance Involvement
Screening Test (NM-ASSIST) based on the WHO ASSIST working
group. It first queries lifetime and then recent use in 12 drug classes,
then the presence or absence of various diagnostic signs of alcohol
and drug problems.
5. The Fagerstrom Test for Nicotine Dependence, a six-item test,
measures nicotine dependence
The Addiction Severity Index (ASI; McLellan et al., 1992) is not a
screening instrument but is a useful multidimensional interview examin-
ing the severity of need for treatment. The ASI measures problems in
seven domains of life including: (1) medical, (2) employment and support,
(3) legal consequences, (4) drug use, (5) alcohol use, (6) family and social
relations, and (7) psychiatric symptoms. This multidimensional approach is
most helpful in developing a treatment plan specifically focusing on prob-
lem areas that abstinence alone my not resolve. The ASI is in the public
domain, but interviewers require special training to effectively use it.
Biological Measures
Biological measures are not a replacement for self-reports, as discussed
earlier. Urine drug testing (UDT) is more than a verification tool of the
presence of drug. UDT can be used for many reasons: for screening and
early diagnosis of substance use, as an adjunct to self-report of drug use, to
reinforce behavior change, to monitor medication adherence, to advocate
for patients, to uncover suspected diversion, and as a part of an overall
treatment plan. UDT in combination with an appropriate evaluation is
used to formulate treatment decisions in different settings. The immu-
noassay drug tests are designed to classify a substance as either pres-
ent or absent according to a predetermined cutoff threshold. It is the
most common method of UDT. The sensitivity and specificity of the UDT
have improved with the use of gas chromatography–mass spectrometry
(GC-MS) or liquid chromatography–mass spectrometry (LC-MS). GC-MS
and LC-MS specifically confirm the presence of any given drug and can
identify drugs not included in the immunoassay test when the results are
contested. The detection time of a drug in the urine indicates how long
after using a person excretes the drug and/or its metabolites at a concen-
tration above a specific test cutoff concentration.
The UDT is strongly influenced by the individual’s metabolism, drug
administration route, use of legally prescribed medications, and drug
potency. A UDT immunoassay panel screens for cocaine and amphet-
amines, including ecstasy, opiates, oxycodone, methadone, marijuana,
and benzodiazepines. Patients who are taking a prescribed opioid need to
request a limit of detection testing (which depends on the laboratory and
methodology, GC-MS, or LC-MS to increase the likelihood of detecting
prescribed medications. The results of the testing can be used to strengthen
the therapeutic alliance by emphasizing to patients that the results of such
tests are confidential and provide an objective way of monitoring their use
so that they can be provided with valid feedback. This technique provides
objectivity that often elicits motivation and reinforces behavior change. For
156 Substance Use Disorders

example, although marijuana using patients sometimes discuss “second

hand smoke,” passive inhalation of marijuana does not produce positive
results for tetrahydrocannabinol (THC) at typical cutoffs. Positive UDT for
THC is indicative of marijuana use and positive results should be addressed
in the therapeutic encounter as a substance use behavior.
UDT is indicated in patients who (1) are already receiving a controlled
substance, (2) are reluctant to undergo a full assessment, (3) are request-
ing to be tested for a specific substance, (4) are displaying drug-related
behaviors, and (5) are in drug abuse treatment programs.
A toxicology screen includes a blood alcohol level test. It is impor-
tant to remember that alcohol intoxication is not just based on the blood
alcohol level because patients who are severely dependent and have high
tolerance may have a high blood alcohol level without showing signs of
significant intoxication.
Other laboratory tests for alcohol abuse include gamma-glutamyl trans-
peptidase (GGTP), which is a sensitive measure of live enzyme oxidation,
and carbohydrate-deficient transferrin (CDT); both are markers of heavy
drinking. Elevated GGTP is also an indicator of a possible alcoholic liver
disease. AST (SGOT) is elevated in 30% to 60% of patients with alcohol
dependence and 80% of patients with elevated liver enzymes have alcohol
dependence. Elevated mean corpuscular volume (MCV), a measure of red
blood cell size, is found in certain alcohol-related nutritional deficiencies
and can be associated with the effects of alcohol on bone marrow cell
production.
 6 SCREENING, DIAGNOSTIC APPROACHES, & TREATMENT FOR SUDS 157

Assessment of Substance
Use Disorders
Assessment of SUDs is essential to understand the patient’s substance
use history and the multitude of factors that help conceptualize personal-
ized treatment approaches. Assessment involves a combination of tasks,
including: 1) a personalized history of use which incorporates informa-
tion about substance use age of onset; 2) the course of the disorder, e.g.,
periods of most use, periods of sobriety; 3) any medical, psychosocial, and
cognitive consequences he or she is experiencing; 4) level of physiological
and psychological dependence; 5) motivation and/or readiness for change;
5) the presence of co-occurring psychiatric and medical disorders; and
6) other studies, including laboratory tests. The assessment process is in
some ways a moving target and may change somewhat in every encounter
with the patient. Understanding the multiple dimensions of SUDs and how
they are intertwined is a crucial component of the assessment.
158 Substance Use Disorders

Assessment Domains
1. Nature and extent of SUDs: When assessing the nature, extent, and
pattern of substance use, ask about quantity, frequency, variability,
and routes of administration. Remember to avoid simply asking a
“laundry list” of closed-ended questions. Rather, ask an open-ended
question and allow the patient to tell his or her story related to the
question.
2. Medical consequences: These include: acute effects of intoxication;
risk-taking behaviors; overdoses; medical history, medical
consequences from chronic use, such as liver disease, heart disease,
cancers, and nutritional deficiencies; impact on other comorbid
medical illnesses, such as diabetes and hypertension; history of
HIV, hepatitis C virus (HCV), and hepatitis B virus (HBV) testing;
HIV, HCV, HBV, and tuberculosis status; tolerance; physiological
dependence; and history of withdrawal syndromes.
3. Psychosocial and behavioral consequences: These include impact
on employment, financial problems; legal problems, family relations,
interpersonal conflicts, violence, and aggression. Assess for intimate
partner violence. A particular area to assess is the impact of the
patient’s substance use on the family. Separation and divorce are both
the cause and consequence of substance use disorders (Gibb et al.,
2011; Keyes et al., 2011). Children of substance abusers are 2.7 times
more likely to be abused and 4.2 times more likely to be neglected
than children whose parents are not substance abusers (Wells, 2009).
Of course, the long-term effect of substance abuse in families is the
dysfunction it causes and the generational transmission of addiction
through behavioral modeling and because of the consequential
psychiatric, disruptive, and addictive behaviors that the children of
substance abusers develop (Copello et al., 2005).
4. Cognitive consequences: These include impact of substance use
on cognitive functions, adaptive abilities, and intelligence (acute and
chronic effects).
5. Motivation/readiness for change: Motivation is considered one of
the most consistent predictors of how patients respond to treatment.
Assessing patient motivation for change should be incorporated into
the assessment process: One simple question would be: “On a 1 to
10 scale, with 1 being of no importance and 10 being of the highest
importance, how important would you say it is for you to make a
change in your use of the substance?” Another important dimension
related to motivation that should be assessed is the patient’s reasons
for maintaining the status quo, or how important it is for the patient
to continue using drugs (assessing benefits and drawbacks of using).
This is referred to as a decisional balance technique whereby
patients are formally interviewed about the aspects of drug use they
view as positive and those they view as negative. Another aspect
of motivation to assess is the patient’s self-efficacy, defined as the
patient’s belief that he or she is capable of making a particular change
(Bandura, 1997).
 6 SCREENING, DIAGNOSTIC APPROACHES, & TREATMENT FOR SUDS 159

6. Social support network: If possible, it is important to identify the

people involved in the patient’s social network, such as family, friends,
coworkers, and religious communities. For patients who have been
involved in any mutual support groups such as Alcoholics Anonymous
or Narcotics Anonymous, it is helpful to assess their reaction to the
program, including whether they have a sponsor. The social support
system can play a fundamental role in strengthening motivation,
treatment engagement, and alternatives to drug use behaviors.
7. Functional analysis: This involves assessment of the patient’s attitude
toward substance use. It includes identifying high-risk situations,
thought patterns, and decisions that trigger substance use behaviors
and work with patients on analyzing their feelings and actions before
and after substance use. The goal of the functional analysis is for
patients to understandwhat role substance use is playing in their life.
For example, it is important for patients to recognize how specific
triggers such as social influences make them more vulnerable to
substance use. Furthermore, patients must be able to explore and
understand the consequences of using substances.
8. Substance use treatment history: Assess periods of sobriety and
recovery, types and settings of treatment, adherence, and response
to treatment. Ask patients what they found helpful in past treatment
experiences. Remember to assess simultaneous involvement in
12-Step programs and participation in formal treatment since
research suggests the combination is likely the most effective
treatment combination available.
9. Co-occurring psychiatric disorders. SUDs and other psychiatric
disorders commonly co-occur. Co-occurrence worsens the course
of both disorders and compromises treatment response compared
with either disorder alone (Blanchard, 2000). Determine current or
past psychiatric disorders and how these may influence the current
treatment plan.
160 Substance Use Disorders

Diagnostic Approaches
Screening determines whether further assessment is needed. Assessment
is an ongoing process that begins with the first encounter and the gath-
ering of information needed to formulate treatment planning. Diagnosis
determines whether a patient meets specific criteria for having a particular
SUD, which in turn may affect the eligibility for treatment. The diagnosis
of the SUD alone does not determine how to proceed with treatment.
The most common approach to the diagnostic formulation is through a
comprehensive clinical interview comparing an individual’s current clinical
manifestations with specified criteria. Diagnosis of SUDs in clinical set-
tings that specialize in the treatment of mental health and addiction in
the United States is conducted using the criteria that make up the catego-
ries for substance abuse and dependence, as defined by the Diagnostic
and Statistical Manual of Mental Disorders of the American Psychiatric
Association (DSM-IV-TR) (APA, 2000). These 11 criteria are currently
separated into ones that indicate “abuse” and “dependence.” Abuse cri-
teria include (1) recurrent use that interferes with major role obligations,
such as performance in the workplace and responsibilities in the home;
(2) recurrent use in hazardous situations, such as operating a vehicle
while using substances; (3) recurrent substance-related legal problems (or
behaviors that qualify as illegal even if not apprehended); and (4) recur-
rent interpersonal or social problems as a result of use, such as arguing
or fighting while intoxicated. Meeting one of these criteria is considered
consistent with a diagnosis of substance abuse.
Substance dependence criteria include (1) physiologic tolerance of the
drug so that increased amounts are needed to achieve intoxication or a
markedly decreased effect of continued use of the same amount; (2) with-
drawal effects such that a withdrawal syndrome is experienced when the
patient stops using the drug, or uses the drug to avoid withdrawal; (3) the
substance is taken in larger amounts or over a longer period of time than
is intended; (4) there is a persistent desire or attempts to cut down or
stop use of the drug; (5) a great deal of time is spent in activities associated
with drug use, such as obtaining, using, or recovering from the effects of
the drug; (6) important social, recreational, or occupational activities are
given up as a result of drug use; and (7) the drug use is continued despite
the knowledge of having a recurrent physical or psychological problem
associated with the use of the substance, such as continued use of cocaine
despite its exacerbation of cardiac problems or continued use of alcohol
despite recurrent associated blackouts. Meeting three of these criteria sat-
isfies the requirements for substance dependence.
Diagnosis of a Substance Use Disorder
The thinking related to what constitutes a diagnosis is changing with the
objective of modifying the categorical system that the current DSM-IV
guidelines now represent. Of course, severity is an important variable,
and the distinction between physical dependence and nondependence is
necessary for treatment planning in addiction clinics where intensity of
treatment must be matched to problem severity. However, most prac-
titioners are primarily concerned with how any apparent problems due
 6 SCREENING, DIAGNOSTIC APPROACHES, & TREATMENT FOR SUDS 161

to substance use negatively affect their patients. It is more practical to

first assess whether substances are being used in ways that cause dis-
tress or impairment. Therefore, the last decade has seen less focus on the
number of symptoms a person may report, such as what is considered
necessary for meeting the threshold for substance dependence. Rather,
any behaviors that cause distress or impairment associated with use of a
substance may be causing a “disorder.” Hodgson and colleagues (2003)
discuss “hazardous” and “harmful” drinking. Hazardous drinking refers
to a pattern of drinking that may result in future psychological or physi-
cal problems, whereas harmful drinking indicates that such problems are
already present.
Toward this end experts are recommending that the revised edition
of the DSM-IV, the DSM-V, combine the criteria for substance abuse and
dependence into a “dimensional disorder” construct, whereby meeting
even one criterion will result in a diagnosis of SUD. Recommendations
also include removing substance-related legal problems as a criterion and
adding substance craving as a criterion for SUD (Hasin, 2011). Therefore,
a patient who tells her internist that she wakes up after 5 hours on 3
or 4 nights of every week and then goes on to say that she is drinking
two or three alcoholic drinks on these nights doesn’t have a disorder
under current DSM-IV guidelines because she meets only one criterion for
dependence. However, assuming that her doctor suggests she stops drink-
ing to improve her sleep, even if she doesn’t drink at any other time but
continues drinking on the nights her sleep is disturbed, she is now know-
ingly contributing to her sleeping problem. Under the proposed DSM-V
changes, she would meet criteria for an alcohol use disorder.
162 Substance Use Disorders

Interview Scenarios, Problems,

and Resolutions
Case Vignette 1
You are on a rotation in the emergency department (ED). A 23-year-old
man came to the ED at 2:00 a.m. with a badly lacerated hand. He is
visibly intoxicated and told the triage nurse that he tripped with a beer
glass in his hand and the glass broke and cut him as his hand hit a wall.
His blood alcohol concentration (BAC) was 0.19. He also told the doc-
tor who provided his wound care that he had never had an accident
while drinking before and, in fact, that his drinking had nothing to do
with the fall. Rather, it was a loose rug.
You need to screen the patient for substance use to determine
whether a referral to an addiction clinic is indicated. You enter the
treatment room of the ED that accommodates four beds, noting that
one other patient is in a bed next to your patient and that the two have
been conversing. The nurse has just indicated to your patient that he
can get dressed and that she will be back with his discharge papers. You
introduce yourself and your role as a doctor in the ED and ask if you
can talk with him for a few minutes. The patient agrees and suggests that
you sit down.
Problem:
The patient is in a room occupied by others who will be able to over-
hear what is said.
Resolution:
The patient is ambulatory. Find an unoccupied conference room and
interview him there, indicating that you want his health care information
to be confidential.
Problem:
The patient has denied the significance of his alcohol use in contributing
to his injury.
Resolution:
Ask for his view of the accident and, if it is the same as when he was
admitted, indicate your agreement that his perspective is possible. Do
not confront the patient regarding the implausibility of his point of view
because doing so will only increase his contention that his perspective is
correct as a defensive posture. Remember, you are not going to “treat”
alcohol abuse in the ED; rather, the goal is to provide the impetus for
him to consider going for an evaluation.
Problem:
The patient had a very high BAC and noted that he has not had accidents
previously while drinking.
6 SCREENING, DIAGNOSTIC APPROACHES, & TREATMENT FOR SUDS 163

Resolution:
Ask the patient how much he had to drink tonight (note whether he
has a memory for this because blackout is a potential and significant
manifestation of alcohol use disorder) and how often he drinks and how
many drinks he has on a typical drinking day. Note that he told others
he hasn’t had accidents before while drinking. Indicate your acceptance
of his report but ask if he has had close calls with accidents in the past
and in what situations.
Problem:
You have 15 to 20 minutes before the patient is discharged; the patient
has been drinking heavily on this night and has hurt himself badly.
Despite other aspects of his history, it is likely that he should have a
comprehensive evaluation.
Resolution:
Indicate to the patient that it is his decision as to whether he believes
that he drinks too much at times. Review the objective evidence related
to his recent drinking episode, reflecting on level of BAC (personalized
feedback). Indicate your understanding that he may not need specialized
treatment but that a conservative approach is for you to recommend
that he be evaluated by a substance abuse specialist; in your view the
most important goal is for him to be safe and stay out of EDs, and getting
an evaluation could help better understand his alcohol use in his life. If
he agrees, provide information about how to get an evaluation; if not,
give him your card and suggest he call you if he changes his mind.

Case Vignette 2
You are a resident physician treating patients in a community mental
health clinic. You receive a referral of a 44-year-old woman who told
the intake worker that she just got out of a relationship with a man
after living with him for 12 years and that he had been physically and
sexually abusive to her. She reports symptoms of depression and PTSD.
The intake worker also reports that the patient seemed defensive in
answering the questions about substance use—breaking eye contact,
fidgeting, and emphatically stating on several occasions that she is not
there because she needs treatment for substance abuse. She told the
intake worker that she is frustrated because she seems to have to tell
the same story over and over again.
You will be evaluating her psychiatric symptoms and whether she
could benefit from treatment with medications. The intake worker’s
report of her behavior related to being interviewed regarding substance
use suggests that this must be further assessed.
Problem:
The patient is displaying behaviors suggesting that she is not being truth-
ful and open about her substance use.
164 Substance Use Disorders

Resolution:
Begin your interview by explaining that you have little information and
ask the patient in an open-ended fashion to share with you what made
her decide to come in. Acknowledge that it is annoying for her to discuss
her concerns and explain that everyone she sees in the clinic has differ-
ent training and experience and that you may hear things that others
haven’t, which is very important for addressing her concerns and for her
treatment planning.
Problem:
The patient continues to discuss psychiatric symptoms and makes no
reference to the use of substances.
Resolution:
Reflect her answers while asking for more elaboration. Ask about her
relationships, especially her relationship with her last boyfriend, noting
whether she talks about his use of substances. If he used substances,
ask how that affected her life. Ask about symptoms of depression or
other psychiatric disorders she may have had earlier in life. As she dis-
cusses these, provide affirmation for her having endured difficult times.
Provide objective feedback that many patients use substances in order
to “self-medicate” when going through such severe stress. Suggest that
substance use during stressful times is considered to be one “normal”
reaction. Indicate that you see in her intake record that she has already
denied that she uses substances, but ask this again, telling her it is impor-
tant to be thorough about whether she has been using any substance.
Note that your work entails deciding whether she receives medication
for her symptoms and that not knowing about her substance use will
influence the effectiveness of any prescribed medication and could be
harmful to her, depending on what substances she may be using.
 6 SCREENING, DIAGNOSTIC APPROACHES, & TREATMENT FOR SUDS 165

Acknowledgment
The preparation of this chapter was supported in part by the National
Institute on Drug Abuse grant #5U10DA020036-08.
166 Substance Use Disorders

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 Chapter 7 169

Pharmacotherapy of
Substance Use Disorders
Julie Kmiec, Jack Cornelius, and Antoine
Douaihy

Key Points 170

Medications for the Treatment of Alcohol Dependence 174
Medications for the Treatment of Opioid Dependence 184
Medications to Treat Nicotine Dependence 196
Medications to Treat Cocaine Dependence 200
Medications to Treat Methamphetamine Dependence 202
Medications to Treat Cannabis Dependence 204
Common Guiding Principles of the Use of Pharmacotherapy for
Substance Use Disorder 205
Acknowledgment 206
References and Suggested Readings 208
170 Substance Use Disorders

Key Points
• Medication-assisted treatment is an important component in the
overall treatment of substance use disorders (SUDs).
• Medications are often underutilized in the treatment of SUDs.
• Medication-assisted treatment is a tool a patient can use in recovery, in
addition to mutual support groups and individual and group therapy.
• There are U.S. Food and Drug Administration (FDA)-approved
medications for the treatment of alcohol dependence, nicotine
dependence, and opioid dependence.
• Studies are being conducted to develop new medications that may be
used for the treatment of SUDs.
• Behavioral therapies and pharmacotherapy are integrated in an
individualized treatment plan.
Medication-assisted treatment is an important consideration for all patients
with addiction. Some people with SUDs can stop using substances on their
own without any professional intervention or mutual support programs
such as Alcoholics Anonymous (AA) or Narcotics Anonymous (NA;
Dawson et al., 2005). Only a fraction of individuals with substance use
disorders engage in mutual support programs or professional treatment
for addiction (Dawson et al., 2006). Addiction is a relapsing and remitting
illness, with most patients having multiple relapses during their lifetimes.
Psychosocial and behavioral therapies and abstinence-based treatments
are the mainstay of treatment for SUDs. The potential for behavioral
interventions to influence involvement and retention in treatment and
enhance adherence to medication-assisted treatment is well established
(McCaul & Petry, 2003).
The U.S. Food and Drug Administration (FDA) has approved medica-
tions for treatment of addiction to opioids, alcohol, and nicotine. Yet,
only a small percentage of physicians discuss these medications with their
patients, and few patients with addictions are prescribed these medica-
tions. Even when an institution, such as the Veterans Health Administration
(VHA), has a policy strongly encouraging the use of medication-assisted
treatment for addiction, the number of patients treated with medications
for addiction is still very low. A recent study of providers in the VHA found
that only 3.4% of patients who presented with an alcohol use disorder were
prescribed naltrexone, disulfiram, or acamprosate (Harris et al., 2012).
Studies have been done to assess the barriers that interfere with physi-
cians prescribing medications for SUDs. A study done by Mark, Kranzler,
Song, and colleagues in 2003 surveyed members of the American Academy
of Addiction Psychiatry and American Society of Addiction Medicine
regarding their opinions about medications to treat alcoholism. Sixty-five
percent of those surveyed responded (n = 1388). They were asked the
approximate percentage of alcohol-dependent patients they treated in
the past 3 months with naltrexone (13%), disulfiram (9%), antidepressants
(46%), and benzodiazepines (11%). Of note, physicians reported that they
knew of naltrexone and disulfiram, but their knowledge of these medica-
tions was lower than their knowledge of antidepressants.
 7 PHARMACOTHERAPY OF SUDS 171

The reasons that physicians do not prescribe medications for the treat-
ment of SUDs vary and include believing that the medications are not very
efficacious, believing that abstinence is the best treatment, believing that
their patients do not want to take medications for addictions, patients’
concerns about adverse effects, patients’ concerns about acceptance by
others in mutual support groups, and cost of medications (Mark, Kranzler,
& Song, 2003; Swift et al., 1998).
The focus of this chapter is to review medication-assisted treatment for
SUDs (Table 7.1). We will also review medications that are being investi-
gated to treat SUDs. We will examine how pharmacological and behav-
ioral approaches can be combined to optimize outcomes and will review
the guiding principles of the use of pharmacotherapies in the treatment
plan for patients with SUDs. Medications used for the treatment of alcohol
and drug withdrawal are reviewed in Chapter 5.

Table 7.1 Medications Approved or Studied for the Treatment of

Substance Use Disorders
Substance FDA- Medications Medications Medications
Approved with Some under Studied
Medications Evidence of Investigation but Not
Efficacy but No Efficacious
FDA Approval

Alcohol
Acamprosate Baclofen Varenicline SSRIs alone
Disulfiram Carbamazepine Olanzapine Most
antipsychotics
Naltrexone Gabapentin
Naltrexone XR Divalproex
sodium
Ondansetron
Topiramate
Opioids
Naltrexone
Naltrexone XR
Buprenorphine
Buprenorphine-
naloxone
Methadone
Nicotine
Nicotine Nortriptyline Nicotine
replacement vaccine
therapy

(continued)
172 Substance Use Disorders

Table 7.1 (Continued)

Substance FDA- Medications Medications Medications
Approved with Some under Studied
Medications Evidence of Investigation but Not
Efficacy but No Efficacious
FDA Approval
Bupropion SR Clonidine
Varenicline
Cocaine
Modafinil Cocaine vaccine
Bupropion SR
Desipramine
Disulfiram
Topiramate
Cannabis
Buspirone Quetiapine
Dronabinol Divalproex
sodium
Entacapone
Rimonabant
Methamphetamine
Topiramate Aripiprazole
Modafanil Gabapentin
Dexamphetamine SSRIs
Ondansetron
Mirtazapine
FDA, U.S. Food and Drug Administration; SSRIs, selective serotonin reuptake inhibitors.
This page intentionally left blank
174 Substance Use Disorders

Medications for the Treatment of

Alcohol Dependence
FDA-Approved Medications
Acamprosate
Acamprosate (Campral) was approved for the treatment of alcohol
dependence first in France in 1989, and then in the United States in 2004. It
is a gamma-aminobutyric acid (GABA) agonist and N-methyl-D -aspartate
(NMDA) receptor antagonist. After chronic exposure to alcohol, there
is thought to be an upregulation of NMDA receptors in an attempt to
compensate for the constant presence of alcohol, which works on the
brain’s inhibitory (GABAergic) neurotransmitter system. It is thought that
acamprosate, by being an NMDA receptor antagonist, modulates gluta-
mate hyperactivity (DeWitte et al., 2005). Acamprosate is thought to be
helpful with “relief cravings” in which patients drink because of negative
mood states and experience withdrawal-like symptoms before alcohol
intake (Heinz et al., 2003; Mann et al., 2008).
Studies of acamprosate have generally been more positive in Europe
than in the United States. What might account for the difference between
the U.S. and European studies is the fact that the European subjects
had undergone a longer period of abstinence stabilization before being
involved in the study. Acamprosate showed no additional benefit beyond
either placebo or psychosocial therapy in the multisite COMBINE trial
(Anton et al., 2006). However, a Cochrane review of 24 randomized
controlled trials (Rosner et al., 2010), which included 6,915 patients with
alcohol dependence, found that acamprosate significantly reduced the risk
for return to any drinking to 86% of the risk in the placebo group and sig-
nificantly increased the cumulative abstinence duration by 11% compared
with placebo. The number needed to treat was 9.09 (To put this in per-
spective, a recent study by Thase and colleagues (2012) found the number
of depressed patients needed to treat with escitalopram to see a response
was 5.) Acamprosate was associated with a reduction of gamma-glutamyl
transferase (GGT) by almost 12 units per liter, which differed from pla-
cebo. There was no difference between groups in return to heavy drink-
ing. The FDA mentioned that acamprosate may not be helpful in patients
who are actively drinking at the beginning of treatment and in patients who
are using other substances. Diarrhea was the only adverse effect more
frequently reported in the group receiving acamprosate. In 3- to 12-month
follow-up evaluations after discontinuation of treatment, patients in the
acamprosate group had a 9% lower risk for returning to any drinking than
the placebo group and a 9% higher continuous abstinence duration.
Disulfiram
Disulfiram (Antabuse) was approved for the treatment of alcohol depen-
dence in 1949. It is an alcohol-sensitizing medication that deters a patient
from drinking by producing an aversive reaction to alcohol if the patient
were to drink.
 7 PHARMACOTHERAPY OF SUDS 175

Alcohol is metabolized as shown below:

Alcohol

Alcohol dehydrogenase

Acetaldehyde

Aldehyde dehydrogenase

Acetate
Disulfiram is an irreversible inhibitor of aldehyde dehydrogenase.
Therefore, if a person taking disulfiram drinks alcohol, he or she will have
a buildup of acetaldehyde. The acetaldehyde buildup makes a person
feel very sick and is what is known as the “disulfiram-alcohol reaction.”
Symptoms of this reaction are flushing, sweating, nausea, vomiting, dehy-
dration, and increased heart rate. The reaction may be severe and cause
trouble breathing, irregular heartbeat, myocardial infarction, heart failure,
seizures, unconsciousness, and death. These symptoms tend to start 10
to 30 minutes after alcohol is ingested. The effect is in proportion to the
amount of alcohol ingested and the dose of disulfiram. The reaction may
occur for up to 14 days after the last dose of disulfiram (because it may
take the body that long to replace aldehyde dehydrogenase).
Disulfiram is not intended to be an “aversion therapy” because ide-
ally the patient would never experience the reaction. The intended use
is to help the patient achieve a period of abstinence by being adherent to
the medication on a daily basis. Although disulfiram may not reduce the
urge to drink alcohol, the expectation of a severe reaction if one drinks
alcohol may increase the motivation to not drink. Studies have found that
disulfiram is helpful in reducing number of drinking days (i.e., increasing
periods of abstinence; see meta-analysis by Jorgensen et al., 2011). People
who are motivated not to drink and are committed to total abstinence,
have severe alcohol problems, are more socially stable, and attend AA
meetings may do well with this medication and are more likely to adhere
to it (Swift, 2003). Concerned significant others (CSOs) may be enlisted
to observe dosing but should be cautioned against surreptitiously putting
disulfiram in a loved one’s food or drink. CSOs’ role should be to witness
and encourage daily dosing. CSO-monitored treatment with disulfiram has
been found to significantly enhance abstinence when it is associated with
psychosocial treatment (Meyers & Miller, 2001). Another potential use of
a drug similar to disulfiram (in Canada; trade name Temposil) is using it as
a protective drug “as needed,” when the patient feels at risk for drinking.
Patients should be cautioned against using mouthwashes, cough syrups,
aftershaves, and other alcohol-containing products while taking disulfiram
because they may precipitate a disulfiram-alcohol reaction. Vapors such as
paint thinners and varnishes may also have this effect.
Naltrexone
Oral naltrexone (Revia) was approved by the FDA for treatment of alco-
hol dependence in 1994. It is thought that when someone drinks alcohol,
176 Substance Use Disorders

endogenous opioids are released that bind to opioid receptors, thereby

making drinking alcohol pleasurable. Naltrexone is an opioid receptor
antagonist that works by blocking endogenous opioids from binding to
opioid receptors, so someone who drinks alcohol while taking naltrex-
one doesn’t get the rewarding sensation. Changes in the opioid system
also modulate the mesolimbic dopaminergic system, especially the projec-
tions of the dopaminergic neurons from the ventral tegmental area to the
nucleus accumbens. Both areas are involved in reward and reinforcement.
Hence, naltrexone is thought to help with “reward cravings.” Naltrexone
appears to reduce the frequency and intensity of drinking, that is, prevent-
ing a lapse from becoming a relapse (Rosner et al., 2008). Naltrexone’s
efficacy, like any medication, is limited by adherence to the medication
regimen, and patient persistence with this medication has been low in
some studies (Harris et al., 2004; Oslin et al., 2008).
In the large multisite COMBINE study, naltrexone was significantly
more effective than placebo when given in the context of medical manage-
ment (Anton et al., 2006), and the benefits were maintained 1 year after
the naltrexone was stopped. A Cochrane review done in 2010 concern-
ing naltrexone reviewed 47 randomized controlled studies including 3,881
patients who received naltrexone. Naltrexone significantly reduced the
risk for returning to heavy drinking to 83% compared with placebo group.
It did not have a significant effect on return to drinking of any amount. The
number of persons needed to treat to prevent return to heavy drinking
(defined as 5 or more drinks a day) was 9.09. The number of drinking days
was decreased by about 4% and heavy drinking days by 3% when com-
pared with placebo. The amount of consumed alcohol per day decreased
by 11 grams, and GGT values decreased by about 10 units compared with
placebo. Regarding adverse effects, the most common complaints were
abdominal pain, nausea, vomiting, decreased appetite, and daytime seda-
tion. Adverse effects from naltrexone led to a 60% higher risk for dropping
out compared with placebo, but the risk for dropping out regardless of
reason was 8% lower in the naltrexone group. In studies in which sub-
jects were evaluated 3 to 12 months after discontinuation of treatment,
patients in the naltrexone group had a 14% lower risk for returning to
heavy drinking and a 6% lower risk for returning to drinking any amount
(Rosner et al., 2010).
Studies are being done to determine whether there is a particular type
of individual who responds best to naltrexone. Based on studies so far, it
is thought that someone with a family history of alcoholism or who has
cravings for alcohol may be more responsive to naltrexone (King et al.,
1997; Monterosso et al., 2001). Studies of patients with the A1118G single
nucleotide polymorphism, which codes for the Asn40Asp substitution on
the OPRM1 gene (mu-opioid receptor gene), have been conducted to
determine whether there is a genetic variation that predisposes individuals
to a more positive response to naltrexone. Individuals with at least one
copy of the G allele show greater sensitivity to alcohol than those homo-
zygous for the A allele (Ray & Hutchinson, 2004). When given naltrexone,
50 mg for 3 days, individuals with a copy of the G allele experienced
greater blunting of the alcohol-induced high at breath alcohol concentra-
tions of 0.06 (Ray & Hutchinson, 2007).
 7 PHARMACOTHERAPY OF SUDS 177

In 2006, a long-acting injectable formulation was approved for the treat-

ment of alcohol dependence and introduced to the market. The inject-
able form of naltrexone (Vivitrol) is administered once monthly and has
the advantage of improving adherence. In a multisite trial, the individuals
who received the active medication had significantly fewer drinking days
of heavy drinking at follow-up compared with the individuals who received
placebo (Garbutt et al., 2005). It appears that within the context of psy-
chosocial treatment, this medication also helps reduce drinking during
high-risk periods such as holidays (Lapham et al., 2009).
Because acamprosate and naltrexone have different mechanisms of
action, use of both medications may be helpful for patients who are having
trouble controlling their drinking with just one of these medications. The
COMBINE study, however, found that acamprosate plus naltrexone was
no more effective than naltrexone with medical management or psycho-
social treatment (Anton et al., 2006).
In a study of health care costs, utilization outcomes, and continued
pharmacotherapy for FDA-approved medications for alcoholism, patients
prescribed medications the treatment of alcohol use disorders had lower
health care costs than patients not prescribed medications. Despite the
increased cost of extended-release naltrexone, patients prescribed this
medication had lower health care costs (Baser et al., 2011).
Promising Medications for Treatment of Alcohol
Dependence
Topiramate
Topiramate (Topamax) has been FDA approved for treatment of seizures
and migraine prophylaxis. It is sometimes used off-label for the treatment
of alcohol dependence. Topiramate is thought to work by facilitating inhib-
itory GABAA currents at nonbenzodiazepine sites on the GABAA recep-
tors and antagonizing aminomethylphosphonic acid (AMPA) and kainate
glutamate receptors in the corticomesolimbic system. This leads to sup-
pression of alcohol-induced dopamine release in the nucleus accumbens,
thereby limiting the reinforcing effects of alcohol.
Three double-blind placebo-controlled studies of topiramate have
shown that alcohol-dependent subjects taking topiramate decrease their
drinking (Johnson et al., 2003, 2007; Rubio et al., 2009). In a 14-week mul-
tisite study by Johnson et al. (2007), alcohol-dependent participants tak-
ing topiramate (target dose of 300 mg daily) showed a significantly lower
percentage of heavy drinking days from baseline within 4 weeks and at 14
weeks, had a higher rate of continuous abstinence, and achieved 28 days of
continuous nonheavy drinking faster than the placebo group. The medica-
tion also was found to reduce cravings on various obsessive-compulsive
drinking scales that are highly correlated with self-reports of drinking. The
dropout rate due to adverse events was higher in the topiramate group
(18.6%) than the placebo group. Paresthesia, taste perversion, anorexia,
inattention, and pruritus were significantly more common in the topira-
mate group (Johnson et al., 2007). It has been suggested that because
significant effects were reached by week 4 (150 mg daily in the dose titra-
tion schedule), perhaps a lower dose of topiramate should be used, which
would result in a lower side-effect burden and higher adherence.
 178
Substance Use Disorders
Table 7.2 Medications for Treatment of Alcohol Use Disorders
Medication Typical Dose Possible Adverse Effects Metabolism/Excretion;
Recommended Monitoring
Acamprosate 333–666 mg PO TID Diarrhea, anxiety, headache, depression, Excreted by the kidneys, so safe to use
For those with moderate insomnia, fatigue, intestinal cramps, in people with advanced liver disease
renal impairment (CrCl flatulence, change in libido, dizziness,
30–50 mL/min), use 333 mg pruritus, suicidal ideation Contraindicated with severe renal
PO TID. impairment (CrCl <30 mL/min)
Disulfiram 125–500 mg PO daily Rash, acne, drowsiness, fatigue, headache, Metabolized by the liver
impotence, metallic aftertaste, neuropathy,
hepatitis, liver failure, psychosis Check LFTs before starting this
medication and 1 month after starting,
then monitor periodically throughout
treatment.

People with severe heart disease

should not take this medication.
Naltrexone 50–100 mg PO daily Nausea, vomiting, diarrhea, constipation, Metabolized by the liver
If patient has been taking abdominal cramps, headache, dizziness,
opiates, wait 7–10 days after fatigue, sedation, insomnia, chest pain, Check LFTs before starting this
last opiate before giving first arthralgia, muscle cramps, rash, diaphoresis, medication and 1 month after starting,
dose to avoid precipitating delayed ejaculation, precipitated then monitor periodically throughout
withdrawal. withdrawal, acute hepatitis, and liver failure treatment.
Naltrexone 380 mg IM q 4 weeks Nausea, vomiting, diarrhea, constipation, Metabolized by the liver
XR abdominal pain, headache, dizziness,
anorexia, sedation, insomnia, arthralgia, Check LFTs before starting this
muscle cramps, rash, sweating, medication and 1 month after starting,
hypertension, precipitated withdrawal, then monitor periodically throughout
acute hepatitis, liver failure, injection site treatment.
reaction, CK elevation
Topiramate 75–150 mg PO BID Paresthesia, taste perversion, anorexia, Excreted by the kidneys, so safe to use
inattention, pruritus, somnolence, weight in people with advanced liver disease

7 PHARMACOTHERAPY OF SUDS
Not FDA approved for loss, fatigue, anxiety, cognitive dysfunction,
alcohol dependence UTI, ataxia, abnormal vision, diarrhea, CrCl <10 mL/min: decrease dose 75%
mood disturbances, nystagmus, nausea,
May be started without an dyspepsia, nephrolithiasis, metabolic
initial period of abstinence acidosis, osteoporosis
BID, twice daily; CK, creatine kinase; CrCl, creatinine clearance ; FDA, U.S. Food and Drug Administration; IM, intramuscularly; LFTs, liver function tests; PO, orally; TID, three
times daily; UTI, urinary tract infection.

179
180 Substance Use Disorders

Gabapentin
Gabapentin (Neurontin) modulates GABA and glutamate tone and
is approved for treatment of partial seizures, post-herpetic neuralgia,
and neuropathic pain. There is some evidence that it may be effica-
cious in reducing alcohol consumption and craving (Furieri et al., 2007).
Additionally, it has also been shown to be effective in the treatment of
anxiety (Pollack et al., 1998) and insomnia associated with alcohol depen-
dence (Karam-Hage et al., 2000).
A double-blind placebo-controlled study found a significant effect for
gabapentin, 1,200 mg daily (divided 300 mg, 300 mg, 600 mg), on sev-
eral measures of alcohol craving, and it was also significantly associated
with several measures of sleep quality (Mason et al., 2009). In another
double-blind placebo-controlled study, alcohol-dependent participants
received gabapentin, 300 mg twice daily, or placebo. After 28 days, the
group receiving gabapentin showed a significant reduction in the number
of drinks per day and number of heavy drinking days, and an increase in the
percentage of days abstinent (Furieri et al., 2007). When combined with
naltrexone, for the first 6 weeks after drinking cessation, study participants
taking gabapentin plus naltrexone had a longer interval of time to heavy
drinking than those receiving naltrexone alone or placebo. They also had
fewer heavy drinking days than the naltrexone-only group. Of note, the
naltrexone-only group had more heavy drinking days than the placebo
group. After 6 weeks, the gabapentin was discontinued, and the differ-
ences between the groups faded (Anton et al., 2011).
Baclofen
Baclofen is a GABAB receptor agonist and has been approved for treat-
ment of spasticity. GABAB receptors are located in the ventral tegmental
area and control mesolimbic dopamine release from their terminals in the
nucleus accumbens. When baclofen is bound to the GABAB receptors, it is
thought to block alcohol and reducing its rewarding effects. A double-blind
placebo-controlled randomized study by Addolorato et al. (2002) found
that a higher percentage of subjects were abstinent and demonstrated a
higher number of cumulative days of abstinence throughout the 30-day
study period when taking baclofen, 30 mg daily. Subjects taking baclofen
also had lower craving scores for alcohol and decreased alcohol intake.
A later, small double-blind, randomized placebo-controlled study done
using patients with cirrhosis of the liver (Addolorato et al., 2007) found
that subjects prescribed baclofen over a 12-week period were 6.3 times
more likely to remain abstinent, and cumulative number of days abstinent
was twice as many in the baclofen group (62.8 vs. 30.8). There was no
difference between groups in dropout rate. An American group (Garbutt
et al., 2010) tried to replicate the Italian findings but did not find baclofen
to be effective in reducing percentage of heavy drinking days, percentage
of days abstinent, or craving for alcohol. These investigators hypothesized
that perhaps the differing results were due to the subjects in the Italian
studies having higher levels of physical dependence on alcohol, because
their baseline number of drinks was higher, and a different treatment goal
(abstinence) than the subjects in the U.S. study. Use of baclofen for treat-
ment of alcohol dependence in the U.S. is still largely experimental.
 7 PHARMACOTHERAPY OF SUDS 181

Ondansetron
Ondansetron (Zofran) is a 5-HT3 receptor antagonist approved for treat-
ment of nausea and vomiting. Alcohol potentiates selective 5-HT3 recep-
tor–mediated ion currents. There are densely distributed 5-HT3 receptors
in the mesocorticolimbic pathway that regulate dopamine release. In ani-
mal models, use of a 5-HT3 antagonist attenuates dopamine release and
reduces the rewarding effects of alcohol, thereby reducing consumption.
Use of ondansetron is reported to be efficacious in treating people with
early-onset (<25 years of age) alcoholism. In a study done by Johnson
et al. (2000), ondansetron significantly reduced consumption of alcohol
and increased abstinence in patients with early-onset, but not late-onset,
alcoholism. The most efficacious dose was 4 mcg/kg twice per day, but
this was not significantly better than other doses of ondansetron. Use
of ondansetron for the treatment of alcohol dependence is still largely
experimental.
Other Anticonvulsants
Other anticonvulsants, such as divalproex sodium (Salloum et al., 2005,
in treating bipolar patients with alcohol dependence; Brady et al., 2002;
Longo et al., 2002;) and carbamazepine (Mueller et al., 1997) have mixed
or limited evidence for their use in treating alcohol dependence.
Other Agents
Other studies are being conducted now at the National Institute on
Alcohol Abuse and Alcoholism (NIAAA) that are looking at the effective-
ness of other agents, such as varenicline and aripiprazole, and agents that
act of CRF-1 and NK-1 receptors.

Case Vignette 1
John is a 25-year-old man who started drinking alcohol at age 15 years and
reports he started drinking on a daily basis at 17 years of age. He went to
inpatient rehabilitation times; the last time was 2 years ago. He attends AA
meetings regularly when he is not drinking and has a sponsor and home
group. His longest period of abstinence is 8 months. He also smokes 1
pack per day of cigarettes. During the past year, John has had binge drink-
ing episodes when he drank a fifth of liquor daily for several days to a
week and then sought detoxification. He has self-referred to the ambula-
tory detoxification program 18 times in the past 18 months. He denies a
family history of alcoholism. John is currently in the partial hospitalization
program. After a full psychiatric evaluation, his Axis I diagnoses are alcohol
dependence and nicotine dependence. He is interested in a medication to
help treat alcohol dependence and is not interested in quitting smoking.
He has no Axis II or III conditions. He has no insurance and currently is
taking time off of work as an automotive technician to seek treatment.
• What medication would you recommend for John and why?
• Are there any laboratory tests you would check before prescribing
this medication and after starting the medication?
• How would you address John’s continued desired to smoke?
182 Substance Use Disorders

Suggested Approach to Treatment

Of the FDA-approved medications for alcohol dependence, John is a candi-
date for all four. He has no known medical conditions that would preclude
treatment with a medication that is primarily metabolized by the liver or
excreted by the kidneys. Therefore, reviewing all medications approved
for treatment of alcohol dependence with John is appropriate. If John
endorses “relief cravings,” contributing to his drinking, acamprosate may
be an appropriate choice. It is generally well-tolerated by patients but does
require patients to take a medication three times daily, which may be diffi-
cult for some patients to adhere to, which will thereby lower the effective-
ness of the medication. If John reports he is committed to total abstinence,
disulfiram may be an appropriate choice. One concern in prescribing this
medication is patient impulsivity. If John impulsively drinks while taking
disulfiram, he could become very ill and need medical attention. Therefore,
this aspect needs to be further explored. Lastly, either formulation of nal-
trexone may benefit John, especially if he endorses “reward cravings” for
alcohol. The choice of oral versus intramuscular (IM) formulation will likely
be influenced by cost of the medication because the IM formulation costs
significantly more per month.
If prescribing acamprosate, check creatinine at baseline and then peri-
odically throughout treatment because acamprosate is renally excreted. If
prescribing disulfiram or naltrexone, check liver function tests at baseline
and then after 14 days. With disulfiram, also check a baseline complete
blood count and serum chemistry panel.
Because John is still precontemplative regarding smoking cessation,
motivational enhancement therapy may be used build motivation to
change. With John’s permission, information on the effects of smoking on
his health and drinking behavior may be given.
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184 Substance Use Disorders

Medications for the Treatment of

Opioid Dependence
In 1914 the Harrison Narcotic Act was passed. It was a tax on the distribu-
tion of opium and coca leaves and their derivatives. The courts interpreted
it to mean that it prohibited physicians from prescribing narcotic medica-
tions treat addiction.
FDA-Approved Medications
Methadone
Methadone was first used by Vincent Dole and Marie Nyswander in
New York in a study to treat heroin addicts (1965). They admitted 22
heroin addicts to their program who were 19 to 37 years old with no
other substantial addictions or psychosis and who could not remain absti-
nent after prior detoxifications. The subjects were admitted to the hospi-
tal for the first 6 weeks, during which they had a medical and psychiatric
evaluation. Psychosocial problems were reviewed, and job placement
studies were done. Those who hadn’t graduated from high school were
enrolled in GED classes. The patients were stabilized on methadone, and
after 1 week, they were allowed to leave the unit on pass. After 6 weeks,
the patients were discharged home. They presented daily for methadone
dosing, drank the methadone in front of the nurse, and had daily urine
drug screens. Reliable patients were given take-home doses for week-
ends or short trips. Patients were provided with resources for obtaining
jobs, housing, and education. Dole and Nyswander found that methadone
helped treat “narcotic hunger” and that “ex-addict has become a socially
normal, self-supporting person.” Of the 22 patients they admitted, only
two were discharged from the program. Four of the patients used heroin
while taking methadone but reported they did not feel any effect from it.
The patients’ functioning at school and work could not be discerned from
healthy controls. Overall, they concluded that with methadone, addicts
could give up heroin and live productive, law-abiding lives.
Once the results from Dole and Nyswander were published in 1965,
several methadone clinics sprang up under the auspices of investigational
new drug studies. In 1974, the Narcotic Addict Treatment Act was passed,
which amended the Controlled Substances Act of 1970 and recognized
the use of an opioid drug to treat opioid addiction and defined “mainte-
nance treatment” in federal law. When used for the treatment of addic-
tion, methadone is only to be prescribed by a licensed opioid treatment
program. To date, studies have found methadone maintenance programs
important in harm reduction in terms of reducing transmission of HIV
and hepatitis C virus by decreasing injection drug use (Lott et al., 2006;
Metzger et al., 1993; Peles et al., 2011; Turner et al., 2011). Methadone
maintenance also helps patients improve their level of functioning, such
that they are able to hold a job, their participation in illegal activities is
reduced (Anglin et al., 1989; Dolan et al., 2005; Marsch, 1998), and the
quality of relationships improves (Maremmani et al., 2007).
Methadone is a full mu-opioid agonist. It has a half-life of about 24 to 36
hours and therefore is usually dosed once daily for the treatment of opioid
 7 PHARMACOTHERAPY OF SUDS 185

dependence. One exception is for the patient who is a rapid metabo-

lizer of methadone. This is determined by getting a methadone peak and
trough level. The trough level is drawn before dosing, and then peak level
is drawn 2 to 4 hours after dosing. If the peak level is more than two times
the trough level, the patient is thought to be a rapid metabolizer and may
qualify for split dosing, that is, twice daily dosing, if he or she is eligible for
take-home doses.
To be eligible for methadone maintenance, a patient must have at least a
1-year history of dependence on opioids. Three exceptions to these rules
are (1) pregnant women, (2) patients released from correctional facilities
in the past 6 months, and (3) previously treated patients (up to 2 years
after discharge). A person younger than 18 years must have undergone at
least two documented attempts at detoxification or psychosocial treat-
ment within 12 months to be eligible for treatment, and a parent or legal
guardian must consent in writing for an adolescent to start on methadone
maintenance.
Patients are typically started on no higher than 30 mg of methadone
on day 1 of treatment. After being assessed by the physician 2 to 4 hours
after this initial dose, if the patient is still in withdrawal, the patient may
be given an additional 10 mg of methadone for a total maximum first day
dose of 40 mg. The total first day dose of methadone allowed by federal
regulations is 40 mg, unless the program physician documents that 40 mg
was insufficient to suppress opiate withdrawal symptoms in the patient’s
record.
The two phases of methadone treatment are induction and mainte-
nance. During induction, the risk for death from overdose is highest and
is increased with a higher induction dose and sedative use. Forty-two per-
cent of methadone deaths occur within the first week of starting metha-
done. With daily dosing of methadone, a significant portion of the dose
gets stored in the tissue, so even after the second dose, the peak and
trough levels will be increased. These increases level off when a steady
state is reached in 3 to 7 days. Dose changes should be made as needed
every 3 to 7 days to reach a maintenance dose and in 5- to 10-mg incre-
ment doses for patients with high tolerance.
Patients’ doses are titrated to alleviate opioid withdrawal symptoms,
block euphoric effects from self-administered opioids, and eliminate crav-
ings for opioids. The effective maintenance dose range is typically between
80 and 120 mg of methadone daily (Joseph et al., 2000). Patients should be
able to function normally on their dose of methadone without impairment
of perception or physical or emotional responses. Patients can remain at
their maintenance dose for years without adjusting the dose. There is not
much utility in checking methadone serum levels, with the exception of
checking the peak and trough levels as mentioned above. Of note, studies
have shown that serum levels of 150 to 600 ng/mL are necessary to sup-
press opiate cravings (Leavitt et al., 2000).
Methadone is metabolized in the liver, primarily through the CYP450
3A4 isoenzyme, followed by 2D6 and possibly 1A2, 2C9, and 2C19.
Therefore, medications that induce or inhibit these enzymes can affect
serum methadone levels (SML). See Table 7.3 for a list of medications that
can affect SML.
186 Substance Use Disorders

Table 7.3 Medications that May Interact with Methadone

Common Medications that May Interact with Methadone
Inducers— can precipitate withdrawal
Phenytoin Oxcarbazepine
Carbamazepine Modafinil
Phenobarbital Rifampin
Nevirapine St. John’s Wort
Efavirenz
Inhibitors—can lead to higher methadone levels
Cimetidine Amiodarone
Ciprofloxacin Diltiazem
Fluconazole Verapamil
Erythromycin Grapefruit juice
Fluvoxamine Fluoxetine

There is a phenomenon known as “boosting,” in which a patient

takes clonazepam or diazepam about 1 hour after receiving his or her
methadone dose in order to “get high” from methadone. Because clon-
azepam and diazepam are substrates of CYP450 3A4, they compete with
methadone for the 3A4 enzymes and potentiate the sedative effects of
each other.
Table 7.4 lists common adverse effects of methadone. Although some of
these adverse effects may go away with time, constipation and diaphoresis
tend remain throughout treatment.
Chronic exposure to opioids can lead to low levels of follicle-stimulating
hormone and luteinizing hormone, known as opioid-induced androgen
deficiency (OPIAD; Smith & Elliot, 2012). This syndrome may subsequently
result in low libido, erectile dysfunction, menstrual irregularities, infertility,
hot flashes, fatigue, depression, reduced facial and body hair, decreased
muscle mass, weight gain, anemia, osteopenia, and osteoporosis. Patients
with suspected OPIAD should be referred to their primary care physician
or an endocrinologist for further evaluation and treatment.
Consensus recommendations published in 2009 followed the 2006 black
box warning on methadone regarding QT prolongation (Krantz et al.,
2009). The panel made five recommendations.
1. Patients should be informed of the risk for arrhythmia when they are
prescribed methadone.
2. Clinicians should ask patients about a history of structural heart
disease, arrhythmia, and syncope.
3. A pretreatment electrocardiogram (ECG) should be obtained to
measure the QTc interval. A follow-up ECG should be obtained
within 30 days of starting methadone and then annually. Additional
 7 PHARMACOTHERAPY OF SUDS 187

Table 7.4 Common Adverse Effects of Methadone

Common Adverse Effects of Methadone
Low energy QT prolongation Cough
Back pain Abnormal dreams Rhinitis
Edema Anxiety Yawning
Chills Decreased libido Postural hypotension
Hot flashes Depression Bradycardia
Malaise Euphoria Hyperprolactinemia
Weight gain Headache Amenorrhea
Constipation Insomnia Diaphoresis
Dry mouth Somnolence Rash
Blurred vision Sexual dysfunction Urinary retention

ECGs should be done if dose exceeds 100 mg or if there are

unexplained seizures or syncope.
4. If QTc is between 450 and 500 msec, discuss potential risks and
benefits with patients and monitor more frequently. If QTc is greater
than 500 msec, consider discontinuing or reducing methadone dose.
Eliminate drugs that promote hypokalemia.
5. Clinicians should be aware of interactions between methadone and
other drugs that possess QT interval-prolonging properties or slow
the elimination of methadone.
Some medications are contraindicated with methadone because of their
propensity to prolong the QT interval as well. They include ziprasidone,
quetiapine, pimozide, and phenothiazines. Quetiapine’s product informa-
tion guide was revised in 2011 to specifically state that it should not be used
with methadone because of potential QT prolongation and risk for tors-
ades de pointes. Patients should also be made aware that use of cocaine
may prolong the QT interval and put them at risk for the fatal arrhythmia.
The risk for overdose is a serious concern with methadone. Patients
should be advised of the risks of using prescribed or illicitly obtained
benzodiazepines with methadone. Benzodiazepines plus opioids can slow
down respiration and lead to death. Alcohol plus opioids can have the
same effect and consequence.
Patients initially dose at the clinic on a daily basis in front of a nurse or
pharmacist who pours the methadone. Some clinics are closed on Sundays
and federal holidays, and patients are granted a take-home bottle automat-
ically for the day the clinic is closed. Apart from this, patients must apply
for take-home privileges based on eight criteria for take-home medication
specified in federal regulations. Patients must demonstrate the following
to receive take-home privileges:
1. Absence of recent drug and alcohol abuse
2. Regular attendance at the methadone clinic
188 Substance Use Disorders

3. Absence of behavioral problems at the clinic

4. Absence of recent criminal activity
5. Stable home environment and social relationships
6. Acceptable length of time in comprehensive maintenance treatment
7. Assurance of safe storage of take-home medication
8. Determination that the rehabilitative benefit of having take-home
medication will outweigh the possible risk for diversion
Once patients are granted take-home privileges, an infraction of one of
the eight criteria results in a loss of take-home privileges. Each clinic has its
own policies for reinstatement of privileges.
The potential for diversion of take-home bottles of methadone is a
risk of granting take-home privileges because diverted methadone can
lead to overdose and death of persons not enrolled in the methadone
clinic. When checking urine drug testing, you must check specifically for
methadone and its metabolite to ensure the patient is taking methadone.
Because it is a synthetic opioid, it will not trigger a positive screen for
opiates.
Despite the groundbreaking MOTHER study (Jones et al., 2010) show-
ing the efficacy of buprenorphine for treating pregnant women who are
opioid dependent, methadone is still considered the gold standard for
treating opioid-dependent women who are pregnant. Opioids are not
teratogenic, but opioid withdrawal can be harmful for the embryo/fetus
and result in spontaneous abortion. Women who are opioid dependent
and find they are pregnant should be educated about methadone mainte-
nance and referred to the appropriate agency for methadone conversion.
Some women will be admitted to the hospital for methadone conver-
sion, whereas this process will be done as an outpatient in some com-
munities. Babies born to mothers taking methadone or buprenorphine
(or other opioids) may develop neonatal abstinence syndrome (NAS)
and should be monitored for symptoms of NAS using the Finnegan scale
(Finnegan, 1990).
Buprenorphine and Buprenorphine-Naloxone
In 2000, the Drug Abuse Treatment Act (DATA 2000) was passed, which
allowed physicians to treat patients with opioid dependence with Schedule
III through V controlled substances specifically approved by the FDA for
medication-assisted treatment of opioid dependence. In 2002, the FDA
approved the use of buprenorphine (Subutex) and buprenorphine-naloxone
(Suboxone) for the treatment of opioid dependence.
Buprenorphine was first used in France for the treatment of opioid
dependence. Like methadone, buprenorphine can be seen as a harm
reduction strategy, in that it can help reduce transmission of HIV and hep-
atitis C by decreasing injection drug use (Lott et al., 2006; Turner et al.,
2011). Furthermore, patients adherent to the medication show improve-
ments in their social and occupational functioning and engagement with
treatment providers (Parran et al., 2010).
Buprenorphine is a partial opioid agonist that partially binds to the
mu-opioid receptor, and it is an antagonist at the kappa receptor. It has a
very high affinity for the mu receptor and exhibits slow dissociation from
it. Because of its partial agonist activity, buprenorphine has a ceiling effect,
 7 PHARMACOTHERAPY OF SUDS 189

which means that larger doses of the medication do not result in larger
effects of the drug. Therefore, it is safer in overdose than a full opioid
agonist; however, this ceiling effect can be negated when buprenorphine is
used with benzodiazepines or alcohol.
Buprenorphine comes in combination with or without nalox-
one. When it is mixed with naloxone, it is combined in a 4:1 ratio of
buprenorphine to naloxone. Apart from pregnant women and in con-
trolled settings, buprenorphine should almost always be prescribed in
the buprenorphine-naloxone formulation to prevent misuse. Naloxone
was put in combination with buprenorphine to prevent patients from dis-
solving the medication and using it intravenously. If taken sublingually as
prescribed, the naloxone has such low bioavailability (10% or less) that it
has virtually no adverse effects. If a patient uses buprenorphine-naloxone
intravenously, the naloxone should put the patient in opioid withdrawal
or prevent the patient from getting high from the buprenorphine.
A study by Mendelson and colleagues (1997) of opioid-dependent sub-
jects stabilized on methadone and given parenteral formulations of
buprenorphine and buprenorphine-naloxone found that intravenous
use of buprenorphine-naloxone precipitated subjective and objective
opioid withdrawal symptoms and decreased the pleasurable effects of
buprenorphine. Harris et al. (2000), however, found that intravenous
buprenorphine-naloxone use did not precipitate withdrawal or cause any
different effect than sublingual use in opioid-dependent volunteers who
were stabilized on buprenorphine and buprenorphine-naloxone sublin-
gually for 10 days prior.
To prescribe buprenorphine and buprenorphine-naloxone, a physician
must complete an 8-hour Substance Abuse and Mental Health Services
Administration (SAMHSA)-approved course and file a notification of
intent to use opioid medications for maintenance and detoxification with
SAMHSA, that is, file for a DATA waiver. Then he or she must apply for
a special Drug Enforcement Administration (DEA) number, also known
as an “X” DEA registration number. For the first year after receiving the
DATA waiver, a physician is only permitted to treat 30 patients at one
time with buprenorphine. After 1 year, the physician may file a second
notification of intent, this time to treat up to 100 patients at a time and,
once this is approved by SAMHSA, may begin treating up to 100 patients.
To start patients on buprenorphine-naloxone, patients need to be in
visible opioid withdrawal (i.e., not just subjective symptoms) to avoid
precipitating withdrawal. Buprenorphine has a higher binding affinity to
opioid receptors than other opioids. Therefore, it will preferentially bind
to the receptors, displacing other opioids. Because buprenorphine is only
a partial agonist, the person who was previously feeling full agonist activity
from heroin or oxycodone, for example, is now only feeling partial agonist
activity from buprenorphine, and this is experienced as opioid withdrawal.
If a patient takes buprenorphine and has a precipitated withdrawal reac-
tion, do not give him or her more buprenorphine because this will just
worsen the symptoms. The patient’s symptoms of opioid withdrawal can
be treated with clonidine, and anxiety can be treated with hydroxyzine
pamoate.
190 Substance Use Disorders

On induction, the recommended first dose of buprenorphine-naloxone

is 2/0.5 mg to 4/1 mg, and this may be repeated 2 to 4 hours later for
a maximum dose of 8/2 mg. The daily dose can be titrated over the
first 3 days. The average daily maintenance dose is 16/4 to 20/5 mg. In a
positron emission tomography (PET) study by Greenwald and colleagues
(2003), 78.9% to 91.5% of the mu-opioid receptors in selected regions of
interest were occupied when given 16 mg of buprenorphine versus 84.1%
to 98.4% of the mu-opioid receptors after 32 mg of buprenorphine, a dif-
ference that was not statistically significant. Because of the ceiling effect,
there is no significant benefit expected at doses greater than 32/8 mg.
Typical adverse effects of buprenorphine include diaphoresis and con-
stipation. Other adverse effects may include headache, insomnia, pre-
cipitated withdrawal, nausea, vomiting, hypotension, sexual dysfunction,
seizures, hepatitis, and hepatotoxicity. Buprenorphine, unlike methadone,
is not known to prolong the QT interval.
Buprenorphine is metabolized by the liver, primarily through CYP450
3A4 isoenzymes. Therefore, its levels may be affected by some of the same
medications that affect methadone’s levels (see Table 7.3). Buprenorphine
has a half-life of about 36 hours and can be dosed daily or every other day.
When performing urine drug testing, buprenorphine will not cause the
opiate screen to be positive because it is a synthetic opioid. Therefore,
like methadone, you need to explicitly order a test for both buprenor-
phine and its metabolite, norbuprenorphine. It is important to check for
the metabolite in the urine because this shows that the patient is actually
taking the buprenorphine, and not just putting a piece of buprenorphine in
the urine specimen and diverting the rest. To be certain that patients are
not taking synthetic opiates, you must also order a screen for oxycodone
because the regular screen for opiates usually will not detect it. Check
with your local laboratory to see if their opiate test includes oxycodone.
In 2010, the Maternal Opioid Treatment: Human Experimental Research
(MOTHER; Jones et al., 2010) study showed that babies born to moth-
ers taking buprenorphine had as good of an outcome as babies born to
mothers taking methadone for opioid dependence during pregnancy. In
fact, babies born to mothers taking buprenorphine required significantly
less morphine to treat neonatal abstinence syndrome (1.1 vs. 10.4 mg),
shorter hospital stays (10 vs. 17.5 days), and a shorter course of treatment
for neonatal abstinence syndrome (4.1 vs. 9.9 days). However, women
taking buprenorphine were more likely to discontinue treatment than
women taking methadone. It was hypothesized that buprenorphine may
not have adequately treated opioid dependence, thereby resulting in sub-
jects switching from buprenorphine to methadone maintenance.
Methadone Versus Buprenorphine
There are several considerations to be made when referring a patient for
either methadone or buprenorphine treatment.
First, one needs to consider the amount of monitoring the patient will
need. If the patient is also dependent on several substances, a methadone
clinic may be a better option because the patient will be seen by a nurse
or pharmacist each day at the dosing window, and if the patient appears
impaired, he or she can be assessed and the methadone dose will be held,
 7 PHARMACOTHERAPY OF SUDS 191

if appropriate. Similarly, if a patient has a history of selling drugs, referral

to a methadone clinic, where he or she is not given a take-home supply of
medication until meeting the eight criteria, is a better option than giving
the patient a week’s supply of buprenorphine at the first visit.
Second, if a patient has no insurance, a methadone clinic is likely to
be more affordable than buprenorphine. Some physicians prescribing
buprenorphine do not take insurance and charge $75 or more per office
visit. Depending on the physician, the patient may need to return for
weekly visits. Suboxone film without insurance costs between $7 and $11
per 8/2-mg film strip.
Third, if a patient has a prolonged QT interval or is on medications that
prolong the QT interval, buprenorphine is the safer option.
Fourth, methadone has a broader dosing range. Suboxone doses typi-
cally range from 2/0.5 to 24/6 mg daily. Methadone doses vary from as
little as 1 mg daily to 200 mg or more daily. With methadone, there is an
opportunity to adjust a patient’s dose by 1 mg at a time.
Naltrexone
Naltrexone is an opioid antagonist. It has a high affinity for the mu-opioid
receptor and displaces bound opioid agonists. It also blocks opioids from
binding the mu-opioid receptors, thereby preventing the euphoria from
illicit opioid use. Naltrexone tablets were first approved by the FDA for
the treatment of opioid dependence in 1984. Naltrexone extended-release
injection (Vivitrol) was approved by the FDA for treatment of opioid
dependence in 2010.
A Cochrane review of oral naltrexone (Minozzi et al., 2008) found that
naltrexone maintenance therapy alone or with psychosocial therapy was
more effective in limiting heroin use during treatment than placebo alone
or with psychosocial therapy. However, when comparing naltrexone
alone to placebo, it was not more effective.
In an 8-week multicenter double-blind, parallel group, placebo-controlled
study of sustained-release naltrexone, patients dependent on heroin
were detoxified and given oral naltrexone for 3 days. They were then
randomized to receive placebo or extended-release naltrexone at 192
mg or 384 mg. They received the same dose of medication 4 weeks later.
Subjects attended twice-weekly relapse-prevention sessions. Adverse
effects were assessed at each visit, and patients gave observed urine sam-
ples for toxicology analysis. Blood samples were collected weekly to test
liver function and naltrexone and 6-beta-naltrexol levels. Sixty patients
were randomized into the study, including 18 patients in the placebo
group, 20 patients in the 192-mg naltrexone group, and 22 patients in
the 384-mg naltrexone group. The subjects receiving 384 mg of naltrex-
one were retained in treatment a significantly greater number of days
(48 days) than subjects receiving placebo (27 days) or 192 mg of naltrex-
one (36 days). When assuming missing urine specimens were positive
for opioids, subjects in the 384-mg and 192-mg naltrexone groups had a
significantly higher percentage of opioid-free urine specimens (61.9% and
47.1%) than subjects in the placebo group (25.3%). When this assumption
wasn’t made, there was no difference between the groups in negative
192 Substance Use Disorders

urine specimens because the negative urine specimens ranged from 73.5%
to 79.4%, suggesting that retention in treatment was the important factor.
Naltrexone is usually prescribed 50 mg orally daily or 380 mg intramus-
cularly every 4 weeks for treatment of opioid dependence. Alternatively,
one could take the oral preparation three times a week, at doses of 100
mg on Monday and Wednesday and 150 mg on Friday.
Possible adverse effects of naltrexone are listed in Table 7.2. Because
naltrexone is metabolized through the liver, baseline liver function tests
should be performed, checked after the first month of treatment, and then
monitored throughout treatment.
A naltrexone implant is being studied. It has been shown to be more
effective than placebo in retaining subjects, decreasing heroin use (Hulse
et al., 2010), and improving the clinical condition of subjects (Tiihonen
et al., 2012). It has also been shown to decrease amphetamine use
(Tiihonen et al., 2012).
Despite what appears to be a very appealing drug that defies the criti-
cism that the patient is “just replacing one drug for another,” naltrexone’s
use has been limited by the following: (1) patients are less willing to take
an opioid antagonist and are far more willing to start agonist therapy,
(2) patients must be abstinent from opioids or will go into precipitated
withdrawal with the first dose, (3) impersistence with treatment is com-
mon (O’Connor & Fiellin, 2000). Naltrexone may be a good medication
for highly motivated patients such as health care professionals (Ling &
Wesson, 1984) or patients being monitored by the criminal justice system
(Cornish et al., 1997). It also is a good choice of medication for patients for
whom opioid agonist treatment is unsafe because of comorbid alcohol or
sedative-hypnotic-anxiolytic (i.e., benzodiazepine) dependence.
In a study by Baser and colleagues (2011) on health care utilization by
opioid-dependent individuals, patients prescribed medication for opioid
dependence (either buprenorphine-naloxone, buprenorphine, naltrex-
one tablets or injection, or methadone) had fewer hospital admissions
of all types, and their total health care costs were 29% lower compared
with opioid-dependent patients who were not treated with medication.
 7 PHARMACOTHERAPY OF SUDS 193

Case Vignette 2
Michael is a 25-year-old man who started using pill opioids recreation-
ally at 20 years of age. His use advanced quickly from weekend to daily
use, and at its highest, he was using 60 to 80 mg of extended-release
oxycodone (OxyContin) intranasally daily. Michael completed an out-
patient detoxification program where he was detoxified from opioids
using clonidine for opiate withdrawal symptoms. After completing the
detox program, he continued to use oxycodone and decided to start on
Suboxone. Michael didn’t have insurance and said he would pay cash for
the medication; however, his income was limited because he worked in a
pizza shop. An addiction psychiatry fellow agreed to see him and started
him on Suboxone. On day 1, he was successfully induced on Suboxone,
4/1 mg, and on days 2 and 3, he was prescribed 8/2 mg. He was seen
on day 4 and continued on 8/2 mg for another 2 weeks. About 3 weeks
into treatment, Michael was approved for the pharmaceutical company’s
patient assistance program, which paid for his medication. About a week
after he got this news, he started complaining about having cravings and
urges to use opioids and asked for his dose to be increased. His dose
was increased to 12/3 mg daily. The next week when he was seen in
clinic, he still complained of cravings and urges to use, citing stress at
home, and asked for another dose increase; his dose was increased to
16/4 mg. The following week, he stated he was doing much better. He
even mentioned that things were going so well he was already starting his
Christmas shopping. Curiously, at this visit the doctor noticed his urine
drug screen result from the prior week had not returned. When asked
about this, Michael assured her that he went to the lab the week before.
The next day, the urine drug screen result returned from the prior day’s
visit and was positive for cocaine and negative for buprenorphine and
norbuprenorphine. The psychiatry fellow called Michael and asked him
to come to the clinic for a urine drug screen and bring his prescription
in for a film count. Michael agreed. Michael brought in an empty bottle
with a story about how he got a “partial fill” of Suboxone, which was not
corroborated by the pharmacist. Regarding the abnormal drug screen
results, he stated that friends spiked his beer with cocaine and that he
absolutely is taking the Suboxone as prescribed. His urine collected dur-
ing the callback was abnormal. It had a creatinine value of less than 10 and
a specific gravity of 1.000, and the lab tech stated she believed that it was
a combination of water and soap.
• What are some of the clinical concerns regarding Michael’s
treatment with Suboxone?
• What does it appear Michael is doing?
• How would you approach Michael’s treatment considering his recent
behaviors related to his treatment with Suboxone?
Answers to Case Vignette 2
What are some of the clinical concerns regarding Michael’s treatment with
Suboxone?
There are several clinical concerns. (1) As soon as Michael no longer
was paying for the Suboxone, he started complaining of cravings and
194 Substance Use Disorders

urges to use opiates after being stable on a lower dose of Suboxone for
several weeks, essentially asking for a dose increase. (2) Shortly after the
Suboxone dose was increased, it appears he did not complete a urine
drug screen as required. (3) After the Suboxone dose was increased, he
had extra money to allow him to go Christmas shopping. (4) Urine toxi-
cology was positive for cocaine and negative for buprenorphine and its
metabolite. (5) Michael did not bring in the correct number of Suboxone
film strips for the count when requested by the doctor and made up a
story that was not corroborated by the pharmacist about receiving a
“partial fill.” (6) Urine toxicology from the callback was not consistent
with urine because the specific gravity was 1.000 and creatinine was less
than 10.
What does it appear Michael is doing?
It appears that Michael has been selling his Suboxone and using cocaine
and tried to conceal this by skipping a urine drug screen and giving a
false urine specimen.
How would you approach Michael’s treatment considering his recent behav-
iors related to his treatment with Suboxone?
There are too many clinical concerns to continue prescribing Suboxone
to Michael. Because he hasn’t been taking Suboxone, he does not need
a taper. If Michael would like to continue with medication-assisted
treatment, he may be offered naltrexone or methadone maintenance.
Alternatively, he could pursue psychosocial treatment only. The phar-
maceutical company should be called to remove him from their patient
assistance program.
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196 Substance Use Disorders

Medications to Treat Nicotine

Dependence
FDA-Approved Medications
Nicotine Replacement Therapy
Nicotine replacement therapy (NRT) takes the place of cigarettes or
smokeless tobacco. When people try to quit smoking, they experience
nicotine withdrawal, and symptoms often include irritability, impatience,
anxiety, depressed mood, difficulty concentrating, restlessness, decreased
heart rate, increased appetite, and weight gain. People often resume
smoking because they cannot tolerate nicotine withdrawal symptoms.
People start nicotine replacement therapy to take the place of cigarettes
or smokeless tobacco, and then the dose of nicotine is gradually reduced
so that patients do not suffer as much nicotine withdrawal as they would
if they quit “cold turkey,” thereby increasing their chances of successfully
quitting smoking.
Nicotine replacement therapy comes in five different formulations
(gum, lozenge, patch, inhaler, and nasal spray). The first three are available
over the counter, whereas the inhaler and nasal spray are available by
prescription only.
The gum, lozenge, inhaler, and nasal spray are used as needed for nico-
tine cravings. The nicotine in the gum, lozenge, and inhaler is absorbed
through oral mucosa, whereas the nicotine in the nasal spray is absorbed
through the nasal mucosa. The nicotine patch works by continuously
releasing nicotine through the skin. Table 7.5 details NRT products, doses,
typical duration of treatment, and possible adverse effects.
Smoking cessation can facilitate abstinence from other drugs and alco-
hol. Effective programs use a combination of NRT and tapering with
behavioral interventions. NRT is usually recommended as a short-term
therapy and possibly as long-term-therapy for difficult-to-treat smokers.
NRT has been shown to be efficacious compared with placebo in multiple
studies on measures of abstinence at the end of the trial and at follow-up
after 6 and 12 months.
A Cochrane review of nicotine replacement products in 2012 found
that use of NRT increases the chances of successfully quitting smoking
by 50% to 70%. All forms of NRT have similar efficacy. The effective-
ness of NRT was independent of additional counseling. Combining the
slow-release patch with a faster-release nicotine product, such as the gum,
increased the chances of success. There were five studies comparing the
nicotine patch to bupropion, which found no difference in efficacy and that
combining the patch with bupropion was more effective than bupropion
alone (Stead et al., 2012).
Bupropion SR
Bupropion SR (Zyban) is thought to help people quit smoking by reduc-
ing cravings and symptoms of nicotine withdrawal by mimicking nico-
tine’s effects on dopamine and norepinephrine. It also may block nicotine
receptors so that nicotine from tobacco cannot attach to them, thereby
 7 PHARMACOTHERAPY OF SUDS 197

Table 7.5 Nicotine Replacement Therapies

NRT Dose For Duration of Possible
Product Smokers Therapy Adverse
Who Smoke Effects
Patch 21 mg >10 4–6 weeks Headache,
cigarettes nausea,
daily insomnia, skin
14 mg 6–10 2–6 weeks irritation, vivid
cigarettes dreams
daily
7 mg 5 or fewer 2 weeks
cigarettes
daily
Gum 4 mg ≥25 12 weeks Headache,
cigarettes nausea,
daily insomnia,
2 mg <25 12 weeks mouth
cigarettes irritation, bad
daily taste
Lozenge 4 mg First cigarette 12 weeks Headache,
within 30 nausea,
minutes of insomnia,
waking mouth
2 mg First cigarette 12 weeks irritation, bad
after 30 taste
minutes of
waking
Inhaler 4 mg, of Not specified Up to Headache,
which 6 months nausea,
2 mg is insomnia,
absorbed, mouth
up to 16 and throat
times daily irritation,
cough
Nasal spray 0.5 mg Not specified 3–6 months Headache,
spray nausea,
in each insomnia, and
nostril, nose, eye,
up to 40 and throat
doses per irritation
day

blocking the pleasant effects of smoking. It has been shown to improve

quit rates compared with placebo at short-term and long-term follow-up.
Possible adverse effects include headache, dizziness, tremor, insomnia,
dry mouth, pruritus, rash, nausea, vomiting, constipation, weight loss, sei-
zures, and suicidal thoughts. Bupropion lowers the seizure threshold and
198 Substance Use Disorders

therefore is contraindicated in patients with a seizure or eating disorder

because of increased risk for seizures.
Because bupropion is an antidepressant, it may be a good choice for
people who are depressed and want to quit smoking.
The typical starting dose for bupropion SR is 150 mg orally daily for
3 days, then increase to 150 mg orally twice daily thereafter. The second
dose should be given around dinnertime to avoid interfering with sleep.
When starting a patient on bupropion, he or she may continue to smoke
or use smokeless tobacco for the first week. During the second week,
the patient should quit smoking. You may prescribe nicotine replacement
therapy with this medication to increase the likelihood of successfully quit-
ting smoking.
A Cochrane review of bupropion SR for smoking cessation reviewed 19
randomized trials and found that bupropion doubled the odds of success-
ful smoking cessation versus placebo (Hughes et al., 2004).
Varenicline
Varenicline (Chantix) is a partial nicotine agonist/antagonist that binds to
the alpha-4, beta-2 nicotinic acetylcholine receptor. By partially binding to
the nicotinic receptor, it acts as an agonist, stimulating receptor-mediated
dopamine release, which reduces cravings and nicotine withdrawal symp-
toms (Rollema et al., 2007). At the same time, by partially binding to
the receptor, it has antagonist activity because it blocks nicotine from
tobacco from binding to the nicotinic receptors. Varenicline appears to be
efficacious as an aid for smoking cessation for people in recovery (Hays
et al., 2011).
Possible adverse effects include headache, bad taste, change in appetite,
dyspepsia, nausea, vomiting, constipation, drowsiness, insomnia, unusual
dreams, and rash. The FDA issued a black box warning in 2008 to monitor
for behavior change, hostility, agitation, depression, suicidality, and wors-
ening of preexisting psychiatric illness.
Almost anyone who is psychiatrically stable may take this medication.
Some insurance companies do not cover this medication because there
are less expensive alternatives available.
The typical starting dose of varenicline is 0.5 mg orally daily for three
days, then 0.5 mg orally twice daily for 4 days, then 1 mg orally twice daily
thereafter. Treatment should be continued for at least 12 weeks.
When starting varenicline, patients may continue to smoke for the
first week. During the second week, they should quit smoking. Use of
nicotine replacement therapy is generally not recommended because it
may increase risk for nausea. However, in the first few days and weeks,
patients on varenicline who have quit smoking may need short-acting nico-
tine replacement to help with nicotine withdrawal.
A Cochrane review of varenicline (Cahill et al., 2008) found that var-
enicline increased the chance of long-term (6 months or more) success-
ful smoking cessation by two-fold and three-fold compared with placebo.
More subjects quit with varenicline than bupropion SR at 1 year. An
open-label study of varenicline versus nicotine patches showed a modest
benefit of varenicline. The most common adverse effect of varenicline was
nausea, which subsided over time.
 7 PHARMACOTHERAPY OF SUDS 199

Other Non–FDA-Approved Medications for Smoking

Cessation
Nortriptyline
Nortriptyline (Pamelor) is a tricyclic antidepressant. It is a second-line
agent used for treatment of nicotine dependence. Its efficacy in treat-
ing smoking cessation is thought to be through inhibiting norepinephrine
reuptake in central synapses or through nicotinic anticholinergic receptor
antagonism. The dose used in clinical trials for smoking cessation was 75
to 100 mg daily for 8 to 12 weeks. Compared with placebo, nortriptyline
almost doubled the rate of smoking cessation (Hall et al., 1998; Prochazka
et al., 1998).
Clonidine
Clonidine (Catapres) is an alpha-2 adrenergic agonist that reduces cen-
tral sympathetic activity. It is a second-line agent in treatment of nicotine
dependence and is thought to suppress symptoms of nicotine with-
drawal, including tension, anxiety, irritability, restlessness, and cravings.
A Cochrane review found that clonidine, both oral and transdermal, was
more effective than placebo, with up to two times higher rate of absti-
nence (Gourlay et al., 2004).
Medications Under Investigation for Smoking Cessation
Nicotine vaccines are being developed. NicVAX is one of the vaccines
under development that prompts the immune system to produce anti-
bodies that bind to nicotine in the bloodstream. This creates an anti-
body–antigen complex that is too large to cross the blood–brain barrier,
thereby reducing the amount of nicotine getting into the brain. With less
nicotine entering the brain, smoking and smokeless tobacco become less
rewarding, which makes it easier to quit. NicVAX is currently in phase III
development.
For More Information
For more information on the latest research on treating nicotine depen-
dence, see www.treatobacco.net.
200 Substance Use Disorders

Medications to Treat Cocaine

Dependence
There are no medications with FDA approval to treat cocaine depen-
dence. Several medications have been studied in the hope that they will
be helpful in treating cocaine dependence.
Modafinil
Modafinil (Provigil) is a nonamphetamine stimulant that enhances dopa-
minergic and glutamatergic transmission and perhaps decreases GABA
release. Because modafinil is a stimulant, it is proposed to work in cocaine
dependence as an agonist or substitution-type therapy, analogous to
how methadone works for opioid dependence. However, studies have
not given credence to this analogy. In a double-blind placebo-controlled
12-week study and 4-week follow-up of cocaine-dependent subjects ran-
domized to placebo, 200 mg of modafinil, or 400 mg of modafinil daily,
there was no difference between groups in the average weekly percentage
of days they didn’t use cocaine (Anderson et al., 2009). Similarly, in a 2012
study by Dackis and colleagues, the primary outcome measure, cocaine
abstinence based on urine benzoylecgonine levels, was nonsignificant.
However, there was a trend found while doing a gender analysis show-
ing that male patients treated with 400 mg of modafinil a day tended to
be abstinent more commonly than males treated with placebo (p = .06).
Bupropion
Bupropion (Wellbutrin SR) has not been found to be effective in treating
cocaine dependence alone (Shoptaw et al., 2008). However, when bupro-
pion was combined with contingency management, cocaine-positive urine
toxicology specimens significantly decreased.
Desipramine
Desipramine (Norpramin) was found in a double-blind randomized
placebo-controlled study to decrease cocaine use compared with lithium
and placebo. Fifty-nine percent of subjects treated with desipramine were
abstinent for at least 3 to 4 consecutive weeks compared with 17% of sub-
jects taking placebo and 25% of subjects taking lithium (Gawin et al., 1989).
Disulfiram
Disulfiram (Antabuse) is a functional dopamine agonist because it blocks
the conversion of dopamine to norepinephrine, thereby increasing the
concentration of dopamine. This may reduce cravings for cocaine or alter
the subjective high. In a double-blind study in which participants were ran-
domized to receive either placebo or disulfiram, participants taking disul-
firam reduced their use of cocaine significantly more than those taking
placebo (Carroll et al., 2004). Patients on methadone maintenance treated
with disulfiram versus placebo decreased the frequency and quantity of
cocaine use significantly more than those treated with placebo (Petrakis
et al., 2000). Likewise, participants on buprenorphine maintenance with
cocaine dependence had a higher number of cocaine negative urine drug
 7 PHARMACOTHERAPY OF SUDS 201

screens and an increased number of weeks abstinent than participants

receiving placebo (George et al., 2000).
Topiramate
Topiramate (Topamax) blocks voltage-gated sodium channels, enhances
GABA transmission at GABAA receptors, blocks the AMPA/kainate sub-
type of glutamate receptors. Through this mechanism is thought to reduce
the rewarding properties of cocaine and cocaine craving. In a randomized
double-blind placebo-controlled trial, 40 cocaine dependent individuals
received up to 200 mg of topiramate daily versus placebo for 13 weeks in
addition to twice weekly cognitive behavioral therapy. The group receiving
topiramate used significantly less cocaine than the placebo group, and 59%
of the topiramate group was abstinent for at least 3 consecutive weeks
(Kampman et al., 2004).
GABA agonists, such as baclofen and tiagabine (Gabitril), show some
evidence of efficacy in decreasing cocaine use.
Cocaine Vaccine
A cocaine vaccine (TA-CD) has been developed and is in phase II trials.
The vaccine works by binding a cocaine derivative, succinyl norcocaine, to
a nontoxic subunit of the recombinant cholera toxin. Antibodies specific
to cocaine are generated in response to TA-CD, and when these antibod-
ies bind to cocaine, the antibody–antigen complex created is too large to
permeate the blood–brain barrier where cocaine has its rewarding effects.
When the reward from cocaine is diminished, people may find it easier
to abstain.
Studies have found that the vaccine is well tolerated, it produces highly
specific antibodies after four or five vaccinations over 8 weeks, and anti-
body levels peak between 10 and 14 weeks. However, antibodies are
essentially absent 6 months later, and there is high variability in antibody
production (Kosten et al., 2002; Martell et al., 2005, 2009). Hence, patients
would need booster vaccinations to maintain the antibody level over time,
and not everyone receiving the vaccine will mount the immune response
needed to produce a therapeutic antibody level.
In a study of methadone-maintained opioid-dependent patients with
concurrent cocaine dependence (Martell et al., 2009), only 38% of patients
produced antibody levels greater than 43 mcg/mL in response to TA-CD,
which is the level that is thought to be needed to sufficiently capture
circulating cocaine and dampen its euphoric effects. It took about 8 weeks
to reach this level. When comparing subjects who produced high levels
of antibodies to low levels, 53% of the high-antibody group was abstinent
from cocaine more than half of the time during weeks 8 to 20 compared
with 23% of the subjects who produced low levels of antibody.
A study looking at how the cocaine vaccine affects the subjective effects
of cocaine found that the higher the antibody level, the lower the subjec-
tive ratings of euphoric effects and cocaine quality in the laboratory. These
individuals also had a greater heart rate after cocaine administration in
week 13 than they did in week 3, owing to having increased peripheral
sympathetic activity secondary to free cocaine in the plasma that is dynam-
ically bound and rebound to antibody (Haney et al., 2010).
202 Substance Use Disorders

Medications to Treat
Methamphetamine Dependence
There are no FDA-approved medications for the treatment of metham-
phetamine dependence, but a variety of medications have been studied.
Aripiprazole (Abilify), gabapentin (Neurontin), selective serotonin reup-
take inhibitors (SSRIs), ondansetron (Zofran), and mirtazapine (Remeron)
have failed to show efficacy in clinical trials. Topiramate (Topamax) does
not promote abstinence but does appear to reduce the amount used and
reduce relapse rates in those who are already abstinent from metham-
phetamine (Elkashef et al., 2012).
Bupropion SR
Bupropion SR (Wellbutrin) blocks the dopamine transporter to inhibit
dopamine reuptake, thereby increasing dopamine concentration in the
synaptic cleft. Methamphetamine promotes dopamine release into the
synapse through the dopamine transporter and also blocks dopamine
reuptake. Chronic methamphetamine use results in low dopaminergic
tone. Therefore, it was hypothesized that bupropion may be helpful in
treating methamphetamine dependence because it may restore homeo-
stasis. In a double-blind placebo-controlled study (Elkashef et al., 2008),
subjects were started on either bupropion SR, 150 mg twice daily, or pla-
cebo. A regression analysis found that over the 12-week study period,
there was a modest trend of improvement in urine drug screen results
in the bupropion group versus the placebo group (p = .09). A second-
ary analysis showed that subjects with lower baseline methamphetamine
use (<18 days of the last 30) taking bupropion had a significantly higher
percentage of negative urine drug screens over the 12 weeks compared
with placebo.
Modafinil
Modafinil (Provigil) is a nonamphetamine stimulant that enhances dopami-
nergic and glutamatergic transmission. It was therefore hypothesized that
it could alleviate symptoms of methampthamine withdrawal and decrease
methamphetamine use and craving. In a randomized double-blind
placebo-controlled study, methamphetamine-dependent patients were
assigned to either modafinil, 200 mg daily, or placebo for 10 weeks and
then followed for an additional 12 weeks. There was no difference in treat-
ment retention, adherence to medication, abstinence from methamphet-
amine, or craving (Shearer et al., 2009).
More recently, a randomized double-blind placebo-controlled trial of
modafinil 200 mg versus 400 mg versus placebo found no group differ-
ences in urine drug screen results over a 12-week period. Study results,
however, appeared to be limited by adherence to the medication regimen
because when secondary analyses were performed, separating groups
based on adherence to medication, the group of patients who took the
medication had significantly a higher maximal duration of abstinence
(Anderson et al., 2012).
 7 PHARMACOTHERAPY OF SUDS 203

Dextroamphetamine
Use of dexamphetamine substitution therapy has been proposed and
tested. Results of a double-blind placebo-controlled study done in Australia
using sustained-release dexamphetamine (20 to 110 mg daily; medication
dispensed daily under pharmacist supervision) found increased retention
in treatment and a significantly lower degree of methamphetamine depen-
dence at the conclusion of the study in subjects taking dexamphetamine.
Both groups, however, had significant decreases in methamphetamine
concentrations based on hair analysis (Longo et al., 2010).
204 Substance Use Disorders

Medications to Treat Cannabis

Dependence
A variety of medications have been studied for treatment of cannabis
dependence, but there are no FDA-approved medications.
Buspirone
Buspirone (Buspar) is a 5HT-1A receptor agonist and D2 antagonist. In
a 12-week open-label study, 10 cannabis-dependent men taking up to 60
mg of buspirone daily had significantly reduced frequency and duration of
cannabis cravings and reduced irritability and depression (McRae et al.,
2006). A following study in which patients were randomized to buspirone
or placebo plus motivational interviewing for 12 weeks found that sub-
jects taking buspirone had a higher percentage of cannabis-negative urine
samples (McRae-Clark et al., 2009).
Dronabinol
Dronabinol (Marinol), a synthetic form of THC, was found to be helpful
in suppressing cannabis withdrawal symptoms (Haney et al., 2004). This is
important because adequate treatment of cannabis withdrawal symptoms
may help prevent patients from resuming use of cannabis once they stop.
A more recent double-blind placebo-controlled study used drobabinol as
an agonist maintenance therapy and found that although there was no
difference between the dronabinol and placebo groups in the proportion
who achieved 2 weeks of abstinence at the end of the maintenance phase,
the dronabinol group had a higher retention rate and fewer withdrawal
symptoms than the placebo group (Levin et al., 2011).
Of note, Quetiapine (Seroquel) and divalproex sodium (Depakote) are
not effective in treating cannabis withdrawal (Cooper et al., 2012; Haney
et al., 2004).
Entacapone
Entacapone (Comtan), a catechol-O-methyltransferase (COMT) inhibitor,
was found to suppress cravings in 52.7% of cannabis-dependent subjects in
an open-label trial (Shafa, 2009).
Rimonabant
Rimonabant, a cannabinoid (CB1) receptor antagonist, is not approved
for use in the United States. It was used for weight loss in Europe but
was removed from the market because of adverse psychiatric effects. In a
randomized double-blind parallel group study, it was found to attenuate
the effects of a cannabis cigarette and subjective effects of cannabis after
8 days (Huestis et al., 2007).
 7 PHARMACOTHERAPY OF SUDS 205

Common Guiding Principles of

the Use of Pharmacotherapy for
Substance Use Disorder
1. Pharmacotherapy is implemented and monitored within the context
of a therapeutic alliance in which the patient feels listened to and
understood, and believes the doctor is genuinely interested in helping
with the addiction.
2. Comprehensive medical evaluation is necessary before making a
decision on a pharmacotherapeutic approach.
3. Pharmacotherapy should be a part of the treatment plan, which can
include a structured program (e.g., residential rehabilitation, partial
hospitalization, intensive outpatient) or individual, group, and/or
family therapy.
4. Pharmacotherapeutic intervention should identify and address factors
affecting adherence to the medication regimen, such as effectiveness,
motivation for change, adverse effects, ease of dosing, availability
and cost, cognitive deficits, environmental supports, and attitude and
perceptions about one’s illness and taking medication.
5. Behavioral interventions should be incorporated with
pharmacotherapeutic interventions even though some patients prefer
medications as the only intervention for their addiction.
6. Family members and concerned significant others need to be
educated about medications for the treatment of addiction so that
they can be enlisted to ensure adherence to the medication regimen
if needed by the patient.
7. Patients may struggle with the concept of “not really being clean”
if they take methadone or buprenorphine. They may receive this
feedback at mutual support groups and from concerned significant
others.
206 Substance Use Disorders

Acknowledgment
The preparation of this chapter was supported in part by the National
Institute on Drug Abuse grant #5U10DA020036-08.
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208 Substance Use Disorders

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 Chapter 8 213

Psychosocial
Interventions for
Substance Use Disorders
Dennis C. Daley and Lisa Maccarelli

Key Points 214

Roles of the Medical Trainee in Treatment of Substance Use
Disorders 216
Continuum of Care and American Society on Addiction
Medicine Framework 220
Psychosocial Interventions for Substance Use Disorders 224
Summary of Psychosocial Issues in Treatment and
Recovery 240
Acknowledgment 242
References and Suggested Readings 244
214 Substance Use Disorders

Key Points
• Psychiatric residents and fellows may assume many roles in evaluating
and treating patients with substance use disorders (SUDs) and their
families.
• Knowledge of the levels of care for treatment and the continuum
of services available is necessary to determine treatment needs of
patients with SUDs.
• There are many effective psychosocial interventions to help patients
engage in treatment and address their SUDs. These include individual,
group, family, and combined approaches.
• The goals of most psychosocial treatments are to assist patients with
SUDs stop or reduce their use of substances, make personal and
lifestyle changes, and engage in long-term recovery.
• Teaching coping skills is a focus of many of these treatments. Skills
enable patients to meet the challenges of recovery such as managing
thoughts of using, cravings, and negative emotions; building social
supports; and identifying and managing high-risk relapse factors.
• Motivational interviewing is an approach to get patients to examine
their substance use and/or engage in psychosocial treatment.
• Patients receiving psychosocial treatments may benefit from
medication-assisted treatments for addiction to opioids, alcohol,
or nicotine. This is especially helpful for patients with more severe
addictions with histories of multiple treatment episodes who have had
difficulty sustaining their recovery.
• Many mutual support programs are available for patients with SUDs.
Those who attend these in addition to professional treatment
show improved outcomes. Although 12-step programs (Alcoholics
Anonymous, Narcotics Anonymous, and others) are the most
common ones used and most readily available, other programs and
support services exist, including online resources.
• Both professional treatment and mutual support programs provide
patients with SUDs the opportunity to learn strategies to initiate and
maintain abstinence and make personal and lifestyle changes.
This chapter provides an overview of evidence-based psychosocial interven-
tions and the continuum of care for substance use disorders (SUDs), the roles
of psychiatric residents and fellows in the treatment of SUDs, and a summary
of clinical issues that may be the focus of treatment. These interventions are
described in treatment manuals and papers summarizing results from clinical
trials and can be found under “References and Suggested Readings.”
Psychosocial interventions provided by professionals include individual,
group, and family approaches, which may be used singly or in combination
as part of a total “treatment program.” These interventions may also be
combined with medication-assistedtreatments for alcohol, nicotine, and/
or opioid dependence. Because mutual support programs (both 12-step
and other types) are recommended by addiction professionals, we will
discuss how to help patients get involved in, and benefit from, these pro-
grams. Even if you do not directly provide psychosocial interventions,
familiarity with them can help you in working with clinicians and patients
in designing, implementing, and monitoring treatment plans for an SUD.
This page intentionally left blank
216 Substance Use Disorders

Roles of the Medical Trainee

in Treatment of Substance Use
Disorders
You may be asked to perform any number of roles in your work with
patients who have SUDs. Although the specific roles you assume will
depend on the context of your rotations, knowledge of these can help
you integrate into the programs in which you provide clinical services.
As a physician, you have a certain status in the eyes of patients that can
help you influence them in making decisions about psychosocial treat-
ment. Following is a brief discussion of specific ways in which you can help
patients with an SUD or their families.
1. Provide medication evaluation and management.You may manage
an addicted patient during medical detoxification; provide
medication-assisted treatment to patients with more severe forms
of alcohol, nicotine, or opioid dependence; or evaluate patients with
co-occurring psychiatric disorders who may need medication. Patients
addicted to alcohol or opiates with a history of multiple episodes
of treatment should be assessed for medications that can aid their
recovery. Recommend to clinicians on your treatment team that they
talk with patients about medication-assistedtreatments for cases of
more severe and/or chronic addiction to alcohol, opioids, or nicotine.
2. Coordinate care with addiction clinicians.Provide your input on
evaluation of patients, consultation, supervision, and/or direct
care as part of a “team” helping a cohort of patients in any type of
treatment setting or program. For example, if you think a patient you
are seeing for medication-assistedtreatment for alcoholism needs
a higher level of care than weekly individual or group counseling,
you can initiate a discussion with the program’s clinicians to discuss
your recommendations and the rationale. Or, if you believe a patient
has a coexisting psychiatric disorder that needs to be addressed for
recovery from addiction to progress, you can discuss this with clinical
staff to determine a plan of action for the patient.
3. Monitor participation in psychosocial treatment. Ask if your patient is
attending a treatment program. You can discuss how the program is
going, what problems the patient is discussing in individual or group
sessions, what he is learning about addiction, recovery or relapse
prevention, or any other concerns of the patient. If your patient is
missing psychosocial treatment sessions or has dropped out, you can
discuss the reasons for this and facilitate his improved adherence or
reinvolvement in the program. One helpful intervention is to include
a member of the treatment program staff while the patient is in your
office in a joint discussion so that you can problem-solve the issues
contributing to poor compliance or treatment dropout.
4. Educate, facilitate, or monitor patient involvement in mutual support
programs. Knowledge of these programs enables you to have
 8 PSYCHOSOCIAL INTERVENTIONS FOR SUDS 217

productive discussions of how they can help your patient, thus

reducing resistance to using these programs as part of a total
recovery program. You can give your patient information about
types and purposes of mutual support programs and discuss the
components of these programs if needed (e.g., meetings, sponsors,
the 12steps, recovery literature, service or components of
non–12-step programs). Monitoring involvement in mutual support
programs may enable you and the patient to catch warning signs of
an impending or an actual lapse or relapse to substance use. This may
lead to the patient reducing relapse risk or taking action if a lapse
or relapse has occurred. You should treat a relapse to addiction
no differently than a relapse to a psychiatric disorder. Your goal is
to help the patient get back on track, get into the proper level of
care, and then learn from the relapse. Avoid judging the patient as
“unmotivated” or “not working the program” because of a relapse
because this can occur even when patients “work” a recovery
program. If a patient is resistant to 12-step programs, discuss other
options available in the community, such as Rational Recovery,
SMART Recovery, Women for Sobriety, or Secular Organizations
(SOS) for recovery. We recommend that you attend a variety of
mutual support program meetings so that you better understand
these programs, “see” recovery in action, and feel more comfortable
promoting recovery and talking with patients about potential benefits
of these programs.
5. Consult with the patient’s family or significant other(s).This may involve
eliciting or providing information to them, discussing treatment
options for the patient and family, discussing the role of the family
in treatment, and/or encouraging families to get involved in mutual
support programs such as Al-Anon or Nar-Anon. Families will
appreciate the opportunity to provide input about the patient as well
as share their experiences. This can be valuable information to use in
your sessions with the patient.
218 Substance Use Disorders

Case Vignette 1
Matt is a 39-year-old, employed, married father of children ages 14 and
11 years. He is being treated for cocaine dependence, alcohol abuse,
and major depressive illness. During his recent medication visit, the psy-
chiatric resident noted changes in Matt’s demeanor and mood, and felt
that something significant was happening that Matt was not sharing. He
also noted that Matt had missed his last two group therapy sessions. The
resident shared his observations with Matt and inquired about what was
going on, telling Matt he was worried that he missed his past two group
treatment sessions. He also found out Matt had cut down on his NA
attendance without discussing this with his therapist. During this discus-
sion, Matt admitted he had been drinking alcohol the past 2 weeks, but
initially minimized the potential adverse impact of this on his recovery.
However, on further discussion, Matt agreed that drinking alcohol raised
his risk for relapse to his cocaine addiction. And, it affected his mood.
The resident and Matt agreed that he would call his therapist and report
his alcohol use, request a session for himself and his wife, return to
group and discuss his relapse with his peers, and return to regular NA
attendance the next day. Matt agreed to discuss his reluctance to seek
an NA sponsor with his treatment group. Given the recent relapse, the
resident scheduled Matt to return in 2 weeks. The resident also told
Matt he would consult with his therapist to coordinate the plan to sup-
port Matt’s re-engagement in counseling sessions.
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220 Substance Use Disorders

Continuum of Care and American

Society on Addiction Medicine
Framework
The American Society on Addiction Medicine (ASAM) delineates sev-
eral levels of care for SUDs, from the least to the most intensive (Ries
et al.,2009). Some patients will participate in multiple episodes of treat-
ment before they stabilize their SUDs and achieve long-term recovery.
Some will use many different levels of care and services. Following is a
summary of these levels of care and the goals of each intervention.

Screening, Brief Intervention, and Referral to

Treatment
Only 10% to 15% of individuals with SUDs receive treatment. Many who
receive treatment do so as a result of screenings and interventions of pro-
fessionals who encounter these patients in medical, psychiatric, and other
settings. Research shows that many patients benefit from all aspects of
screening, brief intervention, and referral to treatment (SBIRT), with the
more severe cases requiring referral to specialty treatment for addiction.
For example, if you work in a psychiatric emergency department, inpatient
unit, or ambulatory program, you will encounter patients who can benefit
from education, support, and a brief motivational intervention aimed at
getting them to examine their alcohol or drug use. As a result, they may
reduce their substance use or take other steps to help themselves. You
will also encounter patients with addiction who may need detoxification
in an addiction program or on a psychiatric unit, where their psychiatric
condition can be evaluated, monitored, and stabilized.
Hospital-Based Detoxification or Rehabilitation
Programs
These are short-term, medically managed services aimed at helping
patients safely withdraw from addictive substances. These services are
recommended for more severely addicted patients with significant medi-
cal histories or current problems such as seizures or delirium tremens, or
a significant psychiatric history of current problems, such as suicidality or
severe mood or psychotic symptoms, which require access to physicians
and nurses for closer monitoring. Hospital detoxification lasts several
days, depending on which drugs the patient is addicted to, and aims to
help the patient safely withdraw from substances and develop a plan for
follow-up care. Hospital-based rehabilitation programs are usually brief
(≥2 weeks), structured, recovery-oriented group programs that aim to
help the patient stabilize from acute problems, understand and accept the
addiction, and prepare a follow-up plan.

Short-Term Residential Rehabilitation Programs

These are medicallymonitored programs that educate, motivate, and help
patients engage in recovery and develop a follow-up plan that usually
 8 PSYCHOSOCIAL INTERVENTIONS FOR SUDS 221

includes professional treatment and participation in mutual support pro-

grams. Most last 2 to 4 weeks, although some programs last longer. Group
treatments are the primary approaches used in residential programs,
although patients may also receive individual and family sessions, exposure
to mutual support programs onsite or in the community, HIV education,
testing and/or counseling, case management, or referral to other medical,
social, or vocational services. Medication-assistedtreatments may also be
provided in these programs. An important issue is for the patient to suc-
cessfully transition to the next level of care, which is based on patient need
and available community resources.

Long-Term Residential Programs

These include therapeutic community (TC) and halfway house (HWH)
programs lasting several months to a year or longer. Both TCs and HWHs
focus on helping patients make personal and lifestyle changes. TCs usually
are more rigorous in terms of the therapy provided. Following a period of
stable adjustment in these programs, the patient may attend academic or
vocational training programs to prepare for the job market. The patient
may continue in these programs while working in order to receive sup-
port while adjusting to his or her potential new employment situation.
Individual and group counseling and participation in mutual support pro-
grams are offered in these programs.

Partial Hospital or Intensive Outpatient Programs

These are time-limited, structured treatment programs that help patients
stabilize from the addiction and learn strategies to remain sober. They
may serve to divert patients from inpatient or residential programs, as
a “step-down” from residential or inpatient treatment, or as a “step-up”
from less intense outpatient care for patients unable to establish and sus-
tain abstinence. Partial hospital (PH) patients may attend 4 days or more
per week for several weeks for 4 hours or more per day. Intensive out-
patient programs (IOPs) involve fewer treatment days and hours per day
than the partial program, but have similar goals. Both PH and IOP aim to
get patients involved in an ongoing recovery process through participation
in mutual support programs like AA or NA. Group treatment is the pri-
mary approach used in these programs, although patients may also receive
individual or family sessions, or medication-assistedtreatment for addic-
tion to alcohol, nicotine, or opioids.
Outpatient or Continuing Care
Patients with less severe SUDs, or those who complete higher levels
of care such as a residential, PH or IOP, often benefit from individual,
group, and/or family sessions, the frequency of which will depend on their
current needs. Continuing care is especially important for patients who
needed higher levels of treatment, such as medical detoxification, hospital-
or residential-based rehabilitation, or IOPs. They may also benefit from
medication-assistedtreatment and/or participation in mutual support pro-
grams as part of their continuing care program.
222 Substance Use Disorders

Other Services
Some patients with SUDs need case management, HIV testing and coun-
seling, psychiatric assessment, vocational assessment and counseling, social
work services, neuropsychological assessments, chaplain services, leisure
counseling, and/or participation in community mutual support programs.
These services address problems or needs that often interfere with the
patient’s ability to utilize treatment. However, some of these services,
such as vocational training, may not be offered until the patient dem-
onstrates an ability to remain substance free for a period of time (e.g.,
6 months or longer). And, not all programs can offer all of these services.
The figure below shows all of the components of a comprehensive treat-
ment program.
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224 Substance Use Disorders

Psychosocial Interventions for

Substance Use Disorders
There are many effective individual, group, family, and combined interven-
tions for SUDs (Antonet al., 2006; Connors, Donovan,&DiClemente, 2001;
Daley &Marlatt, 2006; DiClemente, 2003; Miller, Forcehimes,&Zweben,
2011; NIDA, 2009; SAMHSA, 2004, 2005a). Approaches such as 12-step
facilitation therapy (NIAAA, 1995c; Nowinski& Baker, 2003) and coping
skills training (Mack, Harrington,& Frances, 2010; NIAAA, 1995b) are used
with individuals and groups of patients. Following is a brief review of these
psychosocial interventions, some of which are also used with patients
who have co-occurring psychiatric disorders. Most of these approaches
are described in clinical treatment manuals. Several of these interventions
include patient or family recovery materials that can be used with the treat-
ment manuals (e.g., see the matrix model (Rawson et al., 2005; SAMHSA,
2006a,2006b) and integrated treatment of co-occurring disorders models
(Daley &Thase, 2004; McMain et al., 2007; Mueser et al., 2003; Najavits,
2002; Roberts, Shaner,&Eckman, 1999; SAMHSA, 2005b; Weiss & Connery,
2011). And, some of these have CD-ROMs that provide training materials,
PowerPoint slides, training videos, and/or research articles (NIDA, 2008).

Behavioral Couples Therapy

The behavioral couples therapy (BCT) model provides up to 12 sessions
with individual couples or a group of couples, and is often part of a total
program that includes other individual and group therapies (O’Farrell,
Choquette,&Cutter, 1998; SAMHSA, 2008). BCT addresses alcohol or
drug use and focuses on strategies to change the interaction styles within
a marriage to support abstinence from substances. The goals of BCT are to
decrease negative interactions that may contribute to relapse and increase
positive interactions that support an improved marital relationship. This is
accomplished through behavioral and problem-solving strategies. First, a
functional analysis of the behaviors, within the relationship, that may trig-
ger alcohol or drug use is conducted. Then, the therapist helps the couple
develop new interaction styles that are less likely to trigger substance use.
This may be accomplished by planning behavioral alternatives to current
interaction styles. The couple learns which communication styles are most
likely to create stress in the relationship and be a potential trigger for relapse.
The therapist then teaches ways to alter these communication styles through
behavioral experiments. For example, a spouse will purposely search for
positive behaviors in the other spouse and provide positive reinforcement.
The couple is encouraged to plan rewarding activities versus constant arguing
about substance use. The therapist may explore the nonaddicted spouse’s
thoughts regarding new behaviors and utilize cognitive restructuring tech-
niques to alter faulty assumptions about the new behaviors.

CognitiveBehavioral Therapy
Cognitive behavioral therapy (CBT) is a short-term, evidence-based approach
that has been widely studied in the treatment of SUDs. CBT focuses on
 8 PSYCHOSOCIAL INTERVENTIONS FOR SUDS 225

addressing an individual’s distortions in thinking as well as associated mal-

adaptive behaviors (Beck, Wright,&Liese, 1994; NIDA, 1998a). Although not
an exhaustive list, examples of cognitive distortions include the following:
• All-or-nothing thinking leads to views of situations and events as all good
orall badwith an inability to find the middle ground. All-or-nothing
thinking tendsto result in aninflexibility in one’s interpretation of
events, frequently leading toa parallel inflexibilityin an individual’s
corresponding emotions. An example ofall-or-nothing thinking inthe
treatment of SUDS would include a patient, diagnosed with alcohol
dependence andsober for 9 months, having one drink and telling
herself, “What does it matter nowanyway . . . everything is ruined.
I already had one drink, so I may as well keepdrinking.” This type of
thinking may significantly contribute to a possible slip/lapseprogressing
to a full-blown relapse.
• Jumping to conclusions includes the distortions of mind reading and
fortune telling.Mind reading is the assumption that an individual knows
what another is thinking and reactsaccording to that interpretation.
An individual who is discussing a difficult situation in atherapy session
and engaging in mind reading may say to himself, “Here we go
again . . .Iknow my therapist thinks I am a big failure, and I cannot do
anything right.” Based onthis belief/interpretation, the patient does not
attend the next two scheduled sessions withthe therapist and will not
return phone calls resulting in an interruption in treatment.
• Fortune tellinginvolves the prediction of negative outcomes in
the absence of any evidence. A patient has been clean and sober
for 12 months, is engaged in treatment, and is doing well. She is
certain she is going to get fired from her currentjob because of
her experiences of being terminated from previous positions. In
this current job, all reports and evaluations from her boss have
been positive, and feedback has indicated she is a valued employee.
Because of the patient’s fortune telling distortion as well as her
related emotional experiences, including anxiety, fear, and shame,
the patient’s job performance may be ultimately affected owing to
the certainty with which the belief/interpretation of being fired is
maintained.
• Catastrophizing is characterized by the tendency to believe that
an event orcircumstance is or will be the worst-case scenario. If
individuals engage in catastrophicthinking, it may appear as if they are
“making a mountain out of amolehill.” A patientleaves his appointment
with his therapist and psychiatrist, reporting that no oneunderstands
his situation because if they did, he would be given the medications he
isrequesting. The patient continues to report that there is absolutely
no way he is going tobe OK without these medications.
The assumption in CBT is that changes in cognitions and/or behaviors will
also elicit shifts in emotional experiences. CBT works toward increased
awareness of and overall changes in the relationship among an individual’s
thoughts, feelings, and behaviors. In line with these goals, CBT is helpful
in the treatment of SUDs because it directly and indirectly addresses the
patient’s interpretation of events. Specifically, one’s interpretation of an
event or situation has an impact on her or his emotional experiences and
226 Substance Use Disorders

potential behavioral responses. Therefore, the more patients are aware

of this process, the greater is the likelihood of emotional and behavioral
regulation and control. CBT is appropriate for both individual and group
treatment and integrates skills training through the utilization of various
therapeutic tools, including role playing, examination of evidence, psycho-
education, Socratic questioning, thought records, and functional assess-
ments of behaviors (FABs). FABs may be frequently utilized in CBT as a
means to help patients break down situations and identify specific triggers,
thoughts, feelings, behaviors, positive and negative consequences, andwhat
may be done differently in subsequent situations. FABs may be initially
challenging for patients because it can be difficult to separate and identify
the various components of a situation, so practicing both with the thera-
pist and as homework is critical. The emphasis on homework is consistent
with a CBT approach because CBT treatment consistently incorporates
homework in a variety of forms and may include out-of-session practice
exercises to increase general coping and relapse prevention skills such as
coping with cravings, drug refusal skills, and so forth.
For example, in working to help a patient cope with cravings, time would
be spent on increasing awareness regarding the patient’s individual experi-
ences of cravings as well as providing education on the occurrence of crav-
ings as “expected” and “normal” components of recovery. Identification
of craving triggers would also be included in the sessions along with the
discussion and planning of possible ways to avoid certain triggers. In addi-
tion, sessions focusing on cravings would explicitly incorporate discussions
and practice regarding strategies to cope with the cravings, including dis-
traction skills, talking about cravings, going with the craving/urge surfing,
recalling negative consequences of substance use, and the use of self-talk.
Community Reinforcement Approach
The community reinforcement approach (CRA) utilizes individual counsel-
ing to help patients learn skills to manage their SUD (e.g., learn to iden-
tify and manage high-risk situations, learn to refuse substance use offers),
improve family communication and relationships, engage in nonthreaten-
ing recreational activities, get vocational counseling if needed, and utilize a
social network to support recovery (Meyers & Smith, 1995; NIDA, 1998b).
CRA may add vouchers as incentives to reinforce sobriety, which is usu-
ally measured by urine samples. The goal is to develop reinforcers that
effectively compete with the reinforcing properties of substance use. In
the CRA plus vouchers approach, patients earn points toward exchange-
able retail items by remaining abstinent from drugs. Along with abstinence,
patients are encouraged to make major lifestyle changes to support sobri-
ety. Other techniques include behavioral contracting, goal setting, model-
ing, and shaping. This counseling is active and focused. If patients have
particular issues or problems, they are addressed, but the focus of the
CRA session remains primary. A session protocol will first review uri-
nalysis results. A negative result is reinforced, in contrast to a positive
result, which removes reinforcement. If a drug screen is positive, then the
counselor and patient will analyze the relapse process to determine prob-
lem areas. The rest of the session reviews progress with treatment goals,
problem solving around the goals, skills training, and establishing new goals
 8 PSYCHOSOCIAL INTERVENTIONS FOR SUDS 227

if necessary. The skills training aspect of the program develops behaviors

conducive to the maintenance of sobriety (e.g., avoidance or refusal skills,
recreational planning, vocational counseling, and social skills training).
Community Reinforcement Approach and Family Training
Community reinforcement approach and family training (CRAFT)was
developed from the CRA approach to help families or concerned signifi-
cant others (CSOs) engage a treatment-refusing member into treatment
because families are often adversely affected by a loved one’s SUD and
may be in a position to influence him to enter care (Smith & Meyers, 2004).
Many patients enter treatment as a result of pressure from the court, an
employer, or the family. CRAFT is usually provided in 12 weekly sessions
of 1 hour each. The main goals are to get the member with the SUD into
treatment and to help him stop or reduce his substance use. Another goal
is to improve the functioning of the family members or CSOs affected by
the loved one’s SUD. This is a nonconfrontational approach that aims to
help the member with the SUD change by providing positive reinforce-
ment for improvements in substance use behaviors. CRAFT helps family
members and CSOs understand internal and external triggers to their
loved one’s substance use and how to replace substance use behavior with
more pleasurable, nonsubstance behaviors. It also helps families and mem-
bers with the SUD improve how they communicate. For example, CRAFT
encourages family members and CSOs to avoid nagging, pleading, threaten-
ing, yelling, or lecturing the member with the SUD because these behaviors
are not effective. It helps them learn to cope with their own strong nega-
tive reactions to the member with the SUD. Results of many studies show
that CRAFT has a significant impact on helping families get loved ones into
treatment, and both patients and families show improvements.
Contingency Management (Motivational Incentives)
This behavioral approach uses positive incentives to reward patients
who attend treatment and maintain abstinence from substances (Kirby
& McCarty, 2010; NIDA, 1998a, 2008, 2009). Patients earn low-cost
incentives (valued from $1 to $25 in most cases) for submitting negative
urines or attending treatment sessions. These incentives may include
food or household items, movie passes, other personal goods, or gift
cards to grocery or other stores. Many studies show that incentives are
highly effective in promoting abstinence from substances and increasing
treatment adherence and retention. In our PH program for co-occurring
disorders, incentives improved attendance by 60%, which is a significant
improvement. Patients who attend treatment have a greater likelihood
of improvement than those who drop out early. Hence, incentives can
affect treatment adherence as well as substance use in positive ways.
This is one of the most effective interventions used with many groups
of patients, and its effectiveness is supported by numerous clinical trials.

Continued Care and Recovery Check-Ups

Continued care following completion of an inpatient, residential, or ambu-
latory rehabilitation program helps patients sustain gains made in the early
phase of care and enables them to address current problems and concerns
228 Substance Use Disorders

as well as engage in recovery. Continued care can occur at a treatment

facility or by telephone check-ups and provides patients with a connection
to professionals in addition to mutual support programs (Dennis, Scott,
&Funk, 2003; White, Kurtz & Sanders, 2006). Recent years have seen an
increase in the focus on “recovery” for patients with SUDs as a way of
managing their addiction and engaging in a process that enables them to
make personal changes and use active coping skills because addiction is a
chronic condition for many patients (CSAT, 2006; Dennis & Scott, 2007).
Coping Skills Training
There are several versions of coping skills training (CST) from a brief (8
to 12 sessions) to a more comprehensive (26 sessions) version (Mack,
Harrington,& Frances, 2010; NIAAA, 1995b). The goal of CST is to help
the patient improve interpersonal and intrapersonal skills, to deal with
high-risk situations, and to obtain social support for ongoing recovery.
Substance abuse is viewed from a social learning perspective in which
patients use substances to change the way they feel. Over time, patients
begin to expect positive feelings from substance use, and this motivates
their substance-seeking behavior. As the addiction progresses, patients
have less confidence in their ability to cope without the use of substances
(low self-efficacy). Intrapersonal skills include managing thoughts of sub-
stance use; decreasing negative thinking; learning problem-solving strat-
egies; increasing pleasant activities; learning to relax and manage stress;
becoming aware of anger and managing it so that substances are not used;
learning to interrupt seeminglyirrelevantdecisions, developing a plan for
emergencies; and coping with persistent problems. Interpersonal skills
include improving communication; using “feeling” talk; assertiveness; refus-
ing substances; developing intimate relationships; and enhancing social
support networks. Individual and group sessions may focus on specific
topics whereby the patient learns information, shares thoughts and feel-
ings, and practices coping skills.
Strategies used in CST include roleplaying and homework assignments.
Roleplaying facilitates the use of coping skills in real-life situations (e.g.,
saying no to an offer of alcohol or drugs, asking a friend for help and
support, asking an NA or AA member to be a sponsor, sharing feelings
with others in healthy ways). Homework is used to encourage the prac-
tice of skills in real life outside the therapy office. Skills are also taught
through therapist modeling, verbal presentation, treatment contracts, and
self-monitoring forms. The therapist is active and directive in carrying out
the treatment protocol and encouraging collaboration with the patient.
Dialectical Behavioral Therapy
Dialectical behavioral therapy (DBT) was originally developed by Marsha
Linehan and her team at the University of Washington for the treatment
of borderline personality disorder (BPD), specifically for those individuals
experiencing chronic suicidality (Linehan, 1993). Although DBT has roots
in CBT, Dr. Linehan has integrated Eastern and Western psychology/
philosophy, particularly Zen philosophy and practices. With this integra-
tion, DBT moves away from solely a “technology of change” focus associ-
ated with traditional cognitivebehavioral approaches to a dual focus on
 8 PSYCHOSOCIAL INTERVENTIONS FOR SUDS 229

a “technology of acceptance” as well asa “technology of change.” This

is done in DBT with an ever-present balance of acceptance and change
through the use of validation and problem-solving strategies.
Since its origin, DBT has been adapted for numerous patient popula-
tions, including those individuals diagnosed with co-occurring BPD and
SUD(McMain et al., 2007). In this adaptation, the core modes of DBT treat-
ment remain the same, including individual therapy, group skills training,
telephone consultation, and consultation team. As with the original model,
the application of DBT to the co-occurrence of BPD and SUDs main-
tains a hierarchical approach to behavioral targets: a decrease in suicidal
and life-threatening behaviors; decrease in therapy-interfering behaviors;
decrease in quality-of-life interfering behaviors; and increase in behavioral
skills. Overall, this treatment approach seeks to decrease serious behav-
ioral dyscontrol and increase more adaptive and skillful behaviors. Addictive
behaviors are viewed as learned behaviors functioning to regulate emotions.
A key component to this model of DBT is the dialectical approach to
abstinence, a balance of harm reduction principles (acceptance) and abso-
lute abstinence (change). Dialectical abstinence “is a synthesis of unrelenting
insistence on total abstinence before any illicit drug abuse and radical accep-
tance, nonjudgmental problem solving, and effective relapse prevention after
any drug use” (Linehan, 1993, p. 151). In addition, DBT for co-occurring BPD
and SUDs identifies the treatment engagement difficulties that are frequently
present for those individuals with SUDs. DBT refers to those patients who
come in and out of treatment as “butterflies” and provides strategies for
attachment to increase engagement, including explicit discussion with the
patient regarding the concept of the butterfly attachment difficulties. Other
strategies include increasing contact, providing in vivo treatment, building
connections to the social network, flexibility in session length, actively pur-
suing patients, mobilizing the team when the therapist feels demoralized,
and building the patient’s connection to the treatment network.
Because co-occurring BPD and SUDs can present numerous clinical chal-
lenges, DBT’s focus on tending to both the patient and clinician is critical.
This model provides an integrated treatment approach for patients as well
as offering support and frameworks for conceptualization to the clinician.
Family Approaches
Multisystemictherapy (MST), multidimensional family therapy for ado-
lescents (MDFT), and brief strategic family therapy (BSFT) aim to help
families engage the member with an SUD in treatment and to provide
treatment for the family (SAMHSA, 2004). The goals are to stop or
reduce substance use and to make positive changes (the member with
the SUD and the family). These therapies deal with substance use issues
as well as family interactions to improve how members communicate and
relate to each other. Family treatment may help stabilize and reorganize
the family through restructuring family roles and rules while developing
appropriate family boundaries. Therapy is often difficult because families
are entrenched in their unhealthy interaction patterns and any change
is threatening to the family homeostasis. The therapist must tolerate
the family’s expressed emotion, ambivalence, and what often seems
like tremendous effort to help the family change unhealthy patterns of
230 Substance Use Disorders

interaction. Therapists can use a variety of strategies to change these

patterns but must progress at a pace tolerable to the family. Studies
show that these approaches help engage the SUD member in treat-
ment, reduce substance use and other problematic behaviors, improve
academic and social functioning, and improve how the family relates.
Group Approaches
Group treatment is the modality most frequently used in the treatment of
SUDs. There are numerous models of group treatment, including group
drug counseling (Daley & Douaihy, 2011a; NIDA, 2002), the matrix model
(Rawson et al., 2005), 12-step facilitation (Nowinski& Baker, 2003), coping
skills training (Monti et al., 2002), relapse prevention (Daley &Douaihy,
2011b), motivational CBT (Sobell&Sobell, 2011), and the stages-of-change
approach based on the transtheoretical model of behavior change
(Velaquez et al., 2001). Some of these models are brief (e.g., the motiva-
tional CBT model involves eight sessions), whereas others are extensive
(e.g., the matrix model conducted over 6 months or longer provides 70
or more group sessions on early recovery skills, relapse prevention, family
education, and social support).
Types of groups offered include any combination of the follow-
ing: (1) structured groups that focus on a topic or issue pertinent to
addiction or recovery (these sessions have specific goals and information
to becovered in an interactive manner); (2) therapy or problem-solving
groups in which the particular cohort of patients determines the focus
of the sessions, which usually relates to current problems, concerns, and
issues of group members; and (3) other groups (goal setting, family educa-
tion, art or music therapy groups, or groups in which specific cognitive and/
or behavioral skills are taught and practiced, or relapse prevention groups).
Goals depend on the specific type and function of the group. In gen-
eral, groups aim to help patients(1) learn information about addiction,
treatment, and recovery; (2) increase self-awareness of personal problems
and issues; (3) receive support from peers and give support to them; and
(4) learn coping skills to deal with challenges of recovery (e.g., manag-
ing cravings, social pressures to use, upsetting emotions). Groups such as
therapy or problem-solving groups may also provide an excellent forum
for peer feedback from others recovering from SUDs. Peer feedback
about behavior is often more powerful than feedback from professionals.
In relation to groups, you can help patients in several ways. First, you can
encourage and help link patients to group programs or specific treatment
groups based on their clinical needs. Second, you can ask patients to describe
their experiences in groups (e.g., What are you discussing in groups? What
are you learning? What do you find helpful? What issues/problems should
you be discussing with your peers?). Third, you can collaborate with group
clinicians to discuss the progress (or lack of) with specific patients. Finally,
for patients who drop out of groups or show poor adherence, you can dis-
cuss the reasons and attempt to get them re-engaged in groups.
Individual Drug Counseling
Individual drug counseling (IDC) was originally developed as a 9-month
counseling program (twice weekly for 3 months; weekly for 3 months;
 8 PSYCHOSOCIAL INTERVENTIONS FOR SUDS 231

monthly for 3 months) for cocaine addiction, but has been adapted to
other types of SUDs for briefer periods of time (NIDA, 1999). This
approach reflects the 12-step philosophy in which addiction is viewed as
a biopsychosocial disease that affects many areas of functioning (physical,
psychological, social, spiritual). These areas are addressed in treatment.
IDC is different from psychotherapy because it focuses on behavioral goals
that target substance use. IDC focuses primarily on present issues and
behavior and does not delve much into issues of the past. Each session
inquires as to the last time the patient used substances, current substance
use, or any urgent problems the patient has; gives feedback about drug
urinalysis tests; and discusses other relevant recovery issues.
The primary goal is achieving and maintaining abstinence from all sub-
stances. In IDC sessions, patients learn coping strategies and “tools” for
ongoing sobriety. They are encouraged to engage in mutual support
groups and follow a 12-step program, so they continue to learn ways to
manage their addiction while receiving support from peers in recovery.
In the early initiation stage of IDC, therapists deal with patient denial and
ambivalence about recovery. The goal is to help them realize they have a
disease and need to break the addictive cycle. In the early recoverystage,
patients learn about drug use triggers and gain skills to successfully deal with
these. In the maintenance stage, the patient continues to learn about the
relapse process, which includes identifying and coping with triggers, cravings,
and urges. The patient continually practices learned skills and makes ongo-
ing changes to support sobriety. Finally, advanced recovery is a continued
commitment to change and growth. Formal treatment may end at this stage,
but the patient continues to engage in activities such as NA, AA, or other
mutual support programs that support sobriety and help facilitate change.
Integrated Treatment for Co-occurring Disorders
Integrated treatment for co-occurring disorders (CODs) addresses both
the SUD and comorbid psychiatric disorders (Daley & Moss, 2002; Daley
&Thase, 2004; Mueser et al., 2003; Weiss & Connery, 2011). Addiction
treatment programs vary in their ability to manage patients with CODs.
Some programs provide limited COD services to patients with mild to
moderate severity of psychiatric illness. These are patients who are fairly
stable in terms of their psychiatric condition (e.g., an alcoholic with mod-
erate depression or anxiety). Other programs, usually embedded in a
mental health system, help patients with more severe types of CODs.
This includes patients with psychotic, bipolar, recurrent major depres-
sion, or other persistent and chronic types of psychiatric illness. Many
models of COD exist, including those that are general in focus (these
focus on both the psychiatric and SUD issues regardless of diagnoses)
and those specific to a particular type of psychiatric illness, such as
post-traumatic stress disorder (PTSD), schizophrenia, or bipolar illness.
Many studies show that integrated treatment of COD is effective, but
becausemany patients have multiple chronic disorders, they are prone
to relapses to the SUD or the psychiatric illness. Patients in a COD pro-
gram may receive any combination of individual, group, family, or milieu
therapies; ancillary services (case management, vocational counseling);
and medication evaluation and treatment.
232 Substance Use Disorders

Case Vignette
Allison is a 37-year-old single unemployed white woman who has a
15-year-old daughter from a previous relationship. Allison has had
long-standing difficulties with alcohol, cocaine, and benzodiazepine use
as well as a history of depressive and anxiety symptoms, loss and trauma,
and self-injurious behaviors. In addition to diagnoses related to her sub-
stance use, Allison has been diagnosed with multiple mood and anxiety
disorders, including PTSD, as well as BPD. Allison has been involved in
outpatient, inpatient, and residential treatment beginning as a teenager.
Her most recent hospitalization occurred following an overdose. When
discussing the overdose, Allison reported she had been feeling stressed
and overwhelmed due to constant family conflict, responsibility for her
daughter, and pressure to get a job. She also indicated difficulties regard-
ing the lack of a support system due to family members’ struggles with
active substance use and mental health concerns.
• What is key to conceptualizing Allison’s case that will guide your
treatment approach?
• What type of overarching treatment approach would be best for
Allison?
• What could this approach help Allison achieve?
Answers to Case Vignette
What is key to conceptualizing Allison’s case that will guide your treatment
approach?
If Allison were your patient, you would want to consider her significant
struggles with co-occurring disorders.
What type of overarching treatment approach would be best for Allison?
Based on this conceptualization, an integrated approach to treatment
is critical. This type of approach mirrors patients’ experiences of their
disorders by treating the whole person—not just the addiction piece or
the mental health component—and gives patients permission to discuss
all symptoms and difficulties.
What could this approach help Allison achieve?
An integrated treatment approach also allows Allison to increase her
awareness regarding the relationships among her SUD and other symp-
toms/diagnoses, thus leading to more effective coping, including direct
implications for relapse prevention. Specifically, as patients increase their
own understanding regarding the connections among their symptoms,
the likelihood of successful recovery is enhanced, therefore decreasing
the risks for and/or severity of relapse.

Matrix Model (Stimulant Abuse or Addiction)

This intensive outpatient model was developed for individuals who
abuse or are dependent on stimulants (Rawson et al., 2005; SAMHSA,
2006a,2006b). It involves 16 weeks of structured group programming fol-
lowed by up to 36 weeks of continuing care. The matrixmodel incorpo-
rates elements of cognitive behavioral therapy, psychoeducation, relapse
 8 PSYCHOSOCIAL INTERVENTIONS FOR SUDS 233

prevention, 12-step approaches, and family support. The program involves

3 individual or family sessions, 8 early recovery skills group sessions, 32
relapse prevention group sessions, 12 family education group sessions, and
38 social support group sessions. Each session has a curriculum that struc-
tures the session topic. The individual and family sessions orient patients
and families to treatment, focus on current crises, review progress, and
discuss any issues of concern to the patient or family. The early recovery
skills group helps patients to learn about recovery skills and mutual sup-
port programs like AA, NA, Cocaine Anonymous (CA), or Crystal Meth
Anonymous (CMA). Issues addressed in these early recovery skills groups
include addiction, triggers, and cravings; format and benefits of 12-step
programs; physical challenges of recovery; ways to maintain abstinence;
how to control thoughts and emotions; and how to use 12-step program
sayings.
The relapse prevention groups introduce patients to the pitfalls of
recovery and factors contributing to relapse. They provide a context for
long-term involvement with peers in learning and practicing recovery
skills. Issues addressed in relapse prevention groups include other sub-
stances, emotions (anger, boredom, depression, guilt, and shame), work
and recovery, motivation, staying busy, warning signs of relapse, trust, life
and money management, emotional triggers, stress, relationships, mutual
support programs, and other compulsive behaviors.
The social support groups provide patients with opportunities to con-
tinue to learn and practice skills and explore problems in recovery with
peers. Although the needs of the specific group dictate the topic of the
group sessions, topics discussed may include any of the following: anger,
codependence, commitment, compulsions, control, cravings, depression,
emotions, fear, friendship, fun, grief, guilt, happiness, honesty, intimacy,
isolation, patience, physical recovery issues, relationship issues (isolation,
intimacy, rejection, masks to hide feelings, sex, trust), relaxation, rules,
scheduling time, selfishness, spirituality, thought stopping, and work issues.
The family education groups help families understand SUDs, the impact
on the member with the problem and the family, treatment, and recovery.
These sessions also provide a context for family members to discuss their
experiences, questions, and concerns about their loved ones with the SUD.
Although these are not family therapy sessions, these groups encourage
families to learn how to cope with the members with the SUD, and change
some of their behaviors (e.g., reduce or stop enabling behaviors). Families
learn about recovery and are encouraged to take care of themselves and
not focus most of their time, attention, and energy on the member with the
SUD. They also learn about mutual support programs for families and how
these can help them (e.g., AA, Alateen, NA, Codependents Anonymous,
and others). Some of the topics reviewed in groups include triggers and
cravings, substances (alcohol and other drugs), recovery, relapse, rebuilding
trust, family issues in recovery, and communication issues.
Motivational Enhancement Therapy
Motivational enhancement therapy (MET) is a brief, individual therapy (4
to 6 sessions) that aims to resolve ambivalence about engaging in treat-
ment or stopping substance use (NIAAA, 1995a; SAMHSA, 1999). MET is
234 Substance Use Disorders

patientcentered and is not confrontive. It incorporates principles of moti-

vational interviewing to strengthen motivation and build a plan for change.
This is accomplished by asking questions that get the patient to look at
the discrepancies in his or her current behavior in comparison to personal
goals. Therapists enhance discrepancy by providing nonjudgmental and
objective feedback about the patient’s behavior. The two main issues that
patients are asked to consider are(1) how much is their drinking or drug
use behavior affecting them and causing problems, and (2) what are the
costs and benefits of changing their substance use. If the patient becomes
motivated to change, the therapist can offer advice and possible alterna-
tives to facilitate change. The therapist always emphasizes that change is
the patient’s personal decision.
There are three primary phases of MET treatment. In the first phase, the
therapist attempts to build motivation within the patient to change. This is
accomplished by understanding the patient’s perceptions and feelings. The
therapist then elicits self-motivating statements by creating ambivalence
through feedback, questioning, and reframing situations. The therapist is
always looking for discrepancies between the patient’s behavior and his
goals. Resistance is dealt with nondefensively and is considered a natural
part of the change process. In the second phase, the therapist attempts to
strengthen the patient’s commitment to change. This is accomplished by
weighing consequences of change versus no change, offering information
and advice, dealing with resistance, and communicating the patient’s free
choice in the change process. In the final phase, the patient and therapist
review progress and renew the commitment to change. Further interven-
tions to increase motivation are utilized as necessary.
Motivational Interviewing
Motivational interviewing (MI) is a patient-centered, directive method to
enhance intrinsic motivation to change by helping the patient explore and
resolve ambivalence to change (Miller &Rollnick, 2002; Rollnick, Miller,&
Butler, 2008). This involves collaborating with the patient in exploring sub-
stance use and related problems rather than confronting the patient. It
engages the patient in active discussions of these problems while conveying
that change is the responsibility of the patient. MI is used with many types
of SUDs, psychiatric disorders, and medical problems. It may be used to
help engage patients in treatment or as part of a total treatment program.
There are four principles of MI. The first is to express empathy to con-
vey that you understand the patient’s subjective experience and to do
so in a warm, nonjudgmental manner. The second is to develop discrep-
ancy between the patient’s substance use and important goals or values.
The third is to roll with resistance and avoid arguing with the patient
to change, confronting resistance or defending your position regarding
behavior change. The fourth principle is supporting self-efficacy, which is
your belief that the patient can make positive changes.
Methods used in MI sessions include open-ended questions, affirmations,
reflections, and summarizing your discussions. Open-ended questions
encourage patients to talk and elaborate on their beliefs and experi-
ences, and invite them to share their perspectives. This also helps patients
with self-exploration. Affirmations are compliments and statements of
 8 PSYCHOSOCIAL INTERVENTIONS FOR SUDS 235

appreciation or understanding. Reflections involve making statements and

not asking questions, and are a way to check what a patient may mean
by what is shared in the session. Summarizing is a way to provide a brief
review of the discussion from the patient’s perspective and emphasize
any change that the client has identified as well as the necessary steps to
make this change.
Relapse Prevention Therapy
Relapse prevention therapy (RPT) helps the patient prepare for the
possibility of relapse and reduces relapse risk by identifying and manag-
ing high-risk relapse factors and early warning signs of relapse, making
broader changes to achieve a more balanced lifestyle so that substances
are not desired, and intervening early should a lapse or relapse actually
occur (Bowen, Chawla,&Marlatt, 2011; Daley & Douaihy, 2011b; Mack,
Harrington,& Frances, 2010; Marlatt& Donovan, 2005; NIDA, 1994;
Witkiewitz&Marlatt, 2007).
There are several categories of high-risk relapse factors, including nega-
tive emotional states, social pressures, interpersonal conflicts, and strong
cravings to use substances. Negative emotional states such as anxiety, anger,
boredom, emptiness, depression, guilt, shame, and loneliness are the most
common factors contributing to relapse. However, it is not the emotion
that determines if a relapse occurs, but whether or not the patient uses
active coping skills to manage the emotional state. Interpersonal situations
such as direct or indirect social pressures to use substances or conflicts
with another person are the second and third most common precipitants
of relapse. You can help the patient reduce relapse risk by examining which
emotions or interpersonal situations are perceived to be high risk for
relapse. Then, specific strategies can be discussed on how to manage these
high-risk situations. Strategies should be based on the unique features of the
high-risk situation for the patient. For example, anger problems with one
patient may require helping this individual learn to accept and express anger
appropriately. Anger problems with another patient may require helping
this individual to control anger and rage, and not express it in interpersonal
encounters. Boredom for one patient may be a function of lacking hobbies
or activities, whereas for another patient, boredom may represent a serious
problem in a job in which this person feels underused or not challenged.
Obvious and subtle warning signs often show before a relapse. These
signs show in changes in attitudes, thoughts, feelings, and behaviors. For
example, a patient may miss sessions scheduled with you or cut down
or stop taking medications to aid recovery from addiction without first
discussing this with you or a therapist. You can help patients who have
had previous relapse experiences complete a microanalysis of these expe-
riences to become aware of the warning signs that were ignored. Hence,
you help them learn from past mistakes. You can also help the patient
by pointing out any warning signs you notice or discussing indicators
preceding relapses in the past so that the patient can learn from these
experiences.
Patients can also benefit from broader strategies that reduce stress,
improve their coping ability, or improve health. These include exercise,
meditation, focusing on spirituality, or focusing on achieving a better
236 Substance Use Disorders

balance between “obligations” in life (shoulds) and “desires” (wants).The

belief is that as patients improve the quality of their lives, they have less
reason to want to resort to substance use to cope with stress, feelings,
or life problems.
Patients also need to prepare to intervene early to prevent a lapse from
becoming a relapse or stopping a relapse before it gets out of hand. The
patient’s initial emotional and cognitive response to a lapse determines
whether there is a return to recovery or movement further down the
road to a full-blown relapse. Patients may feel angry, depressed, guilty,
or shameful following a lapse or relapse. They may think, I’m a failure,
I’m incapable of changing, I just can’t do it, or why even bother trying,which
can fuel the relapse further. Teaching patients to challenge such thoughts
and rehearsing a plan to interrupt a lapse or relapse ahead of time can
prepare patients to take action rather than passively accept that there is
nothing they can do.

Therapeutic Community
A TC is a group of people who share a common problem such as addic-
tion and live together in a facility run by professionals, many of whom are
recovering from addiction (DeLeon, 2000). Individuals in TCs usually have
a history of multiple drug use, multiple episodes of treatment, poor coping
skills, antisocial behaviors, and few healthy support systems.
Although each program has its own individual philosophy, all communi-
ties follow social-psychological and self-help theories. In the TC approach,
the primary goalsare to abstain from substances, develop life skills, and
change antisocial attitudes and values.
The TC approach views addiction as a disorder of the whole person,
involving multiple physical, psychological, and spiritual areas of function-
ing. The problem of addiction is within the person; therefore, treatment
focuses on psychological and social changes. Recovery is viewed as a pro-
cess whereby the person makes changes in lifestyle and personal identity.
This is accomplished by following TC values and beliefs that are viewed as
essential to personal growth and healthy living.
The main concepts of TC reflect a focus on group membership and par-
ticipation. Individuals define themselves and their particular roles in refer-
ence to the community. Particular members who reflect positive progress
serve as role models within the community. Members are expected to
adhere to the community norms and values while using these guidelines
as a basis for evaluating individual growth and change. The community
facilitates individual growth through open communication in the context
of group relationships. Members are given feedback from other members
about their progress. The community is the agent through which change
occurs.
The ways in which a TC creates change are by using a variety of activities
to facilitate movement through the stages of change. The stages of change
vary depending on individual programming, but generally reflect an initial
orientation, a primary treatment component, and a re-entry phase into
society. One way change is accomplished is through individual engage-
ment in the group milieu. Patients attend meetings and activities aimed at
 8 PSYCHOSOCIAL INTERVENTIONS FOR SUDS 237

enhancing group cohesion and reinforcing the group structure and goals.
Another method is through group behavior management. This occurs
through the use of privileges and disciplinary procedures. Members are
rewarded for prosocial behavior and lose privileges for negative or anti-
social behavior. The goal is for the individual to internalize the concepts
taught while involved in the TC. This is important because the person has
then incorporated the values as their own and is more likely to use them
after treatment ends.
Twelve-Step Facilitation Therapy
Twelve-step facilitation (TSF) is based on the 12-step philosophy of AA
and NA (NIAAA, 1995c; Nowinski& Baker, 2003). The primary objective is
to facilitate patient participation in 12-step programs. This is accomplished
by helping the patient accept addiction as a progressive illness. By accept-
ing that they have an illness, patients break through their denial and open
themselves to the 12e-step program. Patients must admit that that they
have lost control over their substance use and their life. They must accept
that there is no cure and that only lifelong abstinence and recovery will
arrest the disease process.
Each session has an agenda based on topics related to 12-step philosophy.
The patient is encouraged to attend 12-step meetings, maintain a journal of
his reactions to meetings, and read 12-step recovery literature. TSF involves
12 sessions, with extra emergency sessions if needed. An introductory ses-
sion includes an alcohol use history, previous treatment experiences, and
a determination of a diagnosis. Topics that are covered in the first session
include negative consequences, tolerance levels, and examples of when the
patient lost control of use. Sessions 2 to 11 cover various topics of 12-step
recovery. Each session reviews the patient’s journal, discusses cravings or
episodes of substance use, and then reviews the topic for the session. The
session is then summarized, and a recovery assignment is given.
TSF individual or group sessions are active and focused. Following
the patient’s lead is generally discouraged. However, the therapist will
consider personal issues that the patient is dealing with in recovery.
These issues will not be dwelled on for most of the session. A therapist
who follows this program should have a good working knowledge of the
12steps, readings, meeting places, and networking with other 12-step
members.
Mutual Support Programs
Mutual support programs are supportive recovery resources for many
patients with SUDs (Daley & Donovan, 2009). You can facilitate the use
of these programs by educating the patient on the purpose and structure
of the specific program to which he or she is being encouraged to partici-
pate. Provide brochures, written information, and meeting lists. Discuss
and acknowledge the patient’s resistances, questions, or concerns regard-
ing self-help programs. It is also important, when relevant, to address
common myths regarding mutual support programsbecause misinforma-
tion may affect an individual’s openness and willingness to participate in a
program. In addition, an individual’s disclosure regarding a myth or myths
may only come following active discussion of mutual support programs.
238 Substance Use Disorders

This is in direct support of the explicit approach to these programsas

described above. A few of the more common myths you may encounter
and some ways to address follow:
• I will be pressured to stop my medications if I attend 12-step
meetings. (Possible response: “You do not have to tell anyone except
your sponsor that you are taking antidepressants. Also, if a member
suggests you stop taking medications, ask where he or she received a
medical degree.”)
• These programs only work for people who consider themselves to
be religious. (Possible response: “Some members may push religion, but
most will not. Use the parts of the program that you believe in and think
can help you, and forget the rest.”)
• There is no scientific evidence that these programs work. (Possible
response: “Actually this is not true. Those who get ‘active’ in the
program—get a sponsor, work the steps, and use other components of
the program—do better than those who do not. It has been demonstrated
that these programs are helpful to many people.”)
• All of these programs are the same. (Possible response: “There are
many different types of meetings that focus on different types of addiction.
They follow the same principles, but no two meetings are alike.”)
Help patients with high levels of social anxiety manage their anxiety
and avoidant behavior, which can increase the likelihood they will
attend mutual support programs. It may take time for these patients
to feel ready to attend meetings. Other ways to help include the
following:
• Discuss potential ways in which a specific program can aid the patient’s
recovery (e.g., “Many of our other patients with alcoholism find AA
meetings, getting a sponsor, and working the 12steps very helpful. They
tell us the AA program helps them learn to live without drinking by
managing their cravings and desires to drink, and by getting support from
others who have faced the same challenges in recovery. This makes them
feel that they do not have to recover alone.”)
• Provide specific recommendations regarding a type of mutual support
program or particular meetings (e.g., “Let’s talk about small discussion
group meetings that I think you will like. These give you a chance to
share your ideas and experiences as well as listen to others. There are
meetings each day at 7:00 a.m. in the Cathedral of Learning that many
attend before going to work. Since you work close by, these meetings are
convenient and at time that you prefer.”)
• Negotiate an agreement in which the patient will attend a certain
number of meetings before making a judgment about the potential
usefulness of a mutual support program (e.g., “Thanks for sharing your
concerns about NA meetings based on your past experiences. I would like
to recommend that you attend 12 meetings before reaching any judgment
on their usefulness in your recovery.”)
• Link the patient with members of mutual support programs who
volunteer to help newcomers get acclimated into the programs as
some patients are more likely to attend a program if they do not go
alone (e.g., “I know some of you are hesitant to attend meetings because
 8 PSYCHOSOCIAL INTERVENTIONS FOR SUDS 239

of your anxiety or worries. We have a list of volunteers who will be glad

to meet with you and take you to a few meetings to get your started. This
way, you do not have to go alone and can learn from others involved in AA
or NA.”)
• Monitor participation and discussing both positive and negative
experiences of the patient. (e.g., “Tell me how your discussions with
your AA sponsor are going. How is she helping you and what are
you learning? Also, let me know if there are any problems with your
involvement in AA.”)
240 Substance Use Disorders

Summary of Psychosocial Issues in

Treatment and Recovery
The goals of treatment for addiction are to help patients accept the SUD,
abstain from substances, address problems contributing to or resulting
from their SUD, and make changes. Patients with less severe types of
substance use problems may adopt the goal of reducing the amount and
frequency of use. Treatment provides the opportunity to begin the pro-
cess of recovery and participate in mutual support programs that provide
long-term support for recovery.
The issues in treatment or recovery that the patient may address relate
to physical, behavioral, cognitive, family, interpersonal and social function-
ing, personal growth, and lifestyle. Specific areas of focus in treatment
depend on the motivation and the unique problems and needs of the
individual patient, which may relate to age, gender, sexual identity, and
cultural factors (see Table 8.1 for a summary of potential areas of focus).
Recovery refers to the process of the patient learning to manage the
SUD and engaging in a mutual support program. The patient assumes a
major role in recovery, identifying problems and goals, and takes respon-
sibility for making changes in any of the domains of recovery. Such active
involvement empowers the patient and builds on personal strengths.
Recovery is viewed as an active process in which patients learn infor-
mation about SUDs, treatment, and recovery; gain self-awareness; and
develop coping skills to aid their recovery.
Psychiatric residents and fellows can help patients with SUDs by discuss-
ing problems or issues they are working on in treatment, helping them
re-engage in psychosocial treatment if they have dropped out prema-
turely, and monitoring or discussing their recovery experiences. You can
also ask about their participation in mutual support programs, how their
recovery is going, what they are learning, what changes they are making,
what barriers or roadblocks they are facing, or strategies to get back on
track if they have relapsed to substance use.
 8 PSYCHOSOCIAL INTERVENTIONS FOR SUDS 241

Table 8.1 Psychosocial Issues in Treatment Recovery from Mental

Health or Substance Use Disorders
Physical/Lifestyle Behavioral/Cognitive
• Exercise • Accept the disorder(s) or
• Follow a healthy diet problem(s)
• Get rest and relaxation • Control urges to drink alcohol
• Take medications (if needed) or use drugs
• Take care of medical problem • Change unhealthy beliefs and
thoughts
• Learn to structure time
• Reduce depressed thoughts
• Engage in pleasant activities
• Increase pleasant thoughts
• Achieve balance in life
• Reduce violent thoughts
• Control violent impulses
• Develop motivation to change
• Change self-defeating patterns
of behavior
Psychological Family/Interpersonal/Social
• Monitor moods and/or address • Identify effects on family and
mood disorders significant relationships
• Increase emotional awareness • Involve family in treatment/
• Manage negative emotions or recovery
moods • Resolve family/marital conflicts
• Reduce anxiety • Make amends to family or
• Reduce boredom and other significant people
emptiness harmed
• Reduce depression • Manage high-risk people,
• Reduce guilt and shame places, and events
• Control anger/rage • Engage in nondrinking activities
or healthy leisure interests
• Address “losses” (grief)
• Address relationship problems
or deficits
• Resist social pressures to drink
alcohol or use other drugs
Personal Growth/Maintenance
• Address spirituality issues • Resolve work, school, financial,
• Engage in meditation legal problems
• Develop relapse prevention plan • Learn to face vs. avoid
for all disorders or problems interpersonal conflicts
• Develop relapse interruption plan • Learn to ask for help and
for all disorders or problems support
• Use “recovery tools” on ongoing • Seek and use an AA or NA
basis sponsor
242 Substance Use Disorders

Acknowledgment
The preparation of this chapter was supported in part by the National
Institute on Drug Abuse grant #5U10DA020036-08.
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244 Substance Use Disorders

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 Chapter 9 247

Relapse Prevention
Dennis Daley and Lisa Maccarelli

Key Points 248

Introduction to Recovery and Relapse 249
Recovery 250
Substance Use Lapse and Relapse 252
Summary 264
Acknowledgment 265
References and Suggested Readings 266
248 Substance Use Disorders

Key Points
• Psychiatric residents and fellows can help patients with substance use
disorders (SUDs) reduce their risk for relapse by providing education
and support and by helping them identify and manage relapse warning
signs and risk factors.
• Lapse and relapse are common during and after treatment. This is no
different from other medical or psychiatric disorders in which relapses
are common and should be addressed in treatment.
• The initial episode of substance use following a period of recovery is
a lapse. This may or may not lead to relapse, depending on how the
patient responds.
• Many factors contribute to relapse (emotional, behavioral,
interpersonal, social, spiritual). These are referred to as high-risk
factors or situations.
• However, relapse depends on whether or not the patient uses active
coping skills to manage these high-risk situations.
• Although most pharmacological, psychosocial, and combined
treatments aim to reduce relapse risk, several models of relapse
prevention (RP) have been developed that focus on maintaining change
over time.
• RP interventions can be adapted to individual or group sessions and
incorporated by psychiatric residents or fellows into their sessions.
• Because lapse and relapse are realities for patients with SUDs, they
can benefit from emergency plans that help them intervene early in a
lapse or relapse.
 9 RELAPSE PREVENTION 249

Introduction to Recovery and Relapse

Relapse is common among individuals with substance use disorders (SUDs)
(Marlatt & Gordon, 1985). Patients with SUDs are no different from those
with other psychiatric or medical disorders in that they may experience
relapse during or after treatment (Dennis & Scott, 2007; McLellan, Lewis,
& O’Brien, 2000). Psychiatric residents and fellows can help patients by
facilitating, supporting, and monitoring their involvement in recovery as
well as working collaboratively with their therapists or counselors. You
can also educate patients and assist them in learning and using relapse pre-
vention (RP) skills, such as the early identification and management of the
warning signs of relapse, identifying and managing individualized high-risk
factors, and intervening early if a lapse or relapse occurs.
This chapter provides an overview of recovery from SUDs and relapse.
We start with a discussion of recovery, followed by definitions of lapse
and relapse and a brief review of outcome studies. We then provide a
review of treatments aimed at reducing the risk for relapse among patients
with SUDs, present models of care in which RP is the main focus, and
discuss intervention strategies you can use to help patients reduce their
risk for relapse or intervene early should a lapse or relapse occur. Our
goal is to assist you in being more effective in your work with patients, and
to think about relapse in ways that lead to more effective interventions.
250 Substance Use Disorders

Recovery
Recovery is a process of initiating abstinence from substances and making
intrapersonal and interpersonal changes to maintain this over time (CSAT,
2006; Daley & Douaihy, 2011; White, Kurtz,& Sanders, 2006). Specific
changes and improvements vary among people with SUDs and occur in
any area of functioning: physical, psychological, behavioral, interpersonal,
family, social, spiritual, occupational, and financial.
The focus of treatment and specific recovery tasks depend on the stage
of change of the patient (e.g., precontemplation, contemplation, action).
Recovery and relapse are affected by the severity of the SUD, the presence
of comorbid psychiatric or medical disorders, the patient’s motivation to
change, gender, ethnic background, coping skills, and access to social sup-
port. Recovery is not a linear process, so it is common for many individuals
with SUDs to participate in several episodes of treatments over a number of
years before they sustain their recovery over the long term. Although some
individuals may achieve full recovery, others achieve a partial recovery. The
latter may experience multiple relapses over time. Also, some patients do
not want recovery. They may want help with their SUD, but are not inter-
ested in engaging in recovery. For some, this may mean they want your help
stopping their use, or they only want medications to manage their addiction
to opioids (e.g., some want buprenorphine without any therapy).
You can facilitate recovery for patients in several ways: (1) assess
their interest in recovery and how they view it and their role in change;
(2) discuss the importance of recovery and provide education about the
recovery process and resources that can help them; (3) recommend read-
ings or provide them with interactive workbooks or books on recovery
from SUDs; (4) encourage them to explore recovery issues or barriers
to recovery in more depth in their individual or group therapy sessions;
(5) monitor their involvement in recovery and find out how they are
doing, what is helping them, and what else they can do to maximize their
recovery; and (6) facilitate their involvement in mutual support groups
that provide a “program” to follow.
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252 Substance Use Disorders

Substance Use Lapse and Relapse

Lapse refers to a single episode of use that may not lead to continued use
and an eventual relapse (Marlatt & Donovan, 2005; Marlatt & Gordon,
1985). Relapse refers to ongoing use of substances. Lapses and relapses
vary from mild to severe in terms of amount and frequency of substance
use and the impact on the patient’s life as well as others, such as the fam-
ily. The greatest risk period for relapse is the first 3 months of treatment.
During this early recovery period, patients may feel ambivalent about
abstinence, lack a solid commitment to sobriety, not have sufficient coping
skills, or lack social support.
Causes of Lapse or Relapse
You can help patients increase their understanding of common factors
contributing to lapse or relapse, identify specific high-risk factors, develop
plans to manage their risk factors, and collaborate with other caregivers
to develop a relapse prevention plan or a plan to interrupt a lapse or
relapse. Because clinicians often spend more time with patients than you,
be sure to elicit their input about a specific patient and factors they think
put this patient at risk for relapse or factors that may have contributed to
an actual relapse.
When possible, teach your patients that it is usually a combination of
factors that contribute to a lapse or relapse rather than a single factor.
These may include any of the following (Bradizza, Stasiewicz, & Paas, 2006;
Catalano et al., 1988; Condon et al., 2011; Daley, 2011; Daley & Douaihy,
2011; Douaihy et al., 2009; Gossop et al., 2002; White et al., 2006; Marlatt
& Donovan, 2005; Miller et al., 1996; Noone, Dua, & Markham, 1999;
McKay, 1999; Zywia et al., 2006):
1. Affective. Upsetting emotional states, such as anger, anxiety,
boredom, depression, and loneliness, and in a small number of
relapses, positive emotional states affect relapse. It is not the
emotional state, but rather is whether or not the patient uses active
coping strategies, that determines whether a lapse or relapse occurs.
In some instances, negative emotional states may reflect a mood or
anxiety disorder that requires assessment and treatment. You can
assess patients for co-occurring psychiatric illness and help manage
disorders that require psychiatric intervention.
2. Behavioral. Poor problem solving, social, stress management, and
leisure time management skills can affect relapse. The greater the
repertoire of cognitive and behavioral coping skills, the more likely
the patient is to cope without using substances. The use of skills or
coping strategies, more than the high-risk situation, determines the
actual outcome.
3. Cognitive. The patient’s attitudes or beliefs and thinking about
substance use or recovery, beliefs about the ability to cope with
difficult situations, and expectancies for behaviors can contribute to
relapse. For example, if a patient believes that she can successfully
cope with a difficult challenge such as a drug craving or pressures
from others to use substances, relapse is less of a threat to recovery.
 9 RELAPSE PREVENTION 253

A patient with low self-efficacy who does not believe she can cope
with a high-risk situation is at increased relapse risk. A patient
with positive outcome expectancies related to substance use (“I
think I’ll smoke a joint to relax”) is also at increased relapse risk.
Using substances to cope with stress implies an expectation that
substances will relieve the stress in that situation. Negative outcome
expectancies (“If I drink I’ll have a hangover tomorrow or cause
havoc in my marriage”) can reduce relapse risk. Attribution of
causality is a cognitive process that is relevant when a patient engages
in substance use because these attributions influence later behaviors.
For example, a patient who believes an initial lapse will lead to total
loss of control and was caused by personal “weakness” is more
likely to continue using substances. If a patient believes that he used
substances because he made the mistake of not using his recovery
skills, he is more likely to stop the lapse before it gets out of control.
Poorer cognitive functioning is associated with worse substance use
outcomes because cognitive dysfunction can interfere with the ability
to benefit from treatment, learn and process new information, follow
directions, and make decisions.
4. Conditioned cues (triggers). The repeated pairing of substance use with
places, events, people, things (objects), and internal states results
in triggers. Your patient may have a strong physiological response
experienced as an intense craving for alcohol or drugs as a result of
a trigger. The severity of the SUD influences the range and number
of conditioned cues, the strength of the response to the conditioned
cues, and the tendency to pay more attention to conditioned cues
related to substance use than to other elements of one’s environment.
5. Co-occurring psychiatric disorder (COD). A COD can affect recovery
and contribute to poor treatment outcomes, including relapse to
either disorder. Symptoms of intoxication or withdrawal from drugs
and alcohol can mimic or mask symptoms of co-occurring psychiatric
disorders. When possible, help your patient get “integrated
treatment” that focuses on both the SUD and the psychiatric illness.
6. Environmental. The easy availability of substances, social pressures
to engage in substance use, and major unexpected life changes
for which the patient is ill prepared can affect relapse. Poor social
support systems or networks with others who have active SUDs can
threaten a patient’s recovery. Family members who are nonsupportive
or hostile can create tension and negative emotions. For example,
Lenny’s wife often berated him when he was sober and even told him
once that she liked him better when he was drinking. After repeated
conflicts with his wife, Lenny said, “I got tired of being attacked by her.
I couldn’t do anything right. So I said the hell with it and starting drinking
again.” Although Lenny has to assume responsibility for his relapse,
his wife did play a role. After he was stable from his relapse, Lenny’s
counselor worked with him and his wife and discovered that her
hostility toward him was caused in part by her feeling threatened that
her role as primary parent was changing as their children took more
to Lenny when he got sober. Even though she knew her kids needed
their father, sharing the power in the family was an adjustment for her.
254 Substance Use Disorders

7. Interpersonal or social. Pressures from others to use substances,

conflicts with family members or friends, the influence of a negative
social network (e.g., mainly consisting of others who have substance
problems), or lack of nonsubstance leisure activities can contribute
to relapse. However, it is the patient’s use or nonuse of coping
skills that determines whether a relapse occurs in response to these
problems.
8. Multiple SUDs. These increase risk for relapse and treatment
dropout. For example, patients who are diagnosed with cocaine
dependence and co-occurring alcohol dependence are at high risk
for leaving treatment before completion. Alcohol or marijuana can
be a powerful conditioned cue for cocaine use and may increase
patients’ desires for cocaine.
9. Physical. Strong cravings for substances, pain, or use of medications
for medical problems that trigger an addictive urge can affect
relapse. For example, a patient recovering from an opioid addiction
who was prescribed a narcotic to ease the pain after dental work
can experience a reawakening of the desire for drugs. Chronic
and acute pain is difficult to manage in people who are opioid
dependent. Management requires a team effort involving addiction
medicine, pain management, and other relevant medical specialties.
Even time-limited use of medically necessary opioids in controlled
settings can be a risk factor for relapse. Close collaboration with
medical providers can help you better manage your addicted
patients.
10. Stress. Exposure to high-risk factors can increase stress, especially
if it creates an imbalance between “wants” and “shoulds.” If the
patient views the benefits of substance use more highly than those
of abstinence or recovery, he raises his risk for relapse.
11. Spiritual. Strong feelings of guilt and shame, and lack of meaning or
purpose in life or feeling disconnected with others may contribute
to relapse. Some patients feel an “emptiness” or “void” when they
stop using substances and need help changing their thinking if they
are to sustain recovery. Others need to develop new behaviors
and get involved in activities that they find enjoyable or bring them
meaning. Many in the latter stages of recovery report that helping
others in 12-step programs, involvement in formal religion, or the
pursuit of spiritual knowledge adds meaning to their lives.
12. Treatment-related stresses. Any treatment provider can contribute
to a patient’s relapse through negative attitudes, negative feelings,
or enabling behaviors. For example, following a relapse, Kala
returned to treatment and was told by a therapist in one of her
early sessions that she was not serious about her recovery because
she had problems complying with treatment sessions and Narcotics
Anonymous (NA) meetings. Kala knew she had motivational
struggles but felt judged by this therapist and dealt with it by
dropping out of treatment without having a discussion with her
therapist. Although the therapist may have been well meaning, she
conveyed judgment in her statement at a time when the patient
was very vulnerable. One of the common systems issues that may
 9 RELAPSE PREVENTION 255

indirectly affect relapse is that so much emphasis is placed on the

acute phase of treatment (the first several months). Many addiction
treatment programs do not provide the long-term follow-up that
is common with chronic mental disorders, expecting that mutual
support programs will provide the ongoing help that patients need.
Although this may be true for many, it is not true for all patients,
many of whom could benefit from long-term connections with
treatment providers.
Outcomes of Treatment
Clinical studies and reviews of the treatment outcome literature show
that while many patients improve, relapse rates are high, which is similar to
other chronic disorders (McLellan et al., 2005; NIDA, 2008). The primary
outcome measure usually relates to substance use, but other outcome
measures can include functioning in any domain (medical, social, psycho-
logical, spiritual, and occupational) and quality of life. Do not view recov-
ery as a linear process because relapses do occur despite improvements
in any area of life or in the quality of life.
Numerous reports by the National Institute on Drug Abuse (NIDA),
the National Institute on Alcohol Abuse and Alcoholism (NIAAA), and
the Center for Substance Abuse Treatments (CSAT) document the fol-
lowing positive outcomes for treatment of alcohol and drug abuse: ces-
sation or reduction of substance use; decreases in post-treatment
medical care and medical costs; decreases in work problems, including
absenteeism and working under the influence; decreases in traffic viola-
tions and other arrests; and improvement in psychological, social, and
family functioning.
Individuals who relapse do not always return to pretreatment levels
of substance use. The actual quantity and frequency of use can vary.
Because drug and alcohol use is only one outcome measure, an individ-
ual may show improvement in other areas of life functioning despite an
actual lapse or relapse to substance use. Patients who remain in treat-
ment the longest usually have the best outcomes. You can help patients
by discussing problems with adherence and ways for them to remain in
treatment for a significant period of time because early dropout raises
the risk for relapse.
Models of Relapse Prevention
The most common is the cognitive behavioral model of Marlatt and col-
leagues that has been used with all types of SUDs, in individual, conjoint,
and group sessions, and with other clinical populations such as overeaters,
compulsive gamblers, individuals with problems controlling sexual behav-
iors, and individuals with psychiatric disorders (Litt et al., 2003; Marlatt &
Donovan, 2005; Marlatt & Gordon, 1985; Witkiewitz & Marlatt, 2007). RP
aims to help patients maintain changes over time, with the patient serving
as a co-therapist. This approach assists patients in addressing their unique
high-risk factors and in learning to use a variety of coping strategies to
manage these. To improve personal habits or lifestyle, patients may also
learn and use other “global” self-control strategies, such as exercise, relax-
ation, meditation, self-hypnosis, and “balanced” living. More recently, this
256 Substance Use Disorders

RP approach has been integrated with mindfulness meditation practices to

help patients learn new types of skills to aid recovery and reduce relapse
risk (Bowen, Chawla, & Marlatt, 2011).
Most RP models incorporate principles from Marlatt’s original
conceptualization of relapse and focus on helping patients (Daley &
Douaihy, 2011; Gorski &Miller, 1982; NIDA, 1994; Rawson et al., 2005;
SAMHSA, 2008):
1. Learn cognitive and behavioral coping strategies to manage warning
signs of relapse and high-risk situations. These skills can be adapted to
many situations.
2. Engage in mutual support programs and develop a recovery social
support system. Patients who actively use these programs do better
than those who only attend meetings.
3. Make lifestyle changes to decrease the need for alcohol or other
drugs. This may involve new activities, new friends, and new daily
routines.
4. Increase healthy nonsubstance activities and pleasures. Many patients
need to learn how to enjoy ordinary pleasures in life. Some need
to find new activities because most of their time evolved around
substance use–related behaviors.
5. Prepare to stop a lapse or relapse early to minimize adverse effects.
An emergency plan helps patients take action early to minimize
damage caused by a lapse or relapse.
Research Support for Relapse Prevention
All treatments for addiction aim to reduce the risk for relapse. Outcome
studies show that there are many behavioral, medication, and combined
treatments that are effective in doing this even though many clients
relapse. Most psychosocial treatments of addiction incorporate strategies
from the RP literature. There is also clinical and research literature specific
to RP. Literature reviews, meta-analyses, and results from multiple studies
show that RP is effective in improving recovery and reducing relapse rates.
Following is a brief summary of research findings:
1. Review of randomized trials. Carroll reviewed 24 randomized,
controlled clinical trials of RP among smokers, alcohol abusers,
marijuana abusers, cocaine abusers, opiate addicts, and other
drug abusers (Carroll, 1996). She reported that RP is superior to
no-treatment control groups, especially with smokers. Carroll also
reported that RP holds the greatest promise in helping the addicted
individual maintain gains after stopping substance use and reducing
the severity of relapses when they occur. Clients with higher levels
of psychiatric and addiction severity appear to benefit most from
RP. Thus, RP may be especially helpful for clients with co-occurring
psychiatric disorders.
2. Meta-analysis of clinical trials. Irvin and colleagues conducted a
meta-analysis of 26 clinical trials on RP with a total sample of almost
10,000 participants (Irvin et al., 1999). The RP approach used in these
studies was consistent with Marlatt’s cognitive behavioral approach
to RP. Irvin found that the strongest treatment effect for RP was with
 9 RELAPSE PREVENTION 257

patients who had problems with alcohol or polysubstance use. They

also found that individual, group, and marital modalities appeared to
be equally effective, and that medication is very helpful in reducing
relapse rates, particularly for the treatment of alcohol problems.
3. RP delivered in groups. Several studies found that RP administered in
groups is as effective as RP delivered in individual sessions (Schmitz
et al., 1997).
4. RP including spouses. Several studies included spouses in the RP
intervention. Maisto and colleagues’ study of the first relapse
episodes and reasons for terminating relapse of men with alcoholism
who were treated with their spouses found that the relapses of
clients receiving RP in addition to behavioral marital therapy (BMT)
were shorter than those of clients not receiving the RP (Maisto,
McKay, & O’Farrell, 1995). O’Farrell found that abstinence rates at
12 months were highest for those who received BMT in combination
with RP (O’Farrell & Fals-Stewart, 2006). Alcoholics who received RP
after completing BMT had more abstinent days, fewer days drinking,
and for those with the poorest functioning at baseline, improved
marriages compared with those who received only BMT.
5. Delayed effects of RP among cocaine abusers and smokers. Several
studies found a “sleeper effect,” or delayed improved treatment
response, for patients who received RP (Regier, 1990). These findings
are consistent with the idea that learning new ways to cope with
high-risk situations takes time for the client with an SUD.
6. RP with alcohol problems. A number of studies showed that RP leads
to reduced drinking, fewer episodes of intoxication, less severe lapses
for shorter periods of time, and stopping drinking much sooner
after a relapse compared with clients in control condition (Laudet,
Morgen, & White, 2006; Monti et al., 2002; Moser & Annis, 1996).
Patients receiving RP have fewer drinks and fewer days drunk than
those in the control conditions.
7. Medication combined with counseling. Many studies show that patients
receiving RP and medication-assisted treatment, such as naltrexone
for alcoholism, are less likely to relapse to heavy drinking after a lapse
compared with a control group (Anton et al., 2006; Bouza et al., 2004;
CSAT, 2005; Mann, Lehert, & Morgan, 2004).
Although RP may not always be better than another behavioral treat-
ment it is compared with, results of studies show it is often as good as
these other treatments. This suggests that many treatments are effective
and help reduce relapse rates among clients receiving treatment, includ-
ing RP. As experienced clinicians know, treating addiction is a challenge
because of the complexity of problems presented by clients, varying levels
of motivation, and degrees of social support. Despite limitations associated
with various studies, the literature shows that RP strategies enhance the
recovery of individuals with SUDs and improve substance use outcomes.
Interventions to Aid Recovery and Reduce Relapse Risk
In this section we discuss interventions that can be used with patients to
facilitate their recovery and reduce their risk for relapse (Daley & Douaihy,
2011; Marlatt & Donovan, 2005; NIDA, 1994; Witkiewitz & Marlatt, 2007).
258 Substance Use Disorders

These include identifying triggers and managing resulting cravings; chang-

ing cognitive distortions; identifying high-risk situations; identifying relapse
warning signs; managing emotional states and moods that may precede
relapse; focusing on co-occurring psychiatric disorders; resisting social
pressures to use substances; developing a recovery network or support
system; using medication as part of a treatment plan; improving adher-
ence to treatment and the recovery plan; and managing a lapse or relapse.
Although you may not have sufficient time in sessions with patients to
implement these interventions, you can encourage your patients to work
on these issues with their therapist and other team members. Your knowl-
edge of these interventions will allow you to support your patient’s par-
ticipation in treatment more directly. Also, getting and giving feedback
among team members helps you and other clinical staff develop RP plans
for patients based on their individual issues and needs.
1. Identify triggers and manage cravings. A patient’s craving for a
substance can be triggered by environmental cues associated with
prior use, such as the sight or smell of the substance, a place where
substances were used, a person with whom the patient used, drug
paraphernalia, and other related objects or experiences. Cravings
have physiological and psychological components. AA, NA, and
other 12-step programs recommend that patients in recovery
“avoid people, places, and things” associated with substances to
minimize exposure to cues. Encourage your patients to remove
substances from their homes as well as paraphernalia (e.g., pipes,
mirrors, needles) used for taking drugs. Teach the patient cognitive
techniques, such as monitoring and recording cravings and
associated thoughts and behaviors; changing thoughts about the
craving or desire to use; challenging euphoric recall; talking oneself
through the craving (e.g., thinking beyond the high by identifying
negative consequences of using and positive benefits of not using);
repeating using recovery slogans (e.g., “this too shall pass”), and
delaying the decision to use when craving a substance. You can also
teach behavioral interventions, such as avoiding, leaving, distracting,
or changing situations that trigger or worsen a craving; redirecting
activities or getting involved in pleasant activities that bring
enjoyment; reaching out for support from others by admitting and
talking about cravings and hearing how others have survived them;
attending mutual support group meetings; or taking medications
such as naltrexone or acamprosate that may reduce cravings.
2. Change cognitive distortions. Errors in thinking are associated with
a wide range of mental health and SUDs (Beck, Wright, & Liese,
1994). These distortions have also been implicated in relapse
to substance use. Twelve-step programs refer to cognitive
distortions as “stinking thinking” and suggest that recovering
individuals need to alter their thinking if they are to remain
alcohol and drug-free. Teaching patients to identify their cognitive
errors (e.g., all or nothing/black-and-white thinking, “awfulizing,”
overgeneralizing, using selective abstraction, catastrophizing, or
jumping to conclusions) and evaluating how these affect the relapse
 9 RELAPSE PREVENTION 259

process are often very helpful. Patients can then be taught to use
counter-thoughts and self-talk to challenge their faulty beliefs or
specific negative thought patterns. Patients can be provided with
a sample worksheet to help them learn to challenge and change
relapse thoughts. This worksheet has three directives: (a) list
the relapse-related thought; (b) state what is wrong with it; and
(c) create new/alternate statements. A list of seven specific thoughts
commonly associated with relapse is used to prompt patients
in completing this therapeutic task. These examples include,
“Why should I take medications to help me deal with my alcohol
addiction?”; “Relapse can’t happen to me”; “I’ll never use alcohol or
drugs again”; “I can control my use of alcohol or other drugs”; “A
few drinks, tokes, pills, lines won’t hurt”; “Recovery isn’t happening
fast enough”; “I need alcohol or other drugs to have fun”; and “My
problem is cured.” Patients seldom have difficulty coming up with
additional examples of specific thoughts that can contribute to a
relapse. Many of the slogans in 12-step programs, such as “This too
will pass,” “Let go and let God,” and “One day at a time” help the
patient work through thoughts of using.
3. Identify high-risk situations. These situations are those in which a
patient may have used substances in the past or in which the patient
feels vulnerable to using substances. These relate to the categories
discussed earlier (causes of relapse). The most common is the
patient’s inability to manage a negative emotional state such as
anxiety, anger, boredom, emptiness, depression, guilt, shame, and
loneliness (Daley, 2011). Other common high-risk factors are direct
or indirect social pressures to use substances, interpersonal conflicts,
strong cravings, pain, or positive emotions. You can help your
patients by identifying and discussing strategies to manage specific
high-risk factors. Strategies should be based on the unique features of
the high-risk situation for each patient. For example, anger problems
with one patient may require helping this individual learn to accept
and express anger appropriately rather than drinking alcohol. Anger
problems with another patient may require helping this individual
to control anger and rage, and not express it in interpersonal
encounters. Depression for one patient may require active
participation in nonsubstance leisure activities, whereas for another,
it may be a symptom of a clinical disorder requiring psychiatric
intervention.
4. Identify relapse warning signs. Obvious and subtle warning signs often
show before a lapse or relapse (Daley, 2011; Gorski & Miller, 1982).
These signs show in changes in attitudes, thoughts, feelings, and
behaviors. An example of a common and obvious warning sign is
when a patient reduces or stops attending treatment sessions and/
or mutual support meetings without first discussing this decision
with a therapist or sponsor. Another common warning sign is when
the patient seeks out and socializes with other people with whom
he used alcohol or drugs. Subtle warning signs vary among patients.
For example, a patient may become more dishonest in his daily
dealings with others, which represents a potential relapse warning
260 Substance Use Disorders

sign. One helpful strategy is to teach patients about common

relapse warning signs and ways to manage these. Another is to help
patients learn which warning signs may be unique to them. Another
helpful intervention is helping patients reframe “failure” associated
with relapse to a “learning experience” that can help them improve
their recovery.
5. Resist social pressures to use substances. Imagine that you had an
addiction to alcohol or drugs for more than 10 years and finally got
help. You have been sober about 3 months, and unexpectedly, you
encounter an old friend who is pushing hard to get you to drink
(or use drugs) together. Pay attention to what thoughts go through
your head and what you feel. How would these thoughts and
feelings influence your decision to use or not use in response to this
social pressure? Direct and indirect social pressures often lead to
increased thoughts and desires to use substances, as well as anxiety
regarding one’s ability to refuse offers to drink alcohol or use other
drugs. You can help your patients identify high-risk relationships
(e.g., living with or dating an active drug abuser or alcoholic) and
situations or events in which the patient may be exposed to or
offered substances (e.g., social gatherings). The next step is to assess
the effects of these social pressures on the thoughts, feelings, and
behaviors of the patient. Planning, practicing, and implementing
coping strategies is the next step. These coping strategies include
avoidance and the use of verbal, cognitive, or behavioral skills. Role
playing to rehearse ways to refuse offers of drugs or alcohol is one
very practical and easy-to-use intervention. The final step of this
process involves teaching the patient to evaluate the results of a
given coping strategy and to modify it as needed.
6. Develop and utilize a support system (Laudet et al., 2006; Daley
& Donovan, 2009; McCrady, Epstein, & Kahler, 2004). Help your
patient evaluate his current support system to determine who to
exclude and who to engage. Some patients need to learn how to
ask others for support. Talk with your patient about the impact
of the addiction on the family or concerned significant others and
how to involve them in treatment and recovery. Encourage your
patient to get actively involved in Alcoholics Anonymous (AA), NA,
or other mutual support groups. For patients in 12-step programs,
suggest that they get and use a sponsor, get a list of phone numbers
and email addresses of others in recovery, touch base daily with
others in recovery, and attend recovery and social events sponsored
by these programs.
7. Managing negative and positive emotional states and moods (Daley,
2006, 2011, 2012). Many patients with SUDs struggle in the
identification of, as well as in their ability to tolerate, emotional
experiences. Patients have used substances to interrupt and avoid
emotions, and therefore, exposure to emotions without the use
of substances can be extremely difficult and a significant risk factor
for relapse. Both positive and negative emotional experiences may
affect recovery. Where positive affect has been linked to lapses,
negative emotions and moods have been associated with major
 9 RELAPSE PREVENTION 261

relapse across a range of addictions. As a result, the focus on

emotional states and moods is critical, including assisting patients
in teasing out and identifying their emotional experiences and
providing skills to help in the management and positive expression
of these emotions. Patients may also struggle with secondary
emotions such as anger as a way to avoid painful primary emotional
experiences. For example, the acronym HALT used in 12-step
programs (which stands for, “don’t get too hungry, angry, lonely,
or tired”) speaks to the importance of the recovering person’s not
allowing himself or herself to become too vulnerable, including too
angry or too lonely, because these two emotional states are seen
as high-risk factors for many. Other high-risk emotional experiences
may include shame and guilt, boredom, grief and loss, anxiety, and
sadness. In addition, if you believe a mood or anxiety disorder is
present, integrate psychiatric interventions into the plan to explicitly
address the co-occurring disorders.
8. Address co-occurring psychiatric disorders. Because there are high
rates of psychiatric disorders among patients with SUDs, work
with your team to determine whether integrated treatment is
needed for a co-occurring disorder (Daley & Douaihy, 2010; Daley
& Moss, 2002; Daley & Thase, 2004; Drake, Wallach, & McGovern,
2005; Kessler et al., 1997; Mueser et al., 2003; Regier, 1990).
These patients are at higher risk for relapse than those with only
a substance use diagnosis, which can result from the effects of
psychiatric symptoms on motivation, judgment, and functioning.
Patients with co-occurring disorders also have higher rates of poor
compliance with medications and therapy sessions, so be sure to
talk about the importance of compliance and about how poor
compliance is a high-risk factor for relapse to substance use as well
as a return or worsening of psychiatric symptoms. If co-occurring
disorders are present, an integrated treatment approach is critical.
This allows patients to better understand the relationships among
their substance use and mental health diagnoses. This increased
awareness can directly influence a patient’s level of vulnerability for
relapse as well as his or her ability to intervene early if a lapse or
relapse does occur.
9. Offer medication-assisted-treatments for alcohol, opioid or nicotine
addiction. Some patients benefit from medications to attenuate or
reduce cravings for alcohol or other drugs, enhance motivation
to stay sober, and increase confidence in their ability to resist
relapse (Bouza et al., 2004; Carroll et al., 1994; CSAT, 2005, 2006).
Others need medications to replace addictions (e.g., methadone or
buprenorphine for opioid addiction). Talk with your patients and
other team members about medication options. Stress with patients
the importance of psychosocial treatments and mutual support
programs in addition to medications because some will only want
medicine and not want to participate in other treatment or mutual
support program recovery activities. Your biggest challenge with
medication-assisted treatment may be with other clinicians, some
262 Substance Use Disorders

of whom may not value or recommend medications to addicted

patients as part of their plan.
10. Focus on the transition between levels of care. Many patients do well
in hospital or residential treatment programs, only to have these
negated as a consequence of failure to adhere to ongoing care. If you
work on a psychiatric or dual diagnosis unit, addiction hospital, or
residential program, stress the importance of follow-through after
discharge with your patients. Linking patients to ongoing care or
recovery check-ups can improve outcomes (Daley & Zuckoff, 1999;
Dennis, Scott, & Funk, 2003; Scott, Dennis, & Foss, 2005). Encourage
multiple relapsers to learn from past experiences and develop an RP
plan with their therapy team members. Questions to consider asking
patients include: What was going on with you that you did not follow
through with care after your previous (hospital, residential) discharge?
Why is continuing your care after discharge important? What might
get in the way of following through? What will you do to make sure
to continue treatment once you leave the unit (or program)?
11. Managing lapses and relapses. Patients need to prepare to intervene
early to prevent a lapse from becoming a relapse, or to stop a
relapse before it gets out of hand. The patient’s initial emotional
and cognitive response to a lapse determines whether there is a
return to recovery or movement further down the road to relapse.
Patients may feel angry, depressed, guilty, or shameful following
a lapse or relapse. They may think, “I’m a failure, I’m incapable of
changing, I just can’t do it, or why even bother trying,” which can fuel
the relapse further. Teaching patients to challenge such negative
thoughts and to rehearse a plan to interrupt a lapse or relapse
ahead of time can prepare patients to take action rather than
passively accept that there is nothing they can do.

Case Vignette
Brian is a 37-year-old, employed, married father of three children, ages
7 to 14 years, with an 8-year history of alcohol dependence with several
treatment episodes followed by periods of sobriety up to 30 months. In
the past he completed a 3-week residential program, completed a 6-week
intensive outpatient program, and attended outpatient therapy on several
occasions. Brian also involved his family in treatment sessions and was
active in the AA program, although in recent months, he decreased this
involvement significantly because he got very busy at work.
His recent relapse lasted about 1 month, during which time he drank
excessively, mainly on weekends. Brian reluctantly returned to treat-
ment when his wife Cindy insisted he do so or else she would take
their kids and move in with her parents. Cindy stated he had been doing
well in his recovery and seemed a bit shocked when he had this recent
relapse.
As the practitioner trainee working with the treatment team at an
outpatient program where Brian sought help, you consider the following
questions:
 9 RELAPSE PREVENTION 263

• What are the issues related to recovery and relapse that you think
need to be addressed?
• How can you help Brian learn from his relapse experiences and
prepare for his ongoing recovery?
• Would you consider medications for his alcoholism and, if so, why
and which ones?
• What is the role of the family in this process and how should they
be involved?
Answers to Case Vignette
What are the issues related to recovery and relapse that you think need to
be addressed?
You need to help Brian with understanding relapse (resumed use is com-
mon following addiction treatment as in the care of any chronic medical
illness) as a “process and event” and learning to identify early warning
signs such as his decreased involvement in AA meetings that preceded
his relapse and his decreased motivation for getting re-engaged in treat-
ment and AA involvement (treatment adherence and family involvement
to reduce relapse risk). You should also address the issues of under-
standing recovery as an ongoing process of abstinence and change and
of understanding the importance of continuing to work a “recovery
program” that includes involvement in therapy, AA, and balancing his
lifestyle (remaining employed at the same time working his recovery
program).
How can you help Brian learn from his relapse experiences and prepare for
his ongoing recovery?
The therapeutic approach with Brian includes identifying his thinking pat-
terns and the sequence of events leading to the episode of use (lapse lead-
ing to relapse) and targeting points of intervention. Reviewing his relapse
cues preceding relapse, such as being overconfident about his sobriety, dis-
engaging from AA involvement and outpatient therapy, and learning how
to cope with his busy job and at the same time stay focused on his recovery
program. Learning how to reach out for help and particularly relying on his
support from his wife would help him reduce his risk for relapsing.
Would you consider medications for his alcoholism and, if so, why and which
ones?
The goal of using medication is to help Brian with relapse prevention.
We have to clarify to Brian that the medication is a tool to help reduce
cravings for and reward from alcohol use, thus helping him achieve and
sustain recovery. Some medications to consider are naltrexone (oral or
injectable form), acamprosate, and topiramate.
What is the role of the family in this process and how should they be
involved?
Involvement of family members such as his wife can help her become
more aware of relapse warning signs and how to point them out to him.
Involving his wife in his therapy session helps her learn what she can and
cannot do to help support him in his recovery. Participation in treatment
sessions or support groups (Al-Anon) can also help his wife learn to deal
with their own feelings and reactions to Brian’s addiction.
264 Substance Use Disorders

Summary
As with other chronic medical or psychiatric conditions, relapse is com-
mon among patients in treatment for an SUD. You can help your patients
identify and manage their high-risk factors, catch and intervene when early
warning signs of a potential relapse are present, and prepare to take quick
action should a lapse or relapse occur. There are many clinical and phar-
macologic interventions that can enhance recovery and reduce the risk
for relapse in these patients. Be sure not to judge patients who relapse
as unmotivated or convey negative reactions. Instead, help them to learn
from their mistakes and work with them and/or their team to integrate
recovery and relapse prevention skills into their treatment. And, when
feasible, make sure the family is a part of this process.
 9 RELAPSE PREVENTION 265

Acknowledgment
The preparation of this chapter was supported in part by the National
Institute on Drug Abuse grant #5U10DA020036-08.
266 Substance Use Disorders

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 Chapter 10 269

Hepatitis C Virus, Human

Immunodeficiency Virus,
and Substance Use
Disorders
Shannon Allen and Antoine Douaihy

Key Points 270

Hepatitis C Virus 272
Human Immunodeficiency Virus 276
Acknowledgment 279
References and Suggested Readings 280
270 Substance Use Disorders

Key Points
• Injection drug users (IDUs) represent a disproportionately large
burden of hepatitis C infection.
• Chronic infection with the hepatitis C virus (HCV) is frequently
complicated by the presence of coexisting substance use disorders
(SUDs) and psychiatric disorders.
• The continuing reluctance to treat IDUs is driven by concerns about
the risk for reinfection, high rates of concomitant alcohol abuse, and
high rates of co-occurring psychiatric disorders, all potentially affecting
treatment compliance and effectiveness.
• The available evidence suggests that IDUs can be successfully treated
for HCV.
• Substance abuse has been linked to many new cases of human
immunodeficiency virus (HIV) infection.
• Seeking out high-risk, hard-to-reach substance abusers and offering
them HIV testing, access to treatment, and the interventions to remain
in treatment—both for HIV and for substance abuse—is needed to
help curb the epidemic.
• The evidence makes a strong case for integrating HIV, substance abuse,
and mental health care, which improve outcomes in this population.
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272 Substance Use Disorders

Hepatitis C Virus
The Centers for Disease Control and Prevention (CDC) estimate that
there are up to 3.9 million people in the United States, or 1.9% of the total
population, currently infected with hepatitis C virus (HCV) (Armstrong
et al., 2002). Ninety percent of new infections worldwide (about 54% in
the United States) are contracted through injection drug use (Armstrong
et al., 2002). Every year, 8,000 to 10,000 people in the United States die
from HCV-related causes and more than $600 million is spent annually on
related health care costs (Murphy et al., 2012). In the past decade, trend
analyses have documented an increase in the mortality rate associated
with HCV, and in 2007, HCV infection had a higher associated mortality
rate than both hepatitis B virus (HBV) and human immunodeficiency virus
(HIV) (Murphy et al., 2012). Moreover, HCV has surpassed alcohol as the
main cause of chronic liver disease, cirrhosis, and orthotopic transplanta-
tion in the United States (CDC, 2009; Kim, 2002).
Transmission
Before the 1990s, there was little knowledge or education regarding
blood-borne viruses, and as a result, many people were initially infected
with HCV in the period between 1970 and 1992 (CDC, 2009). With the
discovery of blood-borne viruses, public health initiatives were imple-
mented to mandate screening of blood products and to discourage
needle sharing. Screening of donated blood has decreased the risk for
transfusion-associated HCV infection to less than 1 in 100,000 transfused
units (CDC, 2009). After 1992, intravenous drug use exceeded blood
transfusion as the main route of transmission in the United States (CDC,
2009). Recent surveys of active intravenous drug users (IDUs) indicate
that approximately one-third of young (18 to 30 years) IDUs are HCV
infected. Older IDUs typically have a much higher prevalence (70% to
90%) of HCV infection (CDC, 2009). Seroconversion to HCV in IDUs can
occur at any point in the course of drug use, but most IDUs seroconvert
within the first 1 to 3 years (Hagan et al., 2004). Current studies have not
clearly demonstrated whether specific behaviors of non-IDUs are associ-
ated with HCV infections (Scheinmann et al., 2007). Uncommon routes
of transmission of HCV, which affect less than 5% of individuals, include
high-risk sexual activity, sharing drug paraphernalia (e.g., straws used
for snorting cocaine), sharing contaminated personal items (e.g., razors,
toothbrushes), and maternal–fetal transmission. Sexual transmission of
HCV is rare, except in people who are infected with HIV. However, some
recent evidence suggests that HCV might be passed through sex, if this
activity includes the possibility of blood exposure (Tohme & Holmberg,
2010). Occupational exposures, including needlestick injury and muco-
sal exposure, account for about 3% of transmissions. Inefficient modes
of transmission include casual contact with saliva, snorting or smoking
cocaine, and breastfeeding. The CDC have determined that HCV does
not pass into the breast milk, but they recommend that women with
cracked nipples or active bleeding abstain from breastfeeding until the
breasts have healed.
10 HEPATITIS C VIRUS, HUMAN IMMUNODEFICIENCY VIRUS, & SUDS 273

Screening
The most common test for HCV detects antibodies to HCV in the blood.
A “positive” HCV antibody test could mean that the person is a chronic
carrier of HCV (75% to 85%), has been infected but has resolved infec-
tion (15% to 25%), or is one of the few recently infected (CDC, 2010).
Following HCV infection, it usually takes at least 6 to 8 weeks for the
body to develop antibodies. People who have a positive test result on
an HCV antibody screening test should get additional testing, such as a
follow-up qualitative HCV RNA test, which indicates whether the virus
is present. If HCV RNA is present for at least 6 months, the HCV infec-
tion is considered chronic. The accuracy of a negative HCV antibody test
result is very high. To account for a 6-month window period, people who
engage in high-risk behaviors should be retested every year (Backmund
et al., 2005).
Progression of Infection
Most individuals who are acutely infected with HCV remain asymptomatic
and are infrequently diagnosed. Clinical manifestations after acute infec-
tions can occur in up to 20% to 30% of patients, usually within the first 3
to 12 weeks after exposure to HCV (Alter & Seeff, 2000; Thimme et al.,
2001). These symptoms typically include malaise, weakness, anorexia, and
jaundice. Serum alanine aminotransferase (ALT) levels, signifying hepato-
cyte necrosis, begin to increase 2 to 8 weeks after exposure and often
reach levels of greater than 10 times the upper limit of normal (Farci et al.,
1991; Thimme et al., 2001). Chronic hepatitis C is marked by the persis-
tence of HCV RNA in the blood for at least 6 months after onset of acute
infection. Rarely, the virus will be spontaneously cleared, whereby the
HCV RNA in the serum becomes undetectable and the ALT levels return
to normal (Chen & Morgan, 2006). The rate of developing chronic HCV
infection is affected by many factors, including the age at time of infection,
male gender, African American ethnicity, the development of jaundice
during the acute infection, and HIV infection (Chen & Morgan, 2006). Up
to 85% of patients with acute hepatitis C will remain HCV infected (Loftis
et al., 2006; Seeff & Hoofnagle, 2002; Thomas et al., 2005) and will go on
to develop a subclinical infection with persistent HCV viremia. Cirrhosis
develops in 5% to 25% of individuals with chronic HCV infection, and its
development may take as long as 25 to 30 years (Thomas et al., 2005).
Once cirrhosis occurs, the risk for hepatocellular carcinoma (HCC) is
about 1% to 3% per year (Fattovich et al., 1997). An estimated 30% of
individuals with HCV cirrhosis go on to develop hepatic decompensation
within 10 years (Fattovich et al., 1997).
In the setting of chronic HCV infection, the rate of structural liver dam-
age, also known as fibrosis, varies widely. A more rapid disease progres-
sion is observed among individuals with alcoholism, those infected with
HIV or HBV, males, cannabis abusers, those who acquire the infection at
an older age, and those with comorbid medical conditions (e.g., insulin
resistance, hemochromatosis). Alcohol consumption is one of the most
important risk factors promoting development of fibrosis and is believed
to increase the incidence of cirrhosis in patients with HCV 15-fold (Safdar
274 Substance Use Disorders

& Schiff, 2004). Studies have indicated that daily cannabis use is associated
with accelerated progression to cirrhosis in patients with chronic HCV
infection. Possible mechanisms of action include overactivation of hepatic
cannabinoid receptors, resulting in fatty liver changes and accelerated
rates of fibrosis (Hezode et al., 2005).
Treatment for Chronic Infection
Medical practitioners working with patients with substance use disorders
(SUDS) have been routinely screening and evaluating patients for HCV
and recommending treatment. Pharmacotherapy for opioid dependence is
no longer considered a contraindication for treatment of chronic hepatitis
(Kresina et al., 2008).
There are two main goals of treatment:
1. Sustained virological response (SVR), which is defined as persistent
absence of HCV RNA in the serum for more than 6 months after
antiviral treatment
2. Prevention of progression to cirrhosis, HCC, and decompensated
liver disease
Treatment is generally recommended for patients who meet the following
criteria (SAMHSA, 2011):
• Elevated ALT
• Positive HCV antibody and HCV RNA
• Compensated liver disease (no hepatic encephalopathy, no ascites)
• Acceptable hematologic and biochemical indices
• Liver biopsy consistent with chronic hepatitis
• More than 18 year of age
• No contraindications for pegylated interferon (IFN)
The currently recommended treatment regimen of chronic HCV com-
prises two agents: pegylated IFN alfa, given weekly by intramuscular injec-
tions, and ribavirin, given daily by mouth. In May 2011, the U.S. Food and
Drug Administration (FDA) approved two new oral protease inhibitors,
boceprevir and telaprevir, that work in combination with the traditional
treatments. The addition of protease inhibitors to the existing combina-
tion therapy has resulted in improved sustained virological response (SVR)
rates. SVR differs by genotype, and accordingly, randomized controlled
trials have determined optimal duration of treatment based on the viral
genotype as shown in Table 10.1.
Genotype 1 was the dominant prevailing genotype, accounting for almost
three-fourths of all chronic HCV infections. Almost all patients who are
treated with IFN experience one or more adverse events during the course
of treatment. Common adverse side effects of IFN include anemia, flu-like
symptoms, gastrointestinal upset, neutropenia, thrombocytopenia, hair
loss, ophthalmologic disorders, thyroiditis, glucose intolerance, migraines,
and neuropsychiatric syndromes. In the registration trials of IFN and ribavi-
rin, 10% to 14% of patients had to discontinue treatment early because of
adverse side effects (Hadziyannis et al., 2004). The primary cause of treat-
ment failure was due to neuropsychiatric side effects, which include depres-
sion, anxiety, cognitive side effects, and fatigue (Hoofnagle & Seeff, 2006).
10 HEPATITIS C VIRUS, HUMAN IMMUNODEFICIENCY VIRUS, & SUDS 275

Table 10.1 Standard Duration of Treatment Based on the Viral

Genotype
HCV Rate of Sustained Duration of
Genotype Virological Response Treatment
Type 1 47% 48+ weeks
Type 2 or 3 80%–86% 24+ weeks
Type 4 58% 48+ weeks

Barriers to Treatment
It has been estimated that one in six patients with HCV infection does not
receive ongoing health care following the diagnosis of chronic hepatitis C
(SAMHSA, 2011). Barriers to initiating IFN may include provider’s inability
to engage the patient into treatment, social instability, medical comor-
bidities, insufficient access to HCV specialists, and high cost of treatment
(Hatem et al., 2005).
Many of the patients with HCV belong to a high-risk lifestyle group,
which includes high rates of comorbid psychiatric illness, illicit drug use,
intravenous drug use, and alcohol dependence (Dieperink et al., 2000). It
has been argued that psychiatric disorders and SUDs would lead to non-
adherence, ceasing treatment before completion, and poor viral response
(Edlin et al., 2005). Physicians often withhold antiviral therapy until the
patients have maintained abstinence from all substances and alcohol for a
period of at least 6 months and have achieved 3 to 6 months of stabilized
psychiatric symptoms.
To address this issue, many IFN treatment centers require patients to
undergo a psychiatric assessment before initiating treatment. In addition to
determining eligibility for treatment, clinicians can screen for active psychi-
atric symptoms and substance use, and accordingly implement early inter-
ventions or referrals to specialized treatment centers. With appropriate
initiation of psychiatric or dual-diagnosis treatment, patients with psychiat-
ric disorders and SUDs have been found to have adherence rates and SVR
rates comparable to patients who do not use substances or have psychiat-
ric comorbidities (Edlin et al., 2001). Moreover, substance users who are
stabilized on opioid substitution therapy before starting IFN treatment can
also successfully complete the IFN regimen with comparable SVR rates
(Robaeys & Buntinx, 2005).
276 Substance Use Disorders

Human Immunodeficiency Virus

Typically, 12% (6676) of the estimated 56,300 new HIV infections each
year have occurred in IDUs, who presumably were infected as a result
of sharing equipment and needles (Hall et al., 2008). Another 4% of cases
occur among men who have sex with men (MSM) and also inject drugs.
A significant number of infections have occurred in the context of meth-
amphetamine use, which is frequently associated with high-risk sexual
behaviors (Ostrow et al., 2009). Furthermore, substance abuse and addic-
tion are highly prevalent in HIV-infected populations, including those in
whom transmission of HIV is primarily sexual. Noninjection drugs such
as cocaine and alcohol are also associated with HIV risk through unsafe
sexual behaviors as a result of intoxication and disinhibition. Rather than
simple comorbid illnesses, HIV and SUDs are overlapping epidemics that
act synergistically and contribute to adverse outcomes. Clinical consen-
sus has established the importance of treating SUDs in order to produce
optimal psychiatric and medical outcomes for patients with HIV infection
(Lucas, 2011). The patients with the “triple diagnosis” are HIV positive,
have an SUD, and have a co-occurring psychiatric disorder (Douaihy et al.,
2003a). Women, racial and ethnic minorities, and socially and economi-
cally marginalized people are disproportionately affected by the triple
diagnosis. These patients require integrated, interdisciplinary care to
achieve an optimal outcome (Douaihy et al., 2003b).
Scope of the Problem
The relationship among SUDs, psychiatric disorders, and HIV disease is
represented by data regarding HIV risk behaviors of individuals with psy-
chiatric disorders and/or SUDs, HIV seroprevalence studies in psychiatric
and/or substance use treatment settings, clinical samples of patients with
HIV in various treatment settings, and cohort studies of psychopathol-
ogy among homosexual or bisexual men and IDUs with HIV infection.
HIV-positive survey respondents reported use of a wide range of cur-
rent illicit drugs, with opioids featuring prominently. Fifteen percent of
respondents reported using more than one drug class (Korthuis et al.,
2008). Evidence that a co-occurring SUD and psychiatric disorder con-
fer higher risk for HIV infection than either disorder alone is largely indi-
rect. Psychiatric symptoms also increase HIV risk by producing impaired
knowledge, judgment, and interpersonal skills regarding sexual and drug
use behaviors (Douaihy et al., 2003a, 2003b). Impulsivity, hypersexuality,
impaired judgment, reality testing, and cognitive impairment can be all
associated with psychiatric disorders and SUDs and have the potential
to increase the risk for contracting and transmitting HIV (Douaihy et al.,
2003a, 2003b).
An estimated 21% of HIV-infected individuals in the United States are
unaware of their status (Campsmith et al., 2009). In addition, people
with SUDs who are HIV positive remain an active source of new cases
through risky behaviors (Ostrow et al., 2009). Seeking out high-risk
individuals requires significant outreach efforts. As a result, the CDC’s
recent Expanded Testing Initiative resulted in 2.8 million tests and 18,000
people in the United States newly diagnosed with HIV over a 3-year
10 HEPATITIS C VIRUS, HUMAN IMMUNODEFICIENCY VIRUS, & SUDS 277

period. The current goal is to reach populations very much affected by

the epidemic: African Americans, Latinos, gay and bisexual men, and IDUs
(Fenton et al., 2011). A recent study from the National Institute on Drug
Abuse (NIDA Clinical Trials) demonstrated the value of onsite rapid HIV
testing in drug abuse treatment programs in the United States. This multi-
site HIV Rapid Testing and Counseling Study showed that offering onsite
rapid testing substantially increased testing rates and receipt of HIV test
results. Onsite testing was found to be more effective than referrals for
offsite testing—more than 80% of those tested on site received their test
results, compared with only 18% who followed through when they were
referred to another site for testing (Metsch et al., 2012). By offering rapid
HIV testing to patients in substance abuse treatment programs, practitio-
ners can help more individuals to become aware of their status and seek
care and treatment, which helps to reduce the potential for transmitting
the virus to others.
Medical Complications and Comorbidities
The course of HIV illness may be different for patients with SUDs com-
pared with individuals without SUDs. Frequent alcohol intake, as well as
the combination of frequent alcohol and crack cocaine, accelerates HIV
disease progression (Baum et al., 2010). In addition, crack cocaine use
facilitates HIV disease progression by reducing adherence in those on anti-
retroviral therapy (ART) (Baum et al., 2009). Medical complications in this
population include a significant number of infections, including pneumo-
nias, endocarditis, HCV, Mycobacterium tuberculosis, sexually transmitted
infections, and neurosyphilis. HCV is increasingly significant as a comorbid
condition. Approximately 25% to 33% of people infected with HIV are
coinfected with HCV (Mathew & Dore, 2008). HCV affects the clinical
outcome of patients with SUDs and HIV disease. HIV is a risk factor for
accelerating the course of HCV, and HCV can worsen the outcome of
HIV. When untreated, HCV infection progresses more quickly in people
who are coinfected with HIV than in those who are infected with HCV
alone (Mathew & Dore, 2008). Furthermore, comorbid HCV can increase
the side effects of antiretroviral therapy and limits its tolerability.
Integrated Treatment
Patients with coexisting HIV and SUDs are less likely to receive ART, to
have viral load testing, and to adhere to ART, and they are more likely to
experience HIV-related symptoms, to have higher hospitalization rates,
and to have decreased quality of life and die (Korthuis et al., 2008). The
combined research findings from the past two decades affirm that drug
abuse treatment is also HIV prevention. Despite evidence of the benefits
of both HIV and substance abuse treatment—and evidence on the impor-
tance of combining both–barriers to their integration remain (Berg et al.,
2011; Menza et al., 2010).
Among IDUs, ART has also been associated with dramatic reductions
in HIV-related mortality. Initiating ART as soon as possible is warranted,
particularly because most HIV-positive individuals with SUDs have a sig-
nificant medical comorbid condition. Appropriate treatment of SUD and
HIV requires a comprehensive assessment of the disorders, identification
278 Substance Use Disorders

of psychiatric and medical comorbidities, and collaboration with medi-

cal and social services. Effective treatments incorporate pharmacological
interventions combined with psychosocial approaches and case man-
agement services. HIV prevention strategies should be integrated into
treatment. An integrated, interdisciplinary treatment team approach is
most effective; however, services do not necessarily need to be physi-
cally located in one program (“virtual integration”) (Volkow & Montaner,
2011). An example of an integrated treatment model is the use of
buprenorphine-naloxone treatment for HIV-positive opioid-dependent
individuals. Integrated buprenorphine-naloxone and HIV treatment was
successfully introduced to community- and hospital-based clinics under
the direction of infectious disease, psychiatry, and general internal medi-
cine physicians. Potential benefits of integrating buprenorphine-naloxone
into HIV care include simultaneous treatment of medical and substance
use comorbidities; normalization of patient social functioning; removal of
abstinent patients from settings that may trigger relapse; better adherence
to drug treatment and/or HIV clinical care, including ART; lower probabil-
ity of HIV disease progression; and fewer hospitalizations and drug-related
medical problems (e.g., infections). Ongoing challenges included polysub-
stance use and mental health issues among patients; limited adoption of
buprenorphine-naloxone treatment among colleagues; and the necessity
of incorporating new procedures, including urine toxicology testing, into
established practice (Weiss et al., 2011).
10 HEPATITIS C VIRUS, HUMAN IMMUNODEFICIENCY VIRUS, & SUDS 279

Acknowledgment
The preparation of this chapter was supported in part by the National
Institute on Drug Abuse grant #5U10DA020036-08.
280 Substance Use Disorders

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 Chapter 11 283

Co-occurring Disorders
Dennis C. Daley and Antoine Douaihy

Key Points 284

Overview 285
Prevalence and Consequences of Co-occurring Disorders 286
Subtypes of Co-occurring Disorders 287
Theories of Co-occurring Disorders 288
Relationships Between Substance Use Disorders and Psychiatric
Disorders 290
Components of the Assessment 292
Integrated Treatment for Co-occurring Disorders 294
Effects of Co-occurring Disorders on the Family 300
Promoting Recovery 304
Acknowledgment 309
References and Suggested Readings 310
284 Substance Use Disorders

Key Points
• Patients in mental health and addiction treatment systems show high
rates of co-occurring disorders (CODs)—psychiatric disorder (PD)
and substance use disorder (SUD) combined.
• Patients with CODs have higher rates of medical, social, and family
problems, relapse, suicidality, and hospitalization compared with those
with a single disorder.
• The co-occurrence of these disorders compromises treatment
response compared with either disorder alone.
• There are many relationships between these types of disorders. Having
one type increases the odds of having the other type of disorder.
• A thorough assessment reviews multiple dimensions of the substance
use and psychiatric history. This is used to develop treatment goals
and identify services needed to help patients with CODs.
• Integrated treatment refers to a treatment approach that focuses
on both types of disorders concurrently. A range of psychosocial,
pharmacological, and ancillary services (case management, housing
resources, assertive outreach, and vocational rehabilitation) is often
needed.
• Medications for either type of disorder can be effective and
integrated into the treatment plan for CODs. This includes psychiatric
medications for acute symptoms and maintenance treatment and
medications for detoxification from addictive substances, to reduce
alcohol or drug cravings, and as replacement medications for tobacco
or opioid dependence.
• Families and significant others are affected by CODs. Their
involvement in treatment can help the patients as well as family
members. In some cases, family members need help for their own
SUD or PD.
• An important part of treatment is promoting recovery and facilitating
the patient’s involvement in mutual support programs for addiction,
psychiatric illness, or both. Families may also benefit from mutual
support programs.
• Relapse and recurrence are common among patients with CODs.
Learning about early warning signs of relapse, identifying high-risk
relapse situations and coping strategies to manage them, and
helping patients, concerned significant others, and families prepare
to intervene early in an actual lapse/relapse may facilitate positive
outcomes.
 11 CO-OCCURRING DISORDERS 285

Overview
This chapter provides an overview of dual disorders or co-occurring dis-
orders (CODs), which refers to having both a substance use disorder
(SUD) and a psychiatric disorder (PD). We review prevalence and effects
of CODs, identify subgroups of patients with CODs, and discuss the rela-
tionships between the SUDs and PDs. We then discuss assessment and
treatment of CODs, with a focus on some of the key issues or challenges
for professionals providing care to patients with CODs. This review inte-
grates literature from studies of evidenced-based interventions and writ-
ings describing clinical interventions and recovery strategies. We end this
chapter with two brief case histories, each followed by several questions
for you to address in regard to the management of the case.
286 Substance Use Disorders

Prevalence and Consequences

of Co-occurring Disorders
Epidemiologic studies among community samples and clinical studies show
high rates of CODs among patients treated in psychiatric and addiction
treatment systems (Daley & Thase, 2004; Kelly et al., 2012; Nunes et al.,
2010). Rates of CODs are especially high among patients with antisocial
personality disorders (84%), borderline personality disorder (67%), bipolar
disorder (61%), and schizophrenia (nearly 50%). Many patients have mul-
tiple Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) Axis
I and Axis II diagnoses. Rates of lifetime PDs are highest among patients
with polysubstance dependence (about 80%) or drug abuse/dependence
(>50%), although these rates are also high among patients with alcohol
abuse or dependence (nearly 40%). In addiction treatment programs, nearly
half will meet lifetime criteria for another PD (Grant et al., 2004; Ouimette
et al., 1999). Similar high rates of SUD comorbidity will be found in psy-
chiatric settings among patients with more severe types of disorders such
as schizophrenia or bipolar illness (Blanchard, 2000; Swartz et al., 2006).
Patients with CODs have higher rates of medical, social, and family
problems and are more prone to relapse of either or both disorders and
rehospitalization (Mueser et al., 2003). In addition, these disorders create
a burden for families and significant others who are affected by certain
behaviors associated with SUDs or PDs. Clearly patients with CODs pres-
ent many challenges to clinicians and caregivers who provide services.
Make sure all patients in treatment for a PD are screened and/or
evaluated for an SUD, and that all patients in treatment for an SUD are
screened and/or evaluated for a PD. Patients with CODs in ongoing care
should be monitored to determine whether psychiatric or addiction symp-
toms are present and complicating treatment or recovery of the patient.
For example, excessive alcohol use can complicate recovery from a mood
disorder. Or, using cocaine or marijuana can complicate recovery from a
psychotic or borderline personality disorder.
The issue of “which disorder comes first” is often raised—does sub-
stance use or an SUD cause a PD? Does the PD cause the patient to use
substances or develop an SUD? Do both disorders result from other fac-
tors? The two disorders could be independent of each other, or one may
be the primary disorder and the other one secondary. For example, alco-
holism can develop long after a patient has experienced clinical depres-
sion. Or, a patient with drug dependence can develop a psychotic disorder
after the addiction has been present for some time. It is sometimes dif-
ficult to tell which disorder came first, so you may think of some patients
with CODs as having co-primary SUDs and PDs.
 11 CO-OCCURRING DISORDERS 287

Subtypes of Co-occurring Disorders

Patients with CODs show varying degrees of illness and functioning.
A specific patient may show high, medium, or low psychiatric severity, or
high, medium, or low substance use severity (SAMHSA, 2005). Patients
with high levels of both types of disorders are more likely than others
to experience complications in their recovery because each disorder can
adversely affect the other.
Interventions depend on the severity of the CODs as well as the impact
on the functioning of the patients. For example, an unemployed patient
with alcohol dependence, cannabis dependence, and cocaine abuse with
a chronic PD such as recurrent major depression will need a different
treatment plan than an employed patient with a single episode of major
depression evaluated to be moderate who has coexisting alcohol abuse.
You can intervene by determining the most appropriate treatments
needed, then providing psychiatric and medical management as well as
consultation and/or supervision to clinical staff that provide individual,
group, or family therapies. The team approach to care is especially impor-
tant for CODs given the complexity of many cases and the many diagno-
ses and problems that patients have.
288 Substance Use Disorders

Theories of Co-occurring Disorders

Although numerous theories explain comorbidity between PDs and
SUDs, no single theory has overwhelming support. Some of these theo-
ries include secondary psychopathology models explaining the increase in
comorbidity to the effects of substances causing PDs in vulnerable indi-
viduals. Secondary addiction models explain the increased comorbidity
as related to PDs causing SUDs in vulnerable individuals. Common factor
models and bidirectional models involve one or more independent factors
that increase the risk for either disorder (Mueser et al., 2006).
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290 Substance Use Disorders

Relationships Between Substance

Use Disorders and Psychiatric
Disorders
Following is a summary of potential relationship between SUD and PD
symptoms and disorders (Daley & Thase, 2004).
• Patients with an Axis I and/or Axis II PD are at increased risk for
an SUD. For example, compared with a person without a PD, an
individual with a PD is almost three times more likely to have an
SUD according to the National Institute of Health’s Epidemiologic
Catchment Area (ECA) survey.
• Patients with an Axis I SUD are at increased risk for psychiatric illness.
The ECA survey also found that drug abusers are 4.5 times more
likely to have a lifetime psychiatric diagnosis compared with non–drug
abusers.
• Patients with PDs are more vulnerable than others to the adverse
effects of alcohol or other drugs. Even a small amount of marijuana can
contribute to a psychotic episode.
• The use of drugs can precipitate an underlying psychiatric condition.
For example, Bath Salts, PCP, or cocaine use may trigger psychotic
symptoms, suicidality, or disturbances in mood or behavior.
• A PD can affect the course of an SUD in terms of how quickly it
develops, how a patient responds to treatment, relapse, and long-term
outcome. For example, patients with chronic mental disorders often
have a more complicated course of recovery than those with single
episodes of a disorder who do not experience persistent or chronic
symptoms.
• Substances or intoxication can cause specific psychiatric symptoms.
For example, patients addicted to alcohol or sedatives can appear
clinically depressed. A patient can feel suicidal after an episode of
cocaine use. Or, a patient using hallucinogens can experience a
psychotic episode triggered by the effects of this drug.
• Psychiatric symptoms can result from chronic use of substances
or in response to having an addiction. For example, anxiety and
depression are common when an addicted patient first stops
using substances. Depression may also result from a relapse of an
addiction after a period of sobriety or from becoming aware of
losses associated with addiction (loss of job, relationships, financial
stability, or health).
• Substance-using behavior and psychiatric symptoms may become
linked over the course of time, making it difficult to know which came
first. In these cases, you can think of a patient having “co-primary
disorders” because they are so intertwined and it is difficult to
determine which affects the other.
• These disorders can develop at different points in time. For example,
a patient with bipolar illness may become addicted to alcohol or
drugs years after being stable from a mood episode. Or, a patient with
 11 CO-OCCURRING DISORDERS 291

alcohol dependence can develop a panic disorder or major depression

after a period of sobriety.
• Symptoms of a PD can contribute to relapse of an SUD, and substance
use can contribute to a relapse of a PD. For example, an increase in
anxiety or hallucinations may influence a patient with schizophrenia
to use alcohol or another drug use to manage psychotic symptoms.
Or, a cocaine or alcohol binge may lead to depressive symptoms or
suicidality.
292 Substance Use Disorders

Components of the Assessment

The initial assessment involves a combination of the following: psychiat-
ric evaluation, mental status examination, substance use history, physical
examination, laboratory work, urine drug testing, history of prior treat-
ments for either disorder, screening for infectious diseases, and family and
social history. Patient and collateral interviews and review of previous
records should be a part of the assessment process.
Longitudinal and repeated assessments involve monitoring psychiatric
symptoms and substance use. Discussions with family or other behavioral
or medical service providers, completion of rating scales, blood work (for
patients on certain medications), urine drug testing, and breathalyzer tests can
be used to continuously assess the patient. A major challenge is sorting out the
effects of substance use and withdrawal from those of CODs (McKetin et al.,
2010). This requires skills in differential diagnosis formulation and sometimes
using provisional diagnoses. The path of assessment, diagnosis, and treatment
of CODs is not a conventional one, and reassessments throughout treatment
are often needed to reach an accurate diagnosis (Weiss, 2008).
Assessment should also address the patient’s strengths and resiliencies.
All patients have personal strengths that can aid them in recovery. Many
are resilient and have bounced back from relapses or major life problems.
American Psychiatric Association Diagnostic and
Statistical Manual of Mental Disorders Classification
A comprehensive assessment reviews information on all areas of function-
ing of the patient: reason for seeking help and current stressors; current
and past psychiatric symptoms (including suicidality and homicidality); cur-
rent and past substance use; history of treatment and relapse; medical,
family, social, developmental, academic, occupational, legal, and spiritual
history; and mental status examination.
The substance use history includes a detailed review of current and past
substances used (frequency, quantity, methods of use) and effects of such
use on psychiatric symptoms. It reviews DSM-IV-TR symptoms of SUDs
such as loss of control; inability to abstain despite repeated attempts;
obsession or preoccupation with using, getting, or recovering from the
effects of substances; significant increase or decrease in tolerance; with-
drawal symptoms or using to avoid these symptoms; continued substance
use despite problems; and impairment caused by substance use.
Clinical diagnoses are formulated based on criteria set forth by the
DSM-IV-TR. The DSM-IV-TR provides a comprehensive approach to
assessment of the patient, which is recorded on five axes.
American Society on Addiction Medicine Framework
Clinical interviews can review the American Society of Addition Medicine
(ASAM) criteria below and may use the Addiction Severity Index or other
interview formats, as well as pen-and-pencil questionnaires such as the
Michigan Alcoholism Screen Test (MAST), the Drug Abuse Screening
Test (DAST), or the Dartmouth Assessment of Lifestyle Inventory
(DALI), which is one of the only questionnaires designed for patients
with CODs (note: the DALI mainly addresses alcohol and marijuana use).
 11 CO-OCCURRING DISORDERS 293

Breathalyzers, urine and blood tests, liver function studies and a physical
examination can also aid the assessment process.
ASAM delineates the following six dimensions of functioning to assess
the level of care needed for the patient:
• Acute intoxication and withdrawal potential. Determine whether the patient
needs medical detoxification before initiating another type of treatment.
An important issue is insuring that the patient is linked into continued
treatment and/or mutual support programs following detoxification.
• Biomedical conditions and complications. Determine the level of medical
management required for the patient with acute or chronic medical
problems. Many psychiatric and addictive disorders are associated
with an increase in risk for medical disorders that require medical
management.
• Emotional, behavioral, or cognitive conditions and complications.
Determine whether the patient has a co-occurring psychiatric illness
or other significant symptoms requiring treatment, and whether
treatment in a mental health system is needed for recurrent or
persistent forms of mental disorders.
• Readiness to change. Determine the patient’s level of motivation to
change and the degree to which treatment recommendations are
accepted or resisted. Does the patient accept the PD? The SUD?
Treatment recommendations?
• Relapse, continued use, or continued problem potential. Determine
whether the patient is aware of relapse triggers and has a plan, or
needs to stabilize from a recent relapse. This dimension also aims to
assess whether the patient is suicidal or has psychiatric problems that
may impede his or her ability to engage in treatment.
• Recovery and living environment. Determine whether other people,
school, work, child care, or transportation problems are a barrier to
the patient’s ability to engage in treatment. Assess the degree to which
the patient has a support system that can aid recovery.
The assessment findings are used to recommend a level of care: outpa-
tient, intensive outpatient, partial hospital, medically monitored inpatient
detoxification, short-term residential, long-term residential, or medically
managed inpatient detoxification or residential care. Patients may be
referred to a dual diagnosis (COD) “capable” or “enhanced” program.
Dual diagnosis capable programs are offered in an addiction treatment sys-
tem to treat less severely psychiatrically ill patients. They focus primarily
on treatment of the SUD among patients whose PDs are stable. Dual diag-
nosis enhanced programs are likely to be part of a mental health system
of care. These programs care for patients with more unstable or disabling
PDs such as chronic or recurrent disorders in addition to the SUD.
294 Substance Use Disorders

Integrated Treatment for

Co-occurring Disorders
Integrated treatment focuses on both types of disorders and should
be used when treating a patient with CODs (Horsfall, 2009; Weiss &
Connery, 2011). Parallel or sequential treatment approaches proved inef-
fective (Mueser et al., 2003). Although the patient may use a specific form
of treatment at times (i.e., an addiction rehabilitation program to initiate
abstinence and set the foundation of recovery; a brief psychiatric hos-
pital stay to stabilize severe psychotic or mood symptoms), integrated
treatment focuses on both psychiatric and substance use issues. This
dual focus reduces the chances that an untreated disorder will increase
vulnerability to relapse of another disorder. And, when the same team
provides integrated care, the rates of retention in treatment increase as
well as positive outcomes, such as rates of 6-month periods of remission,
increases in work and social contacts, independent living, life satisfaction,
and decreases in hospitalization and incarcerations (Xie et al., 2010).
Evidence suggests that patients receiving integrated treatment have
higher rates of treatment adherence and improved clinical outcomes
compared with those receiving parallel or sequential treatment, particu-
larly patients with more persistent and chronic forms of mental illness.
However, it is not uncommon in some instances for patients treated in a
mental health setting to receive care that has little focus on the substance
use component of the CODs.
Psychosocial Treatments
Many effective treatments exist for SUDs, PDs, and CODs. Some inte-
grated approaches help patients with any combination of disorders,
whereas others are geared toward specific types of psychiatric illness (e.g.,
bipolar disorder, post-traumatic stress disorder, schizophrenia). Although
goals depend on the specific patient and the diagnoses, following is a list
of potential goals of psychosocial treatments:
• Achievement and maintenance of abstinence from alcohol or other
drugs of abuse: for patients unable or unwilling to work toward total
abstinence, a reduction of the amount and frequency of substance
use and/or the concomitant biopsychosocial sequelae associated with
their SUD
• Stabilization from acute psychiatric symptoms
• Resolution or reduction of psychiatric symptoms and problems,
especially for patients with more chronic or recurrent types of PDs
• Learning to manage persistent symptoms of chronic psychiatric illness
• Improved cognitive, behavioral, and interpersonal coping skills
• Improvement in functioning: physical, emotional, social, family,
interpersonal, occupational, academic, spiritual, financial, and legal
• Positive lifestyle change and improvement in the quality of life
• Early intervention in the process of relapse of either the SUD or PD
 11 CO-OCCURRING DISORDERS 295

Role of Medications in Treating Co-occurring

Disorders
Combined behavioral and psychopharmacological treatments are needed
for many patients with CODs for optimal outcome. When selecting and
using pharmacotherapy for co-occurring SUD and PD, clinicians should
consider the following: unwanted synergy between prescribed medica-
tions and abused substance (e.g., benzodiazepines and alcohol); drug–drug
interactions affecting the efficacy of psychiatric treatment; nonadherence
due to intoxication, withdrawal states, or other reasons; drug-seeking
behavior; intentional or unintentional overdose; and the abuse potential
of medications (Brady, 2008).
Psychiatric Disorders
Data from controlled trials that inform pharmacological treatment of
co-occurring mood disorders and SUDs have been relatively scarce. The
results from these trials of antidepressants, such as tricyclic antidepres-
sants (TCAs) and selective serotonin reuptake inhibitors (SSRIs), showed
a modest beneficial effect of antidepressants on depressive symptoms
(Nunes & Levin, 2004). Importantly, there was no direct impact of antide-
pressant treatment on alcohol consumption, but in those studies in which
the medication had a positive effect on the treatment of depression, a
significant reduction in alcohol use also occurred (Nunes & Levin, 2004).
Overall, the current recommendation is that alcohol and drug abuse not
be considered a barrier to the treatment of depression. Few controlled
trials have investigated treatment for co-occurring SUDs and anxiety dis-
orders. Because there are limited data, the best approach may be to treat
with medications known to be effective for the specific anxiety disorder
while being mindful of contraindications to the use of these agents in indi-
viduals with alcohol dependence.
Treatment considerations for individuals with alcohol and drug depen-
dence and concurrent mood and/or anxiety disorders should include
safety, toxicity, and abuse liability. Low adherence to medications is a fre-
quent cause of recurrence of major PDs and is also a problem in addiction
treatment.
Some studies suggest that some second-generation antipsychotics may
be effective for comorbid SUD in schizophrenia, particularly clozapine and
nicotine dependence. Most important is providing integrated treatment
using behavioral and pharmacological interventions for co-occurring SUD
and schizophrenia because lack of adequate treatment of one of the disor-
ders interferes with recovery (Volkow, 2009).
Medication Adherence
In addition to discussion with patients the purposes of medications you
prescribe, address past adherence problems or potential adherence
problems. This can prepare the patient to take action before a decision is
made to reduce or stop medications without consulting you or another
caregiver. Following are factors that could contribute to poor adherence
medications that you may review with patients:
• Uncomfortable side effects
• Unrealistic expectations of the purpose and efficacy of medicine
296 Substance Use Disorders

• Lack of adequate response to treatment

• Complicated medication regimens
• Negative interactions with alcohol or illicit drugs
• Low motivation to change
• Negative attitudes of patients regarding treatment
• Severity of illness
• Poor judgment
• In the case of substance abuse, the desire to use substances again
Poor medication adherence increases the risk for relapse of the SUD,
PD, or both, and may contribute to rehospitalization. Among patients
with CODs, poor adherence to the medication regimen is associated with
resumption of substance use as well as other problems in functioning.
Numerous studies of psychiatric rehospitalization show that patients who
are readmitted, including high utilizers with multiple admissions, are sig-
nificantly more likely to be noncompliant with psychotropic medications
and significantly more likely to abuse alcohol or drugs. Thus, medication
adherence is an important area in clinical care because research evidence
shows a strong association between poor adherence and negative clinical
outcome. Patients who are poorly compliant with medications are often
poorly compliant with outpatient treatment sessions.
Strategies to Help Patients with Co-Occurring
Disorders
You can help patients with CODs in your direct work with patients, or in
your collaboration with clinicians who provide individual, group, or family
therapies; case management; or other ancillary services. Specific ways to
help include the following:
• Convey helpful attitudes. We have consulted with numerous
professionals about their frustration and negative attitudes in dealing
with psychiatrically ill patients who have SUDs. Anger, frustration, and
judgmentalism are common. Such negative reactions and feelings must
be contained. To be effective you must understand and accept patients
with CODs as being ill, and covey genuine concern and empathy in
your interactions.
• Understand illness from the “inside out.” Try to understand what it is like
to be dependent on substances, or to want to use alcohol or drugs
so badly that you are willing to risk losing your family, job, or health.
Think about what it feels like to have a PD and how this affects your
self-image, ability to function, or your vision of the future. What if you
were a highly successful professional, then deteriorated and lost your
job because of a manic episode? What would this feel like and how
would this affect your life?
• Educate the patient. Provide information about the disorders
(symptoms, etiology, effects, how each disorder affects the other),
treatment options, and recovery. Encourage patients to raise questions
to you during their doctor visits.
• Motivate the patient. Many disorders lower the patients’ motivation
to change or affect their judgment, which may lead to patients being
unaware of their disorder. Use motivational strategies to help patients
engage and remain in treatment and strengthen motivation for change.
 11 CO-OCCURRING DISORDERS 297

• If possible, include the patient’s family and/or significant other. Families

and children are often emotionally hurt by CODs. Helping the patient
examine the impact of the disorders on the family, eliciting support
from the family, and providing or facilitating education, support, and
therapy to the family are some of the ways in which families can be
helped. There will be cases in which individual family members may
need help for a psychiatric illness, an addiction, or both. You (and your
team) can help by providing or facilitating an assessment for the family
member in need.
• Provide integrated assessment and treatment services. As stated
before, integrated treatment services focus on both substance use
and psychiatric issues, acknowledging that each affects the other.
Psychosocial, medication, or combined treatments are needed by many
patients with CODs.
• Integrate evidenced-based interventions into clinical care. Many studies
show the efficacy of various treatments for psychiatric illness,
addiction, or CODs. In your role as a physician, you can help clinicians
become familiar with and integrate these interventions into their work
with patients.
• Facilitate linkages between levels of care. Patients who fail to engage in
the next level of care following completion of another level are at risk
for relapse. For example, psychiatric inpatients who enter ambulatory
care and adhere to an adequate dose of treatment are less likely to
be rehospitalized than those who fail to continue care after hospital
discharge. Patients readmitted to a detox unit, inpatient psychiatric
unit, residential program, or day program should be prepared for
the next level of care. You (and your team) can use motivational
strategies, case managers, or other strategies to increase the likelihood
that these patients will continue their treatment.
• Focus on adherence issues. Patients benefit from treatment to the
extent that they remain in it for a sufficient period of time. No
short-term treatments exist for CODs, particularly for patients who
have more serious and persistent forms of mental illness. There are
many systems and clinical-related strategies that improve adherence.
You (and your team) can routinely discuss adherence problems and
issues with patients (e.g., reasons for failure to show for sessions
or take medications as prescribed). Barriers to adherence can be
identified, and strategies to work through these can be discussed. Try
to help patients learn from their past mistakes such as poor adherence
to treatment.
• Promote recovery from CODs. Educate your patients about mutual
support programs and ensure that they are linked with specific
programs when appropriate. Mutual support programs recommended
may include Alcoholics Anonymous (AA), Narcotics Anonymous
(NA), Cocaine Anonymous (CA), and other addiction support groups,
such as Rational Recovery, SMART Recovery, Women for Sobriety,
Dual Recovery Anonymous, Double Trouble, and other dual recovery
support groups along with mental health support groups. Sponsorship,
literature, slogans, and recovery clubs are helpful in recovery. Do
298 Substance Use Disorders

not assume that a patient cannot recover without involvement in a

12-step group or that failure to attend 12-step programs is a sign of
“resistance.” Patients may use “tools” of programs even if programs
are not attended. However, we strongly encourage all patients to be
educated about mutual support programs and encouraged to attend.
• Focus on relapse issues. Many patients with psychiatric and addictive
disorders relapse of either or both disorder. As discussed in the
chapter on relapse in this book, helpful interventions include
identifying and managing warning sign of relapse; identifying and
managing high-risk factors; developing a recovery support system; and
being prepared to take action if a relapse of either disorder occurs.
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300 Substance Use Disorders

Effects of Co-occurring Disorders on

the Family
The family unit and individual family members and significant others are
affected by CODs. The family system is often disrupted, and communica-
tion, interactions, emotional health, and financial condition of the family
can be harmed. With good intentions, the family may show “enabling”
behaviors that help perpetuate the patient’s problems. Enabling may be
“passive” when the family does nothing and accepts problematic behaviors
related to the substance use or PD of the ill member. Or, enabling may
be “active” when the family covers up problems caused by this member.
Sometimes, this involves bailing the ill member out of legal, financial, or
other types of trouble, or assuming her responsibilities.
CODs can take an emotional toll on parents, spouses, children, siblings,
and other relatives. Stress can be high as a result of exposure to psychi-
atric symptoms or intoxicated, violent, erratic, or unpredictable behav-
iors. Family members may feel upset, angry, confused, anxious, worried,
or depressed. Some family members, especially parents, feel guilty and
responsible for causing the ill member’s problems.
Children are affected by CODs and may have emotional, behavioral,
academic, or substance abuse problems as a direct or indirect result of
exposure to a parent’s disorders. They can benefit from education, sup-
port, and having an opportunity to share their worries, feelings, and con-
cerns. Children with serious problems need treatment.

Benefits of Family Involvement

Family participation is beneficial in many ways. Involving the family can help
you and the treatment team gather more information about the family’s
experience with the patient. You will also get a sense of the strengths (and
deficits) of the family members, which will enable you to assess how they
relate to the member with COD and their ability to support recovery.
Family sessions also provide clinical staff with a perspective on how the
family communicates and gets along. They often benefit from information,
support, and help dealing with their own feelings and reactions to the
member with the COD. Also, you or the treatment team may determine
whether a specific family member may need an evaluation for a PD or
SUD. Although it is not the role of a physician to be a family therapist,
even brief interactions with the family can help with assessment and treat-
ment. This can also be beneficial to the family.

Typical Concerns of Family Members

Awareness of questions and concerns of family members can aid the
counselor in working with the family. These questions and concerns often
include the following (Daley & Thase, 2004):
• Specific DSM diagnoses and the implications of these for the patient.
• Causes of CODs and how SUDs and PDs interact and affect one
another
• Types of treatment available for CODs (psychosocial treatment and
programs, medications, and other), length of treatment, expected
outcome, and cost
 11 CO-OCCURRING DISORDERS 301

• Medications for either disorder, side effects, and interactions with

alcohol, street drugs, or nonprescribed drugs
• The role of the family in supporting the ill member’s recovery
• How treatment can help the family deal with their needs, problems,
and concerns
• How the family can deal with some of the complications of CODS
such as violence or the threat of it, suicidal action or the threat of it,
more severe symptoms of the disorders, or relapse
• Whether other family members are vulnerable to psychiatric illness,
substance abuse, or both, especially offspring
• Whether the ill family member will be able to function at a job, school,
or home
• How to deal with emotional reactions toward the member with the
CODs (e.g., anger, disappointment, worry, guilt)
• When detoxification or psychiatric hospitalization are needed
Types of Family Treatment
There are a variety of family treatments that can be used, depending
on the patient’s situation and the availability of services in a program.
Unfortunately, family services are often lacking in many treatment pro-
grams. Family services may include the following:
• Psychoeducational programs that provide information on CODs
and recovery and on ways the family can cope with their concerns
regarding the ill family member. These are offered to several families
and can be held regularly, such as once a week, or on a periodic basis,
such as monthly or bimonthly. Psychoeducational programs can last
several hours, a half-day, or a full day.
• Family therapy in which issues and problems within a specific family
are explored from a family systems perspective
• Couples therapy in which specific problems of an adult couple are
explored
• Multiple family groups that combine PE, support, and discussion of
mutual problems and concerns of families
• Exposure to family support groups for addiction such as Al-Anon,
Nar-Anon, Alateen, Alatots, Parents Groups, or Co-Dependency
Anonymous
• Exposure to family support groups for mental illness such as National
Alliance of the Mentally Ill (NAMI) groups
Some patients are disengaged from their families and have no one whom
they can involve in treatment. Families may refuse to get involved in treat-
ment, especially those who feel tired or burned out. Family members with
serious illnesses themselves (PD or SUD) may be unable or refuse to
engage in treatment.
Family resistance to treatment or patient resistance to family involve-
ment in treatment should not be taken at face value. There are effective
strategies for engaging the family in treatment. Patience, persistence, and
creativity are often needed on the part of the clinician.
302 Substance Use Disorders

Principles and Strategies for Helping Families

As we stated earlier, you do not have to be a family therapist to help a
family. The following principles and strategies may help guide your interac-
tions with families:
• Do not label the family as “sick, dysfunctional, or codependent.” View
them as allies in the treatment process who may have their own issues
or needs.
• Talk with your patients about the impact of CODs on the family and
the importance of their involvement in their care (when appropriate).
• Have members of the treatment team establish contact with the family
as early as possible in the assessment and treatment processes.
• View the engagement process as important. If a family cannot
be engaged in treatment, the best treatment available will not
benefit them.
• Be patient and flexible with families. Encourage staff to use outreach
phone calls and ask families for help in working with the patient. Do
not rely on the patient to invite the family to sessions because the
patient may sabotage the chances of the family showing up.
• Ensure that you, your program, and/or program staff are accessible to
families. Offer evening appointments if convenient. Family groups can
be held on weekends. Be available by telephone as needed.
• Focus on family strengths. Do not emphasize family deficits or
problems at the expense of overlooking their strengths.
• Provide a framework for the family to understand what is happening
to the patient and family system. Educating the family about SUDs and
PDs, the course of illness, and recovery is an excellent way to provide
this framework. Use the no-fault, biopsychosocial model of illness.
• Connect emotionally with the family by letting them know you
understand their feelings, concerns, and worries. Give them an
opportunity to express their feelings. This will make it easier to help
them explore how to cope with these feelings and adapt to the ill
member’s recovery.
• Provide hope by discussing how treatment for CODs benefits patients
and their families.
• Provide a realistic view of treatment and recovery. Prepare the family
for the possibility of setbacks and relapses. If relevant, discuss issues
around involuntary commitment in cases when the ill member is at risk
for suicide or homicide, or if functioning has decompensated severely
and the patient is unable to take care of basic needs.
• You or clinical staff can link the family with family support groups in
the community or other resources that may help them or the member
with the CODs (e.g., social services agencies, housing agencies).
• If the patient has children, educate the family about the impact of
CODs on their children. Encourage the parents to talk with their
children about the disorders and how they have experienced these.
Parents can elicit thoughts, feelings, and questions from their children.
If a child is abusing substances or appears to have a serious mental
health problem, help the parents arrange for an evaluation of this child.
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304 Substance Use Disorders

Promoting Recovery
Recovery is the process of managing the CODs over time. It involves
making changes in self and/or lifestyle in order to improve functioning
and the quality of life. Recovery is facilitated by the use of mutual support
programs such as AA, NA, Dual Recovery Anonymous (DRA), and other
mental health programs. You can educate patients and families about
recovery, promote engagement in mutual support programs, and encour-
age other clinical staff to do this as well.

Continuing Care
Continuing care helps the patient maintain gains made during inpatient
care, prevent relapse of substance abuse or a recurrence of psychiatric
illness, or intervene early in the relapse process. Participation is associ-
ated with better alcohol and drug use outcomes, improved psychiatric
outcomes, improvement in functioning, lower relapse rates, and lower
readmission rates. Despite the importance of and positive outcome
associated with adherence to continuing care, numerous studies report
serious problems in entering aftercare following completion of inpatient
care. Poor adherence to aftercare is common across a range of SUDs and
CODs and contributes to clinical deterioration, which causes or exacer-
bates medical or psychosocial problems and contributes to the need for
hospitalization.

Preparing Inpatients for Continuing Care

Preparing inpatients with CODs for continuing care before hospital
discharge increases entry rates in ambulatory programs. We found
that a brief, motivational therapy session provided by an outpatient
clinician before hospital discharge almost doubled the initial aftercare
entry rates. Another group of researchers also found that a single
motivational session provided to inpatients before discharge more
than doubled aftercare entry rates. You can talk with patients about
the importance of follow-up care and work with other clinical staff to
address past problems with adherence. Motivational strategies often
improve adherence rates.
Relapse Prevention
Relapse prevention (RP) was initially developed for alcohol and drug
addictions, then expanded for use with other addictive or compulsive
disorders, PDs, and CODs as researchers and clinicians recognized that
relapse (or recurrence) was a significant issue facing patients with any type
of SUD or PD. Most evidenced-based practices incorporate RP strate-
gies. The overall goal is to help patients learn specific skills that they can
use to manage their illnesses or disorders and to improve the quality of
their lives. These skills include, but are not limited to, the following (for
more extensive reviews of RP, see Daley, 2003; Daley & Douaihy, 2010;
 11 CO-OCCURRING DISORDERS 305

Fox et al., 2010; Gingerich & Mueser, 2011; Kupfer et al., 1992; Marlatt &
Donovan, 2005; Marlatt & Gordon, 1985):
• Monitoring and coping with psychiatric symptoms (e.g., mood, anxiety,
psychotic, behavioral, other) or symptoms of their addiction (e.g.,
substance cravings or social pressures to use substances)
• Following a plan of change in which symptoms and behaviors are
monitored, structure is implemented in daily life, and goals are
identified and pursued (with steps to achieve these goals)
• Identifying and developing strategies to manage personal high-risk
factors that could affect relapse or recurrence (e.g., symptoms of an
illness, feelings or emotions, thinking, relationships, support systems)
• Identifying and developing strategies to manage early signs of relapse
of the SUD or PD (e.g., changes in attitudes, behaviors and feelings,
or emotions). Some warning signs are common across many disorders
such as reducing or stopping treatment sessions, attendance at mutual
support programs, or medications. Other signs are unique to the
individual patient and based on the patient’s specific disorders and
coping skills.
• Using a support network to aid ongoing recovery. This may include
peers in recovery, mutual support programs, other community
resources and others whom the patient trusts and feels supported by.
Some patients need help learning to reach out for help and support
from others.
• Making lifestyle changes that improve the quality of life. Such changes
may reduce the need for a patient to use substances. Patients with
meaningful relationships and activities and important connections with
others may feel less vulnerable to negative feelings or moods that can
contribute to relapse.
• Having a plan to intervene if there is a setback, regardless of whether
the setback is minor or major. If the setback is a major one leading to
psychiatric hospitalization or detoxification in a hospital, you can help
the patient learn from the recent relapse.
Case Vignettes
Following are two brief cases with some questions to think about regard-
ing your potential role in treatment. After reading each case, think about
how you would answer the questions that follow.
306 Substance Use Disorders

Case Vignette 1
Michael is a 34-year-old married, employed father of two children,
ages 13 and 9 years, who was involuntarily committed to a psychiatric
hospital following a manic episode in which he became irrational and
threatened to kick his wife and children out of their home, insisted he
was going to take over a business in another state, and quit going to
work. He started drinking after 2 years of sobriety, and was arrested
for trying to solicit teenagers to have sex with him. The police initi-
ated an involuntary commitment when it was clear that Michael was
out of touch with reality and a threat to others. After his mood and
behavior stabilized during his hospitalization, Michael realized the seri-
ousness of his condition and the impact on his behavior and agreed to
continue outpatient treatment. He recognized that his bipolar illness
contributed to an alcohol relapse and agreed that he needed to abstain
from alcohol. During inpatient treatment, he and his wife attended
several multi-family group sessions to gain information about dual dis-
orders and the impact on families and to discuss recovery strategies.
He also had sessions with his wife and children with his doctor and
social worker to discuss the impact of his behaviors on his wife and
kids, their feelings and reactions, and ongoing recovery strategies for
Michael and his family. His wife was encouraged to resume Al-Anon
participation because this had been helpful to her in the past. Michael
and his family were also advised to attend some of his follow-up out-
patient sessions together.
• What do you think the goals of an inpatient hospitalization would
be for Michael or someone like him who has both a psychiatric and
addiction relapse?
• How would you help Michael and his family learn from his relapse
of both of his disorders? How would you address relapse of each
disorder?
• How could you and your team help Michael’s wife and children in a
case like this, which led to a psychiatric hospitalization?
• Which types of mutual support programs might be of help to
Michael or his family?
Answers to Case Vignette 1
What do you think the goals of an inpatient hospitalization would be for
Michael or someone like him who has both a psychiatric and addiction
relapse?
The main goals are to stabilize his psychiatric illness through the use of
appropriate medication regimen (in Michael’s case, a mood stabilizer)
and supportive and psychoeducational approaches and also to address
his drinking through detoxification treatment. After he is stable psychi-
atrically and medically, the goals would be to help Michael start working
on dual recovery that incorporates adherence to medication, staying
sober, and getting involved in treatment, including therapy and mutual
support programs.
 11 CO-OCCURRING DISORDERS 307

How would you help Michael and his family learn from his relapse of both of
his disorders? How would you address relapse of each disorder? What would
you want Michael and his family to learn from his relapse?
Through engagement in treatment focusing on dual recovery and
the integration of treatment of both conditions, psychoeducational
approaches focus on helping Michael and his family better understand
how the co-occurrence of his bipolar disorder and alcohol abuse
worsens the course of both illnesses and compromises treatment
response compared with either disorder alone. Michael needs to be
involved in a dual recovery treatment program to work on prevent-
ing relapse of both disorders and empowering him within a broad
perspective by helping him self-manage his symptoms. Involvement
of his family members in his treatment sessions can help them bet-
ter understand early warning signs of relapse, such as not taking his
medications; not attending his therapy sessions; changes in his behav-
iors and attitudes; difficulty coping with stressful situations, conflicts,
and negative emotional states; and fluctuations of his motivation for
change and treatment.
How could you and your team help Michael’s wife and children in a case like
this, which led to a psychiatric hospitalization?
Educating and involving the family in his care is very important as a
way to promote understanding of the symptoms and effects of his PD
(bipolar disorder), drinking problem, and the medications used in his
treatment. Involvement of the family can help them to cope better
with his illness.
Which types of mutual support programs might be of help to Michael or
his family?
Involvement in DRA or Double Trouble in Recovery (DTR),
designed for people with CODs, can help with greater acceptance
and understanding than may be encountered in traditional 12-step
programs. Participation in these groups can help promote recov-
ery through medication adherence, sobriety, and better quality of
life. Involvement of his family in Al-Anon and other organizations
such as NAMI can help by providing support and resources in the
community.

Case Vignette 2
John is a 28-year-old employed, married man with a history of problems
with alcohol and drugs, and with depression beginning during his ado-
lescence. His alcohol and drug use worsened considerably last year, so
he entered a rehabilitation program, attended outpatient therapy for
6 months, and joined AA following completion of the residential pro-
gram. After being sober for more than a year, John became depressed
and sought outpatient help because he was worried about relapsing to
alcohol use. He benefited from an 8-month trial of medications but is
now medication free. He initially attended therapy sessions weekly but
308 Substance Use Disorders

now comes once each month. In treatment, once his mood was stabi-
lized, John focused on coming to grips with his negative feelings toward
his parents, especially his father. John also addressed what he called
his “self-centeredness” after his wife became pregnant, and he became
aware of feeling deeply jealous and worried about not being the focus
of her attention. His initial negative feelings about fatherhood made him
realize that he had to address some of his personality issues that he
avoided because of his previous perception that he had no serious flaws
to change. John also realized that he had to be more responsible finan-
cially and began looking at ways to handle money better now that he
was going to have a child to support. He grew up in a wealthy family
and developed very poor money management habits over the years.
John has gradually learned to focus less on himself and more on his
pregnant wife.
• If you were part of John’s outpatient treatment team, what would
you suggest for his treatment plan?
• Should his wife attend some sessions with him? Why or why not?
• What would you want to know about his participation in AA other
than that he is attending meetings?
Answers to Case Vignette 2
If you were part of John’s outpatient treatment team, what would you sug-
gest for his treatment plan?
Adherence to therapy addressing his depression and dual recovery
issues and continued involvement in AA.
Should his wife attend some sessions with him? Why or why not?
Involvement of his wife in some of his treatment sessions would allow
her to share her perspective on his struggles and how she could be
helpful in his recovery work and also would give him the opportunity to
be open with her about his issues and share his progress in treatment.
What would you want to know about his participation in AA other than that
he is attending meetings?
Is he participating in the meetings? Is he working the steps of AA? Is he
involved in the fellowship program? Does his have a sponsor, and if so,
how is his relationship with his sponsor?
 11 CO-OCCURRING DISORDERS 309

Acknowledgment
The preparation of this chapter was supported in part by the National
Institute on Drug Abuse grant #5U10DA020036-08.
310 Substance Use Disorders

References and Suggested Readings

American Psychiatric Association. (APA, 2000). Diagnostic and statistical manual of mental disroders
(rev. ed.). Washington, DC: APA.
Blanchard, J. J. (2000). The co-occurrence of substance use in other mental disorders: editor’s
introduction. Clinical Psychology Review, 20, 145–148.
Brady, K. T. (2008). Evidence-based pharmacotherapy for mood and anxiety disorders with concur-
rent alcoholism. CNS Spectrum, 13(Suppl 6), 7–9.
Daley, D. C., & Thase, M. E. (2004). Dual disorders recovery counseling: Integrated treatment for sub-
stance use and mental health disorders (3rd ed.). Independence, MO: Independence.
Daley, D. C. (2003). Preventing relapse. Center City, MN: Hazelden.
Daley, D. C., & Douaihy, A. (2010). Recovery and relapse prevention for co-occurring disorders. Export
PA: Daley.
Fox, L., Drake, R. E., Mueser, K. T., et al. (2010). Integrated dual disorders treatment: Best practices,
skills, and resources for successful client care. Center City, MN: Hazelden.
Gingerich, S., & Mueser, K. T. (2011). Illness management and recovery: Personalized skills and strate-
gies for those with mental illness. Center City, MN: Hazelden.
Grant, B. F., Dawson, D. A., Stinson, F. S., Chou, S. P., Dufour, M. C., & Pickering, R. P. (2004).
The 12-month prevalence and trends in DSM-IV alcohol abuse and dependence: United States,
1991–1992 and 2001–2002. Drug and Alcohol Dependence, 74, 223–234.
Horsfall, J., Cleary, M., Hunt, G. E., & Walter, G. (2009). Psychosocial treatments for people with
co-occurring severe mental illnesses and substance use disorders (dual diagnosis): A review of
empirical evidence. Harvard Review of Psychiatry, 17, 24–34.
Kelly, T. M., Daley, D. C., & Douaihy, A. B. (2012). Treatment of substance abusing patients with
comorbid psychiatric disorders. Addictive Behaviors, 37, 11–24.
Kupfer, D. J., Frank, E., Perel, J. M., Cornes, C., Mallinger, A. G., Thase, M. E., McEachran, A. B., &
Grochocinski, V. J. (1992). Five-year outcome for maintenance therapies in recurrent depres-
sion. Archives of General Psychiatry, 49, 769–773.
Marlatt G. A., & Donovan D. M. (2005). Relapse prevention: A self-control strategy for the maintenance
of behavior change (2nd ed.). New York: Guilford.
Marlatt, G. A., & Gordon, J. R. (Eds.) (1985). Relapse prevention: Maintenance strategies in the treat-
ment of addictive behaviors. New York: Guilford.
McKetin, R., Hickey, K., Devlin, K., & Lawrence, K. (2010). The risk of psychotic symptoms associ-
ated with recreational methamphetamine use. Drug and Alcohol Review, 29, 358–363.
Mueser, K. T., Drake, R. E., Turner, W., & McGovern, M. (2006). Comorbid substance use disorders
and psychiatric disorders. In W. R. Miller & K. M. Carroll (Eds.), Rethinking substance abuse: What
the science shows, and what we should do about it (pp. 115–133). New York: Guilford.
Mueser, K. T., Noordsy, D. L., Drake, R. E., & Fox, L. (2003). Integrated treatment for dual disor-
ders: A guide to effective practice. New York: Guilford.
Nunes, E. V., Ball, S., Booth, R., Brigham, G., Calsyn, D. A., Carroll, K., Feaster, D. J., Hien, D.,
Hubbard, R. L., Ling, W., Petry, N. M., Rotrosen, J., Selzer, J., Stitzer, M., Tross, S., Wakim, P.,
Winhusen, T., & Woody, G. (2010). Multisite effectiveness trials of treatments for substance
abuse and co-occurring problems: Have we chosen the best designs? Journal of Substance Abuse
Treatment, 38(Suppl 1), S97–112.
Nunes, E. V., & Levin, F. R. (2004). Treatment of depression in patients with alcohol or other drug
dependence: A meta-analysis. Journal of the American Medical Association, 291(15), 1887–1896.
Ouimette, P. C., Gima, K., Moos, R. H., & Finney, J. W. (1999). A comparative evaluation of substance
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Substance Abuse Treatment Group (SAMHSA). (2005). Substance abuse treatment: Group therapy.
TIP 42 (BKD515). Rockville, MD: SAMHSA.
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Substance use and psychosocial functioning in schizophrenia among new enrollees in the NIMH
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Volkow, N. D. (2009). Substance use disorders in schizophrenia—clinical implications of comorbid-
ity. Schizophrenia Bulletin, 35, 469–472.
Weiss, R. D. (2008). Identifying and diagnosing co-occurring disorders. CNS Spectrum, 13(Suppl 6), 4–6.
Weiss, R. D., & Connery, H. S. (2011). Integrated group therapy for bipolar disorder and substance
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Xie, H., Drake, R. E., McHugo, G. J., Xie, L., & Mohandas, A. (2010). The 10-year course of remission,
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 Chapter 12 311

Adolescent Substance
Use Disorders
Duncan B. Clark

Key Points 312

Rates and Risks 313
Risk Factors 314
Screening 315
Assessment 316
Diagnosis 318
Treatment 320
Motivational Enhancement Therapy 322
Cognitive and Behavioral Interventions 324
Pharmacotherapy 328
Treatment Outcomes 332
Conclusions 334
References and Suggested Readings 336
312 Substance Use Disorders

Key Points
• Experimentation with tobacco, alcohol, and marijuana is common in
adolescents.
• Risk factors for substance use disorder (SUD) include parental and
peer substance use, substance availability, and mental disorders
including attention deficit hyperactivity disorder, conduct disorder, and
mood disorders.
• Before the assessment, confidentiality issues need to be addressed
with the adolescent and parents.
• A thorough assessment includes distinct assessments of use of
tobacco, alcohol, cannabis, and other drugs, including patterns of use
and problems contributing to diagnoses.
• Because adolescents with SUD may be required to participate in
treatment by parents or other authority figures, treatment initiation
often focuses on motivational enhancement.
• Psychosocial interventions are the primary treatments, including
cognitive behavior therapy and family therapy. Substance abstinence is
the primary goal.
• Frequent marijuana use may cause academic deficits that may be
misdiagnosed as, or exacerbate, attention deficit hyperactivity disorder.
• Pharmacotherapies have little empirical support for adolescents with
SUD, but may be appropriate in selected patients.
For adolescents, substance use disorder (SUD) is among the most common
psychiatric disorders. Experimentation with alcohol, tobacco, and canna-
bis typically begins by middle adolescence. Although a small proportion
exhibit problematic substance use in early adolescence, SUD rates reach
adult levels in late adolescence. Among 18-year-olds, about one in five will
have had an SUD. The psychiatrist evaluating and treating adolescents with
SUD often faces a variety of challenges, including limited motivation to
achieve abstinence, problematic interactions between the adolescent and
parents, and inadequacies in the facilities available to address the adoles-
cent’s range of problems. While acknowledging that current solutions are
not ideal, this chapter will describe realistic approaches to addressing these
challenges. The recommendations described here are generally consistent
with the guidelines of the American Academy of Child and Adolescent
Psychiatry (Bukstein et al., 2005). Psychosocial interventions to enhance
the adolescent’s motivation to achieve abstinence, encourage constructive
parental engagement, and prevent relapse are available. Pharmacotherapy
may supplement but cannot substitute for these efforts. Although some do
not benefit, adolescents with SUD typically receive some help from these
efforts, and most show improvement (Thatcher & Clark, 2006).
 12 ADOLESCENT SUDS 313

Rates and Risks

Prevalence of Substance Use and Substance
Use Disorder in Adolescents
Among adolescents, alcohol, cigarettes, and marijuana are the most com-
monly used substances. Initiation of alcohol use and experimentation with
tobacco in adolescence are normative, and consumption patterns typically
increase significantly during this developmental period. Alcohol is the most
commonly used substance. Community surveys in the United States, such
as Monitoring the Future (Johnston et al., 2012), find that three-fourths
of 12th graders have tried alcohol. Of 12th graders, more than one-half
reported ever having been drunk, and about one-third reported having
been drunk in the prior month, whereas only 3% reported any daily drink-
ing. Cigarettes have been tried by about 40% of 12th graders, with 6%
reporting daily smoking. Marijuana has been tried by about 45%, and 4%
are daily users.
Among adolescents overall, the lifetime prevalence of SUD is about
10%. In parallel with use rates, SUD is relatively uncommon among young
adolescents, and increases to a lifetime prevalence rate of about 20% at
ages 17 to 18 years old (Merikangas et al., 2010). Of these older adoles-
cents with SUDs, the most commonly involved substances are alcohol
and marijuana. In adolescent addiction medicine clinics, adolescents with
severe SUD involving multiple substances that are rare in community
samples are relatively common.
314 Substance Use Disorders

Risk Factors
The risk factors for SUD (Clark & Winters, 2002) highlight characteristics
that may perpetuate substance use and increase relapse risks. A family
SUD history is a risk factor for adolescent SUD that operates through
genetic and environmental mechanisms. At this time, the genetic mecha-
nisms remain unknown. Family history also operates through environmen-
tal mechanisms that can be changed. Parental modeling of substance use
increases use of similar substances in adolescents. Parents need to under-
stand that their own substance use may contradict their exhortation to
their teen to be substance abstinent. In addition, conscientious parental
supervision can delay substance use and improve treatment outcomes.
Adolescents’ and peers’ substance use tend to be similar. Adolescents
who use substances seek out substance-using peers, whereas substance-
using peers and siblings may influence an adolescent to use alcohol and
drugs. Inadequate parental support and perceived parental rejection are
related to affiliation with substance-using peers, whereas assertiveness
and psychosocial maturity in adolescence may reduce the influence of
substance-using peers.
Substance availability influences use. The increase of the minimum
drinking age to 21 years in the United States in 1984 was associated with a
decrease in adolescent alcohol use. Nevertheless, most high school–aged
teens report that they find alcohol, cigarettes, and marijuana relatively
easy to obtain. Teens often obtain alcohol and other substances from an
older sibling or peers.
The behavioral pattern that culminates in adolescent SUD typically
begins in childhood, long before adolescents first experiment with sub-
stance use. A constellation of childhood mental disorders including atten-
tion deficit hyperactivity disorder (ADHD), conduct disorder, and major
depressive disorder predict the development of adolescent SUD. These
mental disorders may be conceptualized as constituting suprathreshold
variations in psychological dysregulation. Psychological dysregulation
reflects difficulties in control with affect, cognition, and related behaviors.
Traumatic experiences, such as physical or sexual abuse, may contribute
to psychological dysregulation, post-traumatic stress disorder, and major
depressive disorder. These risk factors are characteristics important to
consider in treatment planning and implementation.
 12 ADOLESCENT SUDS 315

Screening
Screening instruments are short assessment tools designed to detect the
possible presence of an SUD. To screen for alcohol use disorder in ado-
lescents, the National Institute on Alcohol Abuse and Alcoholism recom-
mends two questions, inquiring about the adolescent’s alcohol use pattern
and alcohol use in his or her peers (NIAAA, 2011). By extension, screening
for frequent use of specific substances followed by a diagnostic interview
for pertinent substances is a reasonable and efficient approach.
An alternative approach is the utilization of screening instruments that
have been shown to identify adolescents likely to have SUD (Cook et al.,
2005). For alcohol use disorder, the Alcohol Use Disorders Identification
Test, or AUDIT, includes three questions on alcohol consumption and
seven on related problems. For SUDs more generally, CRAFFT includes
three questions inquiring about the substance use history (i.e., alcohol,
marijuana, and other drugs), followed by six questions on substance-related
problems. For adolescents with positive screens, a diagnostic assessment
is needed. These instruments include items that are somewhat redundant
with the information collected by the diagnostic interview. Thus, the use
of such screening instruments in the psychiatric setting may unnecessarily
lengthen the assessment protocol.
316 Substance Use Disorders

Assessment
A thorough clinical assessment of SUD in adolescents includes distinct
evaluations by substance types (i.e., tobacco, alcohol, cannabis, other
drugs), stages (i.e., initiation, regular use, frequent use), patterns (e.g., peri-
ods of daily use or abstinence), and related problems (Clark & Winters,
2002). The distinct and explicit evaluation of each substance category is
important to avoid patient misinterpretation or obfuscation. For example,
an adolescent with daily marijuana use may deny “drug use” due to the
misconception that cannabis is not a “drug.” An adolescent may deny
“problems” in an effort to argue against the need for treatment while
being willing to describe use patterns. Treatment planning should not pro-
ceed until a reasonably valid assessment has been completed.
Although unstructured clinical interviews are generally utilized in health
care settings, structured interviews have been shown to better detect and
diagnose psychiatric disorders including SUD in adolescents. For the diag-
nostic interview, a section on SUDs has been included in the Schedule for
Affective Disorders and Schizophrenia for School-Age Children (K-SADS)
available at the Western Psychiatric Institute and Clinic website (psychia-
try.pitt.edu/research/tools-research/ksads-pl).
Confidentiality issues figure prominently in adolescent SUD assess-
ments. To obtain valid reports on substance use from adolescents, coop-
eration is obviously needed. Adolescents often actively conceal the extent
of their substance use from their parents. Although open communication
among parents, adolescents, and treatment team members would usually
be ideal, adolescents are often unwilling to provide accurate reports if the
reports would be shared with parents. The regulations pertaining to ado-
lescents in addiction treatment vary by state. In Pennsylvania, adolescents
receiving treatment in drug and alcohol programs are the consenting party
and retain confidentiality rights. Confidential information can be provided
by the treatment team members to the parents only with the adolescent’s
explicit and written permission. To provide information on the applicable
regulations and clinic procedures, an explicit discussion of the approach to
be taken needs to be conducted with the adolescent and parents before
initiating the assessment.
The reports of adolescents on their substance use may be supple-
mented by laboratory tests of urine, saliva, or blood. The purposes and
the consequences of subsequent findings need to be considered before
testing. In some circumstances, the adolescent, parents, and the treatment
team may agree on the purpose and value of testing. An adolescent may
be interested in providing validation to skeptical parents that they have
achieved substance abstinence. A contingency management arrangement
may involve a test confirming abstinence for a milestone and a related
reward or privilege to be provided. A laboratory test may be required
by a judge as part of a probation requirement, with a positive test leading
to incarceration. The use of laboratory testing by judicial authorities may
be outside the control of the treatment team, yet may be a circumstance
that can be incorporated into treatment planning. A problematic circum-
stance occurs when a parental request for laboratory testing contradicts
the adolescent’s wishes and is intended to circumvent the confidentiality
 12 ADOLESCENT SUDS 317

arrangement. In the latter situation, an explicit discussion is needed, the

structure of consent and confidentiality needs to be reviewed, and the
communication of and responses to laboratory results need to be planned.
Adolescents coerced into providing specimens for laboratory tests may
respond with diminished treatment engagement and may attempt to sub-
vert substance use detection.
Parents and other authority figures may be misinformed about the
appropriate utilization of laboratory tests. Some may believe that such
tests can be used to accurately and conclusively track day-to-day or
week-to-week substance use patterns to monitor treatment effects or
adherence to abstinence. In fact, laboratory tests have considerable limita-
tions. Consequently, laboratory tests cannot be considered a substitute
for valid adolescent reports.
The initial assessment for adolescents with SUDs extends beyond SUD
and comorbid mental disorders to include possible substance use compli-
cations. In addition, the assessment of treatment response is an ongoing
process. The parent–adolescent relationship is a central concern in ado-
lescent SUD treatment. Problematic parent–adolescent relationships may
contribute to or result from SUD. Adolescents with SUD may become
adept at concealing their substance use and subverting parental supervi-
sion. Effective parental monitoring, communication, and emotional support
facilitate psychosocial interventions for SUD. Siblings sharing the house-
hold with the adolescent patient may be influenced to use substances,
and therefore attention to sibling relationships is important. Similarly, peer
relationships need to be assessed and monitored. Adolescent substance
use often interferes with academic achievement. The use of alcohol, mari-
juana, and other illicit drugs subjects the adolescent to legal and social
sanctions, such as school expulsion and incarceration. Intoxicated driving
among adolescents remains a major public health concern. Adolescents
with SUDs are more likely to be sexually active, to initiate sexual activity
at a younger age, to have multiple sexual partners, and to have sexu-
ally transmitted diseases. Unplanned pregnancy is more common among
female adolescents with SUD than among comparable peers without
SUD. Substance use can cause inattention, irritability, impulsive aggres-
sion, anxiety, and depression. SUD is a risk factor for suicidal ideation
and attempts. These effects are often mislabeled as independent of SUD.
Adolescents with SUDs tend to have a high rate of self-reported health
symptoms associated with depression and anxiety, with few abnormalities
on physical examination or laboratory tests. Adolescents with SUDs also
tend to have sleep problems. Although demonstrable substance effects on
adolescent brain development have not been definitively demonstrated,
substance use has effects on neuropsychological functioning, including
impaired working memory and executive functioning. These complications
have implications for treatment planning and implementation.
318 Substance Use Disorders

Diagnosis
Although the fourth edition of the Diagnostic and Statistical Manual of
Mental Disorders of the American Psychiatric Association (DSM-IV) is
the most recent available, the fifth edition (DSM5) is expected in May
2013 (www.dsm5.org). Most of the SUD symptoms items are essentially
unchanged. Craving has been added as a criterion item. The categori-
cal approach to the syndrome has changed, with the DSM-IV distinction
between abuse and dependence eliminated in DSM5.
The application of the DSM items to adolescents requires some con-
sideration of developmental issues. Compared with adults, adolescents
with SUD more quickly transition from regular substance use to SUD, use
alcohol less frequently, and are less likely to experience alcohol-related
withdrawal and blackouts. Because alcohol tolerance occurs as a normal
developmental phenomenon, the definition of tolerance as a criterion for
alcohol use disorder (AUD) may be problematic when applied to adoles-
cents. The item indicating alcohol use was “more than intended” assumes
intentions that may be absent. Because adolescents are often pressured by
parents or other authority figures into addiction treatment, “unsuccessful
efforts to control substance use” may be less common among adolescent
patients than among otherwise similar adults. Explanations may be needed
to solicit valid diagnostic information.

Case Vignette 1
Robert is a 16-year-old male who has been suspended from school for
being in possession of marijuana on school grounds. He arrives at the
clinic with his mother for a scheduled assessment. After being greeted and
introduced to the treatment team member conducting the evaluation, the
mother asks to speak with the clinician alone. The clinician explains that
the information provided by the adolescent to the clinician will be held
in confidence and that she prefers to meet first with the adolescent, then
with the mother and adolescent together. The adolescent describes daily
marijuana use when meeting alone with the clinician, and he comments
that his parents are only aware that he has used in the past. In meeting with
the adolescent and mother, the mother asks that a laboratory drug test be
conducted. The school requires documentation that the assessment has
been conducted for the adolescent to be allowed to attend school.
• How would you best maintain Robert’s engagement and his
confidentiality?
Answer to Case Vignette 1
To abide by the confidentiality agreement and encourage adolescent
participation, the clinician cannot directly share that the adolescent has
confided frequent substance use. Because conducting a laboratory test
would indirectly violate this confidence, the clinician can reasonably
decline conducting this procedure. A note can be provided to the ado-
lescent stating that the clinic visit occurred with no sensitive information.
A recommendation for continuing the assessment and initiating treat-
ment can be provided to the adolescent and mother.
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320 Substance Use Disorders

Treatment
Helpful psychosocial and pharmacological treatment modalities are avail-
able for adolescents with SUD. Some adolescents with SUD substantially
improve without participating in treatment. Adolescents improving with-
out formal interventions cite a variety of constructive influences, including
informal interpersonal support, formal aids, behavioral self-management,
and alternative activities. For adolescents with more severe SUD, related
social problems, and psychiatric comorbidity, spontaneous improvement
is less likely, and systematic interventions are typically needed.
Developmental Considerations
Adolescents with SUD require treatment approaches targeting specific
adolescent issues, including parental involvement, limited motivation,
neurocognitive immaturity, and psychiatric comorbidity. Treatment tech-
niques borrowed from adult addiction programs typically need some
modification to be applicable with adolescents. To one degree or another,
most adolescents are coerced into treatment by parents or other con-
cerned authority figures. Addiction program assessment and treatment
may be required as part of juvenile justice probation requirements or to
gain reinstatement in school after suspension. Of course, similar circum-
stances do occur with adults. However, adults typically express some
interest in treatment and may present themselves voluntarily, whereas
adolescents with SUD typically enter and stay in treatment at the insis-
tence of authority figures. At treatment initiation, adolescents typically
have little personal motivation to reduce or discontinue substance use.
Consequently, motivational enhancement is critical for engaging adoles-
cents in treatment. The involvement of parents or parent figures is also an
essential element. Interactions with parents are central to the daily lives
of adolescents, and treatment of adolescents without regard for parental
involvement is unlikely to be successful.
Adolescents with SUD often have delays or deficits in neurocognitive
development, particularly in executive functioning. Self-control of cognition
and attention, emotions, and behavior are often limited in these adoles-
cents. Insight into the immediate and future consequences of substance use
is often poor. These limitations impair adolescents’ ability to understand the
rationale for treatment and to respond to recommendations. Adolescents’
poor insight about the adverse effects of substance use on mood, cognitive
abilities, and impulse control may hinder their willingness to initiate absti-
nence. Unfortunately, strategies targeting comorbid mental disorders in the
context of ongoing substance use are typically unsuccessful.
Level of Care
Treatment planning for adolescents with SUD is an ongoing process
including selection of a treatment setting, modality, intensity, and dura-
tion. The required level of care is determined by the severity and chronic-
ity of SUD symptoms, associated problems, and prior treatment history.
The level of care most likely to be effective while also the least restric-
tive possible is ideal. Hospital-based inpatient treatment may be needed
when severe alcohol withdrawal or acutely dangerous behavior is present.
 12 ADOLESCENT SUDS 321

Residential settings may be as restrictive as inpatient settings, but medical

support is less available, and treatment may be less intensive. Residential
settings may be needed where adolescents show ongoing substance use
with poor response to treatment and limited psychosocial support. The
selection of treatment setting may be influenced by facility availability,
health insurance coverage limitations, and parental financial resources.
Intensive outpatient programs typically involve lengthy visits several days
each week. Outpatient programs combining weekly visits with interim sup-
port through informal sources, including mutual support groups, represent
the least intensive treatment level.
Psychosocial Treatment
Psychosocial treatment may be structured to include individual sessions,
groups with or without a professional leader, or the adolescent with fam-
ily members. After evaluating motivations for engaging in counseling and
for discontinuing substance use, the interventions may need to be ini-
tially directed toward enhancing motivation. When sufficient motivation
is evident, the adolescent may be engaged in learning techniques that can
enhance control of cognitions, emotions, and behaviors that may inter-
fere with abstinence and social skills to resist peer substance use encour-
agement. Contingency management may be utilized by parents or other
authority figures to increase the likelihood of abstinence or to enforce
sanctions for substance use. Family-focused approaches typically seek to
enhance parent–adolescent communication, support parental supervision
efforts, and involve family members in activities likely to encourage the
adolescent’s substance abstinence.
322 Substance Use Disorders

Motivational Enhancement Therapy

Motivational interviewing and motivational enhancement therapy describe
systematic techniques that facilitate the identification of personal goals and
the recognition of obstacles in achieving goals (e.g., adverse effects of sub-
stance use). Motivational enhancement is often particularly relevant for ado-
lescents with SUD, who may be unable or unwilling to acknowledge that
their substance use has adverse effects. In contrast to confrontational tech-
niques, the hallmark of motivational enhancement techniques is to encourage
the adolescent to identify problems and solutions through their own insights.
Although the therapist generally facilitates rather than directs the topical
focus with this approach, consideration of specific pertinent topics may need
to be encouraged. Because adolescents are often brought to treatment by
concerned parents, an initial focus may be on substance-related conflicts with
adults or other problems that led to treatment initiation. Some substance use
effects may be perceived as problems, although effects on cognitive abilities
and affect may be difficult for some teens to recognize and acknowledge. The
possibility that substance use may lead to legal consequences, including arrest
and incarceration, and the potential hazards of substance use, such as risks for
motor vehicle crashes, may also be worth discussing.
Confrontation and the “scared straight” approach are antithetical to
motivational enhancement approaches. Parents may have confronted the
adolescent before treatment initiation, and punitive methods may have been
attempted. Although examples may be found where punitive approaches
were apparently useful, such confrontations often lead adolescents to be
less communicative and thus tend to be counterproductive for increasing
adolescent engagement. Motivational enhancement techniques encourage
the adolescent to gain insights through self-exploration. By modeling moti-
vational interviewing techniques for parents, the therapist may provide them
with an alternative approach that may improve communication.

Case Vignette 2
Megan, A 17-year-old female, reports binge drinking every weekend. She
believes this is not a problem, and she is not interested in treatment. She
has “hangover” symptoms on Sunday morning. She also has conflicts
with her parents about alcohol use.
• Do you think a motivational interviewing approach to engage Megan
would be appropriate?
• What would the goals of this intervention be?

Answer to Case Vignette 2

The clinician can elect to use a motivational interviewing approach to
structure the style and content of the initial intervention. The goal of this
intervention is to facilitate self-exploration about the perceived benefits
and adverse effects of alcohol use. The style is neither judgmental nor
confrontational. The ideal result is that Megan realizes that alcohol use
is causing problems and that discontinuing alcohol use would be the
optimal approach to solving these problems.
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324 Substance Use Disorders

Cognitive and Behavioral

Interventions
The utilization of individual behavioral and cognitive therapy approaches
assumes that the adolescent’s goal is substance abstinence. Attempts to
utilize these techniques with adolescents intending to continue substance
use are typically frustrating and futile. With adolescents interested in
achieving substance abstinence, the application of behavioral and cognitive
therapy techniques can be effective and rewarding.
Behavior therapy conceptualizes SUDs as learned behaviors facilitated
by specific environmental stimuli and rewarded by substance effects or
social benefits. The analysis of substance use behaviors involves the iden-
tification of antecedents, behavioral characteristics, and consequences
(i.e., “ABCs”). In this context, the examination of antecedents involves
the identification of environmental situations that lead to substance use
initiation, such as encounters with specific substance-using peers, skipping
school classes, or attending parties without adult supervision.
Interventions to reduce social influences may begin with facilitation of
the adolescent’s identification of social situations in which substance use
is likely through focused discussion or diaries. A collaborative analysis of
the thoughts or emotions that may mediate between the situation and
substance use may be useful. The social skills to avoid such situations or
to decline substance use may be described, modeled by the therapist, and
practiced by the adolescent with the therapist. An increase in construc-
tive alternative activities may provide a substitute for problematic behav-
iors. The completion of homework assignments using a diary to describe
problematic situations and responses may be helpful to encourage skill
implementation.
For some adolescents, internal states, including boredom or anger, may
precipitate substance use. Other antecedents reduce the likelihood of
substance use, such as attending school, supervised activities, or construc-
tive hobbies. Thus, one focus may be increasing encounters with positive
antecedents while avoiding antecedents likely to lead to substance use.
The behaviors selected in particular situations also influence whether
substance use occurs. For example, in response to an encounter with
substance-using peers, an adolescent may elect to exit the situation or
exhibit assertive behaviors to resist peer influence. Emotional states may
also be substance use antecedents. An effective response to anxiety may
be the application of relaxation techniques rather than substance use.
Because the selection of SUD behaviors is influenced by cognitions, cog-
nitive behavioral therapy (CBT) adds thoughts and perceptions as ante-
cedents to be considered in behavioral techniques. Expectations about
substance effects are a pertinent example. For abstinent adolescents,
thoughts or cravings about substance use may need to be monitored and
managed. An adolescent may be instructed to monitor his or her behaviors
in response to important antecedent situations to evaluate improvement
and as a behavior change technique. The management of consequences
may also improve outcomes. For example, adolescents may receive nego-
tiated rewards for substance abstinence. Contingency management may
 12 ADOLESCENT SUDS 325

be useful for adolescents not committed to abstinence as well as for ado-

lescents otherwise motivated to discontinue substance use. The concrete
style of behavior modification techniques may be particularly suited to
adolescents, who may struggle to comprehend or perceive value in more
abstract or nebulous psychotherapy approaches.
Family Interventions
To some extent, family interventions are involved in all treatment plans
for adolescents with SUD. The focus on family interactions may target
parental involvement in treatment evaluation and planning, communica-
tion and support, parental supervision, inadvertent or explicit substance
use encouragement by family members, or other problematic family inter-
actions. Parent-directed contingency management may also be considered
a family interaction intervention.
In the process of implementing family interaction interventions, clinicians
must conduct an ongoing evaluation of the optimal balance of individual
and family techniques and the time dedicated to each approach. For par-
ents with realistic expectations who are ready, willing, and able to engage
in learning more effective parenting approaches, listen to their adolescent
in the intervention context, discontinue punitive responses, and invest
time and effort into building their relationship with the adolescent, the
adolescent will likely benefit from a major focus on family interactions.
At the other extreme, spending a significant proportion of intervention
time on family interactions may be counterproductive in some instances.
Parents with their own SUD need to address their problems through inde-
pendent treatment. Some parents may engage in confrontations during
sessions that may be counterproductive to the therapist’s efforts to facili-
tate adolescent engagement. Most families will have a mix of facilitative
and counterproductive characteristics that change over time.
To the extent that the adolescent provides the treatment team with
information that is not conveyed to the parents, parents may need to
be reminded over the course of treatment that they cannot assume that
the absence of reports from the treatment team can be interpreted as
indicating improvement or substance abstinence. On the other hand, ado-
lescents often need to be encouraged to inform their parents about their
substance use in order to engage parents in providing appropriate supervi-
sion, contingency management, and support.
As an alternative approach addressing treatment engagement and
retention problems, experimental programs have been successfully devel-
oped and tested that implement interventions in the home. Although the
opportunity to observe family interaction in the home and the logistics of
home interventions may improve engagement, the time and related cost
required are typically not covered by health insurance programs or other
sources. Such interventions are not widely available.
Groups
Group interventions with adolescents may be conducted with a pro-
fessional leader as part of a comprehensive program or as a leader-
less mutual support intervention. Attendance at 12-step groups (e.g.,
Alcoholics Anonymous [AA] or Narcotics Anonymous [NA]) has been
326 Substance Use Disorders

recommended in some practice parameters. To the extent that group

interventions are effective, their relatively low cost can result in a high
degree of cost-effectiveness. The value of such groups depends on the
compatibility of the approach with the adolescent’s attitudes and charac-
teristics, the group structure, and the characteristics of other group mem-
bers. In the context of comprehensive programs, the group intervention
may be tailored to meet group members’ needs and monitored to avoid
problems.
Mutual support groups without professional leadership or other moni-
toring can be similarly helpful but have potential problems. Many regions
do not have mutual support groups specifically tailored to adolescents,
and attendance would therefore involve a mix of adult and adolescent
members. Some adults may prove very helpful, providing guidance and
support. Unfortunately, some adults may engage in predatory behavior
toward vulnerable adolescents. For groups exclusively composed of ado-
lescents, support and mutual understanding are potentially constructive.
On the other hand, some adolescent group members may engage in inap-
propriate facilitation of substance use and other activities incompatible
with progress. As with any intervention, some direct or indirect oversight
is needed to monitor the intervention implementation and effects.

Case Vignette 3
Claire, a 16-year-old female, is participating in individual psychosocial
treatment and attends AA meetings. She confides that a young adult
male she has met at the AA meeting asked to get together with her after
the meeting. They smoked marijuana, and he has asked to see her again.
• Should Claire continue to go to AA?
• What is your course of action?
Answer to Case Vignette 3
In this circumstance, the self-help group is counterproductive, leading
to an inappropriate interaction. The adolescent can be encouraged to
share this incident with her parents. Even if the adolescent declines, the
clinician can recommend to the adolescent and parents that attendance
at the AA group be discontinued at this time.
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328 Substance Use Disorders

Pharmacotherapy
Pharmacotherapy for adolescents with SUD has a limited empirical basis
(Clark, 2012). Nevertheless, clinicians often utilize medications with these
adolescents, particularly for symptoms of comorbid psychiatric disorders.
Potential pharmacotherapy targets include alcohol metabolism, substance
craving, withdrawal, and comorbid psychiatric disorders. In general, phar-
macotherapy may be useful as an adjunct to but not a substitute for psy-
chosocial interventions promoting abstinence.

Alcohol Aversion Pharmacotherapy

Disulfiram counteracts the reinforcing properties of alcohol consumption
by changing alcohol metabolism. During disulfiram use, alcohol consump-
tion causes nausea, hypotension, and flushing. Disulfiram deters alcohol
use through anticipation of these effects. This approach is appropriate
only in highly motivated, cooperative, and informed adolescents who have
failed other approaches. Disulfiram is not recommended here, and if used
at all, disulfiram should be cautiously used with close monitoring.

Alcohol Craving
Alcohol craving may increase the risk for relapse. Naltrexone and acam-
prosate have been shown to reduce craving in adults with AUD. Although
not particularly hazardous, the benefits of these interventions for adoles-
cents with AUD have not been established. Naltrexone and acamprosate
may be appropriate for some motivated adolescents after alcohol absti-
nence has been achieved.

Alcohol Withdrawal
Pharmacotherapy for alcohol withdrawal is sometimes needed after an
abrupt cessation of daily alcohol use in individuals with severe alcohol
dependence. Severe, acute alcohol withdrawal accompanied by physi-
ological symptoms (e.g., elevated heart rate and blood pressure) is rare in
adolescents. These acute alcohol withdrawal symptoms are very hazard-
ous and require medically supervised detoxification in an inpatient hospital
setting. In this circumstance, benzodiazepines may be utilized to moderate
withdrawal symptoms and reduce the likelihood of seizures and other
serious medical complications. Beta-blockers, clonidine, and antiepileptic
medications may also be needed. This approach should not be undertaken
without continuous medical supervision. Benzodiazepines have high addic-
tion and diversion potential, and their use is inappropriate for adolescents
with SUD under other circumstances.

Nicotine Craving and Withdrawal

Adolescents with SUD often smoke cigarettes, and nicotine dependence
is common in these patients. Interventions to facilitate the discontinua-
tion of cigarette smoking and other tobacco use may improve SUD out-
comes. Along with psychosocial interventions, nicotine replacement and
bupropion are reasonable options. Nicotine replacement may be deliv-
ered through a variety of vehicles, including gum, lozenges, transdermal
 12 ADOLESCENT SUDS 329

patches, inhaler, and nasal spray. Bupropion may also be helpful in some
cases. Since bupropion is also indicated for major depressive disorder and
ADHD, adolescents with these comorbid disorders may be particularly
appropriate candidates for this approach.
Comorbid Psychiatric Disorders
Adolescents with SUD frequently present with comorbid psychiatric dis-
orders, including major depressive disorder, anxiety disorder, ADHD, and
conduct disorder. For adolescents with ongoing substance use, the pri-
mary intervention is substance abstinence. After an extended period of
substance abstinence, the utilization of pharmacotherapies typically used
for adolescents without SUD history is appropriate with some exceptions.
Although these pharmacotherapies are unlikely to be useful in the context
of ongoing substance use, the application of these medications may be
reasonable in some instances when ongoing abstinence may be uncertain.
Major Depressive Disorder
Among adolescents with ongoing substance use, consumption of alcohol,
marijuana, or other substances likely contributes to depressed mood.
These adolescents and their parents need to be clearly informed that sub-
stance abstinence is the initial step in addressing depressed mood and
in evaluating whether medication may be useful. Adolescents achieving
abstinence for several months often show sufficient improvement in mood
that pharmacotherapy is not warranted. Among those abstinent adoles-
cents with ongoing depression symptoms, antidepressant medications are
appropriate to consider. Antidepressant medications have been shown
to be efficacious in adolescents with major depressive disorder without
SUD, and abstinent adolescents with continuing major depressive disorder
symptoms will likely show similar responses.
The consideration of antidepressant medications for adolescents with
symptoms of major depressive disorder in the context of ongoing substance
use is more problematic. Controlled trials and clinical experience indicate
that, on average, these adolescents do not benefit from antidepressant med-
ications (Cornelius et al., 2009, 2010). Systematic psychosocial approaches,
including cognitive behavior therapy and motivational enhancement therapy,
have been found to be helpful for both depression and substance use in
these adolescents (Cornelius et al., 2011). Even with this information, some
adolescents with these characteristics and their parents still prefer to try
antidepressant medications. Particularly when psychosocial interventions
and other approaches have not succeeded, this may be a reasonable deci-
sion. The utilization of antidepressant medications in such less than ideal cir-
cumstances has to be undertaken with the understanding by all concerned
that the likely benefits, side-effect profile, and hazards are unpredictable.
Anxiety Disorders
Like major depressive disorder, anxiety disorders often improve with
substance abstinence. Among abstinent adolescents with ongoing anxi-
ety symptoms, antidepressant medications and buspirone are appropri-
ate options. Adolescents with comorbid anxiety disorders and SUD may
have experienced diminished anxiety symptoms with prescribed or illicit
330 Substance Use Disorders

benzodiazepine use. In most adolescents with SUD, the potential prob-

lems with benzodiazepines include consumption for intoxication, use
in greater than prescribed amounts, dependence, and diversion. These
potential problems offset whatever potential benefit may be realized.
For adolescents with prior problematic substance use, benzodiazepines
remain potentially problematic even after a period of abstinence and
should be avoided.
Bipolar Disorder
Adolescents with SUD often present with labile mood attributable to sub-
stance use or affective dysregulation. Adolescents and parents may label
affective instability as “mood swings” and conclude that bipolar disorder
is causing these symptoms. Adolescents and their parents may need to
be educated about the effects of substance use on mood, including intoxi-
cation and withdrawal, and the distinctions among these syndromes. The
evaluation of bipolar disorder symptoms is hampered by ongoing substance
use. Nevertheless, adolescents with SUD and documented bipolar disorder
meeting diagnostic criteria during abstinent periods may benefit from pro-
phylactic treatment. In some cases, the use of lithium, valproate or other
antiepileptic medications, or second-generation antipsychotic medications
may be helpful. For adolescents with mood instability, substance abstinence
is the primary intervention. Mood stabilizing medications, including antipsy-
chotic medications, may be reasonably considered in some cases.
Attention Deficit Hyperactivity Disorder
A history of childhood ADHD is common among adolescents with SUD.
However, frequent marijuana use causes attention difficulties, diminished
motivation, and poor academic achievement that may be misdiagnosed as
ADHD. In such cases, substance abstinence is the primary intervention.
Ongoing substance use may also exacerbate ADHD. Stimulant medica-
tions, including methylphenidate and amphetamine variants, improve
ADHD symptoms. Their use among ADHD adolescents with substance
abstinence is straightforward. Although there can be abuse or diversion
of stimulant medications, conscientious monitoring can minimize these
problems. For adolescents with ongoing substance use, these medica-
tions may enable SUD by counteracting problematic substance effects. Of
course, interventions that inadvertently facilitate substance use need to be
avoided. Clinical circumstances vary, substance use and symptoms change
over time, and consequently, good judgment needs to be applied. Some
flexibility may be needed to manage stimulant medications with the typical
SUD adolescent. For many, the use of nonstimulant alternatives, such as
atomoxetine or bupropion, may be the optimal approach.
Conduct Disorder
Among adolescents with SUD, impulsive aggression is often a concern.
Substance abstinence remains the primary intervention, and psychosocial
interventions targeting the antecedents to aggressive behavior are more
likely to be helpful. When psychosocial approaches have failed, antipsy-
chotic medications can be considered. Because antipsychotic medications
may have unpleasant side effects and adolescents may not perceive subjec-
tive benefits, lack of adherence can be problematic.
 12 ADOLESCENT SUDS 331

Case Vignette 4
Benedict, a 17-year-old male with no prior history of ADHD symptoms,
reports using marijuana four times per week. The adolescent reports
difficulty concentrating. While in previous years he had been an excel-
lent student, his father reports he has recently been failing tests. The
adolescent reports that his concentration is neither better nor worse
on the days that he smokes marijuana. The adolescent reports he took
an Adderall (i.e., amphetamine-dextroamphetamine) tablet that he got
from a friend, and that he felt better able to concentrate. He has dis-
cussed this experience with his parents. The adolescent and his parents
think that he may have ADHD, and that previous clinicians have missed
this diagnosis. They agree that a trial of Adderall would help determine
whether ADHD is causing his school difficulties.
• What is the most likely cause of Benedicts attentional problems?
• What would be your plan for helping Benedict and his parents?
Answer to Case Vignette 4
In this situation, marijuana use is likely causing attentional problems
and amotivational syndrome. The adolescent and parent need to be
educated about marijuana effects, and the lengthy period of abstinence
needed to determine whether marijuana is causing these academic
problems. This discussion can be conducted without revealing the spe-
cific substance use pattern confided by the adolescent. The adolescent
and parents can also be informed that, even if marijuana use in causing
the concentration problems, Adderall would likely improve attention.
Thus, an Adderall trial would not be informative. The most appropriate
plan at this time is to encourage substance abstinence without starting
pharmacotherapy.
332 Substance Use Disorders

Treatment Outcomes
The explicit and desirable goal of treatment programs for adolescents
with SUD is substance abstinence. In the course of treatment, complete
abstinence is rarely achieved for extended periods. Adolescent SUD tends
to be a relapsing condition. Among adolescents in treatment, complete
substance abstinence occurs in less than one in five over a 1-year period.
Although some behaviors may be intolerable, interventions programs
that eject adolescents for substance relapses are unlikely to be applicable
for most of these patients. Although absolute and complete success is
uncommon, improvement occurs with most adolescents. Among adoles-
cents with SUD, about half will have continuing substance problems in
adulthood. Persisting in treatment efforts is critical because the conse-
quences of failure include worsening substance dependence, academic and
social failure, criminal activity, medical consequences, adulthood substance
dependence, and early death.
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334 Substance Use Disorders

Conclusions
Research Directions
Screening methods that may be helpful to identify adolescents requiring
diagnostic assessments for SUD need further study to determine the most
efficient approach and to clarify thresholds by developmental stage (Clark
& Moss, 2010). The available intervention approaches are not optimally
effective. A better understanding of the causes and consequences of ado-
lescent SUDs would likely lead to more effective preventive interventions
and treatments. Innovative psychosocial and pharmacotherapy treat-
ments need to be developed and tested. In addition, successful interven-
tion programs need to be standardized, costs determined, and advances
implemented in clinical practice. At the present time, the most promising
psychosocial intervention programs are comprehensive and expensive.
The limited resources provided by health insurance, the source of most
funding for adolescent SUD interventions, make such comprehensive pro-
grams infeasible. Although research advances may lead to the develop-
ment of more cost-effective approaches, clinicians will need to work with
the currently available interventions for the foreseeable future.

Clinical Recommendations
Whether in primary care settings or psychiatric clinics, adolescents need
to be assessed for substance use and SUD. Before conducting the assess-
ment, a confidentially agreement needs to be completed with the ado-
lescent and parents. The adolescent needs to be assured that substance
use reports will not lead to punitive consequences. When conducting
SUD assessments, a structured interview is recommended to ensure that
important problems are not overlooked.
Adolescents with SUD should receive developmentally appropriate inter-
ventions. Clinicians accustomed to helping adults with SUD will encounter
challenges when intervening with adolescents. For many adolescents, the
motivation for treatment participation is contributed by the parents. The
adolescent may be initially uninterested in and unwilling to participate in
treatment. For an adult patient, this circumstance would typically result
in a terminated intervention. For an adolescent patient, this circumstance
is the typical beginning of the treatment process. The psychiatrist and the
adolescent’s parents need to collaborate and be persistent in encouraging
treatment attendance, participation, and engagement. The extent and char-
acteristics of the parents’ involvement may involve continuing evaluation
and adjustments. Adolescents need assurance that their confidentiality will
be respected while being encouraged but not required to provide their par-
ents with information about their substance use and intervention efforts.
Aggressive confrontation in the early stages of treatment typically leads
to adolescent disengagement. At the same time, a realistic discussion
needs to occur about substance use effects and the likely consequences
of ongoing substance use. The adolescent may be ambivalent about sub-
stance abstinence, have misperceptions about the benefits of substance
use, and have unrealistic ideas about their economic, academic, or legal
situation. To the extent that treatment team members present their views
 12 ADOLESCENT SUDS 335

and opinions while respecting that the adolescent may disagree, frank dis-
cussions can occur without arguments. Active listening can be combined
with education.
The provision of interventions to these adolescents and their families
typically involves frustrations for the clinician. The adolescent’s ambiva-
lence about participating may result in missed visits or unproductive ses-
sions. Parents dissatisfied with the clinician–adolescent confidentiality
arrangement may attempt to obtain information before or after the ses-
sion. Parents who feel they have exhausted their personal resources for
managing or addressing their adolescent’s problems before the initiation
of treatment may have the unrealistic expectation that these problems
can be addressed without their involvement. For adolescents who have
fallen behind in school, parents may be reluctant to schedule sessions that
would interfere with school classes or other activities. Interactions with
other authority figures, whether in writing, by telephone, or through other
means, may be limited or prohibited by confidentiality issues. For adoles-
cents who do not respond to outpatient interventions, intensive outpa-
tient services, residential programs, or inpatient treatment may be refused
or unavailable. These complications may result in the intervention requir-
ing many uncompensated clinician hours. Ongoing institutional financial
support may be needed for adolescent addiction programs to be viable.
Pharmacotherapy may be considered to supplement these efforts. Some
adolescents, as well as some parents, may hope that a medication will sub-
stitute for a more comprehensive psychosocial approach. Such unrealistic
expectations need to be addressed before initiating pharmacotherapy.
Some adolescents rationalize their ongoing substance use with the con-
cept that their comorbid mental disorder symptoms cause their substance
use, and when these symptoms are effectively treated with pharmaco-
therapy, they will then discontinue substance use. Substance effects may
be falsely attributed to otherwise nonexistent mental disorders by ado-
lescents as well as parents. Unfortunately, many adolescents with SUD
receive little or no benefit from pharmacotherapy. Pharmacotherapy in
the context of ongoing substance use will almost always be unsuccess-
ful. Adolescents and parents may need to be reminded that substance
abstinence in the primary goal and that abstinence will most likely lead to
improvement in other symptoms.
With adolescents engaged in treatment and motivated to achieve sub-
stance abstinence, the program can proceed to include behavior and
cognitive behavior therapy interventions. Interventions focusing on social
skills, anger management, and other effective approaches may reduce the
likelihood of relapse. The involvement of parents in the implementation
of contingency management interventions may also be important, in that
such procedures can be implemented without a high degree of adolescent
engagement or insight. The involvement of adolescents and their parents
in treatment planning, communication and support, constructive relation-
ship improvement, and facilitating abstinence are all important interven-
tion activities. With adolescent engagement, parental efforts, and clinician
persistence, interventions are often successful.
For the interested reader, further discussion of these issues can be
found in textbooks such as Kaminer and Winters (2011).
336 Substance Use Disorders

References and Suggested Readings

Bukstein, O., & the Work Group on Quality Issues. (2005). Practice parameters for the assessment
and treatment of children and adolescents with substance use disorders. Journal of the American
Academy of Child and Adolescent Psychiatry, 44, 609–621.
Clark, D. B. (2012). Pharmacotherapy for adolescent substance use disorders. CNS Drugs, 26,
559–569.
Clark, D. B., & Moss, H. B. (2010). Providing alcohol-related screening and brief interventions to
adolescents through health care systems: Obstacles and solutions. PLoS Medicine, 7, 1–4.
Clark, D. B., & Winters, K. C. (2002). Measuring risks and outcomes in substance use disorders
prevention research. Journal of Consulting and Clinical Psychology, 70, 1207–1223.
Cook, R. L., Chung, T., Kelly, T. M., & Clark, D. B. (2005). Alcohol screening in young persons
attending a sexually transmitted disease clinic: Comparisons of AUDIT, CRAFFT, and CAGE
instruments. Journal of General Internal Medicine, 20, 1–6.
Cornelius, J. R., Bukstein, O. G., Wood, D. S., Kirisci, L., Douaihy, A., & Clark, D. B. (2009).
Double-blind placebo-controlled trial of fluoxetine in adolescents with comorbid major depres-
sion and an alcohol use disorder. Addictive Behaviors, 34, 905–909.
Cornelius, J. R., Bukstein, O. G., Wood, D. S., Kirisci, L., Douaihy, A., & Clark, D. B. (2010).
Double-blind placebo-controlled trial of fluoxetine in adolescents with comorbid major depres-
sion and a cannabis use disorder. Drug and Alcohol Dependence, 112, 39–45.
Cornelius, J. R., Douaihy, A., Bukstein, O. G., Daley, D. C., Wood, D. S., Kelly, T. M., & Salloum, I.
M. (2011). Evaluation of cognitive behavioral therapy/motivational enhancement therapy (CBT/
MET) in a treatment trial of comorbid MDD/AUD adolescents. Addictive Behaviors, 36, 843–848.
Johnston, L. D., O’Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2012). Monitoring the future
national results on adolescent drug use: Overview of key findings, 2011. Ann Arbor, MI: Institute for
Social Research, the University of Michigan. Available at: monitoringthefuture.org.
Kaminer, K., & Winters, K. C. (2011). Clinical manual of adolescent substance abuse treatment.
Washington, DCL American Psychiatric Publishing.
Merikangas, K. R., He, J. P., Burstein, M., Swanson, S. A., Avenevoli, S., Cui, L., Benjet, C., Georgiades,
K., & Swendsen, J. (2010). Lifetime prevalence of mental disorders in U.S. adolescents: Results
from the National Comorbidity Survey Replication—Adolescent Supplement (NCS-A). Journal
of the American Academy of Child and Adolescent Psychiatry, 49, 980–989.
National Institute on Alcohol Abuse and Alcoholism. (2011). Alcohol screening and brief intervention
for youth: A practitioner’s guide. NIH Publication No. 11-7805. Available at: www.niaaa.nih.gov/
YouthGuide.
Thatcher, D. L., & Clark, D. B. (2006). Adolescent alcohol abuse and dependence: Development,
diagnosis, treatment and outcomes. Current Psychiatry Reviews, 2, 159–177.
 Chapter 13 337

Prevention and Harm

Reduction Interventions
Inti Flores and Antoine Douaihy

Key Points 338

Prevention 340
Harm Reduction 342
Specific Areas of Focus: Substance of Use 344
Harm Reduction Practices for High-risk Sexual Behaviors and
Human Immunodeficiency Virus 352
Acknowledgment 355
References and Suggested Readings 356
338 Substance Use Disorders

Key Points
• Effective prevention approaches are required before and after
symptoms become apparent because substance use disorders are
chronic and relapsing illnesses.
• Three levels of prevention interventions are defined as universal,
selective, and indicated.
• The U.S. National Institute of Drug Abuse (NIDA) has developed a list
of principles for prevention, drawn from long-term research studies on
the origins of substance use behaviors and the common elements of
effective prevention programs.
• Prevention programs should enhance protective factors and reverse
or reduce risk factors, should be tailored to address risks specific to
population characteristics, and should be long-term, with repeated
interventions to reinforce the original prevention goals.
• Harm reduction identifies the complexities of high-risk behaviors
instead of pathologizing them.
• Harm reduction approaches provide a middle-way alternative between
total abstinence and continued harmful use or behavior, therefore
allowing different pathways for change.
• Harm reduction strategies are compassionate, pragmatic strategies
that reduce harm, promote quality of life, and even decrease high-risk
behavior.
Traditionally, addiction treatment programs have focused mostly on the
management of individuals with severe substance use disorder (SUD),
who represent a small percentage of all those with alcohol and drug use
behaviors. For instance, heavy drinkers and binge drinkers with no or low
physiological dependence represent a larger proportion of people than
do drinkers with alcohol dependence. Therefore, even though per capita
their risk for causing a fatal crash while intoxicated is less likely to happen,
their large number means that they account for a majority of drunk-driving
consequences, including deaths (Institute of Medicine, 1990). This has
been described as a “prevention paradox,” meaning that if we are focus-
ing primarily on persons with severe SUD, we are not addressing most of
the problem (Babor, 2010; Miller et al., 2011). This chapter discusses the
basic understanding of the principles of prevention interventions and the
three types of prevention interventions. It focuses also on harm reduction
strategies targeting specific substances of use as well as high-risk sexual
behaviors and human immunodeficiency virus (HIV).
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340 Substance Use Disorders

Prevention
Prevention is understood as any approach designed to avoid substance
use behavior and reduce its health and psychosocial consequences. This
approach can include activities aimed to reduce supply, based on the prin-
ciple that the decreased availability of substances reduces the opportuni-
ties for a SUD, and actions aimed to reduce demand, including health
promotion and disease prevention. Epidemiological studies have demon-
strated continuous shifts between periods of increasing and decreasing
abuse of substances (Sulkunen, 1976). Prevention interventions have the
potential to change the trend, generate or reinforce the downward shift,
or help diminish the rising trend. In addition, it is now well established that
effective prevention approaches are required before and after manifesta-
tions are evident because SUDs are identified as chronic and relapsing
illnesses. The prevention of recurrence and relapse is also recognized as
an essential aspect of a public health strategy to reduce prevalence.
The need for an integrated strategy of supply and demand reduction
was addressed during the 20th Special Session of the United Nations held
in New York in 1998 (U.N. Drug Control Program, 1998). The session
emphasized the importance of identifying the problem and assessing it
as fundamental. then targeting it by promoting abstinence and reducing
negative consequences of use through education, public awareness, early
intervention, and facilitating access to care; and then forging partnerships
through the promotion of a community-wide participatory and partner-
ship approach. This approach is the basis for the accurate assessment of
SUDs and the formulation and implementation of appropriate strategies,
integrated into broader social welfare and health promotion policies and
preventive education programs. Another focus should be on specific sub-
groups such as youth, with an emphasis on disseminating messages that are
accurate and culturally appropriate. Three levels of preventive interven-
tions exist on a continuum: universal, selective, and indicated, according
to the level of risk of using substances. Prevention approaches may target
different areas, for example, controlling affordability, availability through
marketing, and harmful consequences of substance use in the population
(Babor, 2010). The NIDA has developed a list of principles for prevention,
drawn from long-term research studies on the origins of substance abuse
behaviors and the common elements of effective prevention programs
(NIDA, 1997).
Universal prevention is the strategy that addresses the general public or
the entire population (national, local community, school, and neighbor-
hood) with messages and programs aimed at preventing or delaying the
use of substances. Gradual changes that reduce availability are effective.
For example, modest tax increases do tend to reduce smoking and drink-
ing, particularly among the young with low income. Overall reductions in
use at the population level are observed in parallel reductions in psycho-
social and health problems related to drug use (Babor, 2010).
Selective prevention includes those strategies targeting subgroups of the
population identified at risk for developing a SUD (these persons may be
at imminent risk or have a lifetime risk). How to identify these individu-
als at higher risk is a major challenge. Significant numbers of studies have
 13 PREVENTION AND HARM REDUCTION INTERVENTIONS 341

examined longitudinal risk factors for alcohol and other drug use disor-
ders. Risk groups may be identified on the basis of biological, psychological,
social, or environmental risk factors known to be associated with substance
abuse (IOM, 1994), and targeted subgroups may be defined by demograph-
ics, family history, place of residence such as high drug-use or low-income
neighborhoods, poverty, lack of health and social services, and psychiatric
comorbidity. The significance of these risk factors varies during the devel-
opmental stages (NIDA, 1997; Villatoro et al., 1998). For example, it is now
clear that the biological relatives of people with SUD are at higher risk
themselves. Another well-established risk factor is relative sensitivity to
alcohol: the ability to try to “hold your liquor” without feeling or appearing
to be affected (Schuckit & Smith, 2010). Apparently this is a heritable trait
on which individuals vary influenced by multiple genes (Joslyn et al., 2010).
“Low-response” people (individuals who exhibit little response to a small
dose of alcohol indicating relative insensitivity to the drug) have substan-
tially greater risk for developing alcohol dependence. Being able to hold
your liquor is not protective. Another example of a population that would
benefit from a preventive approach is offenders with a history of SUD, just
before and after release from jail. Release is a risky transition period, poten-
tially leading to a return to substance use and an increase in drug-related
serious consequences, including death, mostly related to decreased toler-
ance and overdose (Merrall et al., 2010). Exposure to risk factors does
not necessarily lead to substance use or escalation to dependence. For
instance, children raised in problematic family environments, even under
circumstances where substances are easily accessible, may reach adulthood
without having even experimented with substances, owing to the presence
of protective factors that offset existing risk factors (Villatoro et al., 1998).
Indicated prevention interventions are defined as those targeting
high-risk individuals who are already showing detectable signs or symp-
toms but who do not meet American Psychological Association Diagnostic
and Statistical Manual of Mental Disorders (DSM-IV-TR) criteria for SUD,
at an early stage of development. Less emphasis is placed on assessing or
addressing environmental influences, such as community values. The aim
of indicated prevention programs is not only the reduction in first-time
substance abuse but also reduction in the length of time the signs continue,
delay of onset of substance abuse, and/or reduction in the severity of sub-
stance abuse, conduct disorders, and alienation from parents, school, and
positive peer groups. Intervening early is fundamental and necessary. As
with most chronic illnesses, SUDs are usually easier to turn around if rec-
ognized and treated at an earlier stage of development, preventing later
development of significant negative consequences. Another major reason
for intervening early is preventing serious consequences of heavy drinking
and other drug use (Hingsen et al., 2005). The main recommended goal
of the brief intervention with heavy drinkers is to reduce consumption
to a moderate- or low-risk level and also possibly abstinence. Another
strategy for indicated prevention is reaching people in the course of their
use behaviors to offer them services (Velicer et al., 2006). For example,
tobacco quitlines offer free smoking cessation counseling by phone in the
United States (1-800-QUIT-NOW), which have been found to be as effec-
tive as face-to-face services (Lichtenstein et al., 2010).
342 Substance Use Disorders

Harm Reduction
Harm reduction represents both an attitude and a set of compassion-
ate and pragmatic approaches, considered a form of indicated preven-
tion, designed to reduce the harm stemming from high-risk behaviors
and increase quality of life for affected individuals and their communities
(Marlatt, 1998). The recent integration of harm reduction policy into
U.S. law has occurred long after the enactment of more comprehensive
harm reduction policies in many countries in Europe, South America, the
Middle East, and Asia (Ball et al., 2007).
Harm reduction refers to strategies, policies, and programs created in
an effort to reduce the negative consequences to individuals and society
that result from substance use. The compassionate aspect of harm reduc-
tion refers to understanding and approaching high-risk behaviors in a way
that is respectful and inclusive of individuals affected by these behaviors
and their communities. Harm reduction reflects a humanistic approach,
and most recently it is recommended that individuals and their communi-
ties be involved in devising their own means to reduce harmful behaviors
and defining their own ends as to what harm reduction will comprise
(UNAIDS, 2010). The pragmatic aspect of harm reduction refers to the
implementation of evidence-based strategies that have been proven sci-
entifically to reduce harm in accordance with human rights protections
(Degenhardt et al., 2010). Defining harm depends on multiple contextual
factors and their potentially interactive nature.

Principles of Harm Reduction

The principles of harm reduction are based on a pragmatic view of drug
use in society—at any given time, there will always be a segment of people
who use drugs who are unable or unwilling to stop use. A harm reduction
perspective recognizes that drug use represents a continuum of behaviors
with associated harms, and works to meet users “where they’re at” to
reduce specific risks associated with their current patterns of use. Because
the goal of harm reduction is to target well-defined risks, there is no soli-
tary model that will be effective across a range of geographic, social, cul-
tural, and political settings. The principles of harm reduction, however, are
universally applicable.
1. Harm reduction focuses on specific risks and harms associated
with substance use. In order for harm reduction to enact effective
interventions, it must target well-defined risks or harms that are
associated with the use of psychoactive substances. This targeting of
harm reduction to specific risks means that harm reduction practices
might vary substantially from one community to the next. Effective
harm reduction necessitates identifying harms and their causes, and
then implementing targeted interventions designed to disrupt the
path that links drug use to specific negative outcomes.
2. Harm reduction is evidence based and evolving. A harm reduction
approach depends on feedback that demonstrates the effectiveness
of its practices in reducing the risks they target. The techniques of
harm reduction must be safe, practical, effectual, and cost effective.
 13 PREVENTION AND HARM REDUCTION INTERVENTIONS 343

Reduced harm that translates into improved quality of life for

individuals, community, and society is the rubric by which harm
reduction policies are assessed.
3. Harm reduction is incremental, with a continuum of potentially
positive outcomes. Rather than insisting on a single outcome (i.e.,
abstinence), a harm reduction approach recognizes the spectrum of
ways in which an individual or society may benefit from small changes
in drug use behaviors. The goals of harm reduction can be organized
along a continuum that includes abstinence at one end, at the same
time encouraging incremental movement along the continuum to
reduce the negative consequences of drug use. The spectrum of harm
reduction provides a variety of manageable options to drug users to
reduce the risks associated with their own patterns of use.
4. Harm reduction is premised on compassion and respect for the
autonomy of people who use drugs. At its core, harm reduction is
a nonjudgmental approach that accepts people as they are. A harm
reduction framework recognizes that the stigmatization and moral
judgment of substance users contributes to the harms that result
from drug use. By treating people who use drugs with dignity and
compassion, it becomes possible to form an alliance with users to
explore their struggles and target risks associated with their use.
5. Harm reduction recognizes socioeconomic, political, and biological
factors that make individuals vulnerable to drug use and its associated
harms. Not only do conditions of poverty and discrimination along
the lines of race, class, gender, and sexual identity make some
individuals more vulnerable to substance use and abuse, they also
influence access to treatment and risk for specific drug-related harms.
Harm reduction has an investment in social justice to the extent that
social inequities mediate the harms associated drug use.
6. Harm reduction challenges existing practices and policies that
maximize harm. From a harm reduction perspective, addiction and
substance use represent incredibly difficult struggles through which
users require support in order to minimize harm. Unfortunately,
many of the policies affecting drug users are punitive and have the
effect of removing support and services. In addition to implementing
evidence-based practices to reduce harms associated with drug use,
harm reduction uses evidence to challenge practices and policies
surrounding drug control that have the effect of exacerbating the
harms associated with drug use.
344 Substance Use Disorders

Specific Areas of
Focus: Substance of Use
Alcohol
Alcohol is a widely used substance that is associated with a number of
harms costly to both individuals and society. The disease model of alco-
holism has long been the dominant paradigm used to understand problem
alcohol use in the United States. Although this model has certainly been
useful in many respects, it has also made it difficult to focus on the entire
spectrum of alcohol use and alcohol-related harms. For example, although
a minority of individuals has a diagnosable alcohol use disorder (AUD), far
more people use alcohol to a lesser extent, yet their use often still results
in significant harms. Within a disease model in which alcoholism is viewed
as a chronic and progressive process, traditional treatment options have
been specialized, intensive, and abstinence oriented (Marlatt et al., 2012;
Willenbring, 2010).
A harm reduction approach to alcohol use has been incompatible with
the classic disease model of alcoholism in which a single sip of alcohol
is followed by complete loss of volitional control over drinking (Marlatt
et al., 2012). Nevertheless, recent epidemiological research has begun
to challenge traditional notions of AUDs, suggesting that rather than
being progressive and often fatal, most AUDs remit without treatment
(Dawson et al., 2005; Sobell et al., 2006). Changes in the conceptualiza-
tion of AUDs and the epidemiology of problematic alcohol use, in con-
junction with evidence suggesting improved outcomes for drinkers with
both abstinence and reduced drinking, has opened the door to apply harm
reduction approaches to alcohol use (Marlatt et al., 2012). Some of these
evidence-based approaches are discussed below.

Brief Interventions and Motivational Approaches

In contrast to intensive, abstinence-based treatments for a small number
of individuals with severe AUDs, brief interventions have emerged as an
important harm reduction approach to problem alcohol use that can be
employed across a range of different settings. Brief interventions have
been demonstrated to be as efficacious as more intensive approaches and
can be used to target harms associated with mild and moderate alcohol
use (Project MATCH Research Group, 1997, 1998).
Brief interventions can take a multitude of forms. Motivational inter-
viewing and related motivational enhancement therapies have received
extensive support in the literature for their efficacy in promoting reduc-
tions in alcohol use and decreased drinking related harms (Marlatt et al.,
2012). The motivational approach allows clients to explore ambivalence
surrounding their alcohol use. Nonjudgmental exploration of the benefits
and risks of drinking can facilitate identification of harms and assist clients
in negotiating acceptable strategies to limit these harms (Miller & Rollnick,
2009). Motivational interviewing and related adaptations are practically
implemented across a range of environments, including medical, college,
and workplace settings. This is of particular importance given evidence to
 13 PREVENTION AND HARM REDUCTION INTERVENTIONS 345

suggest that college students are at high risk for alcohol use and associated
negative consequences (Marlatt et al., 2012). In addition to face-to-face
brief interventions, various web-based harm reduction interventions are
being explored.
Cognitive Behavioral Skills Training
Cognitive behavioral skills–based treatments (CSTs) to alcohol harm
reduction help clients address specific cognitive patterns associated with
use and build skills designed to reduce use and associated harms. These
approaches are often quite practical, including relapse prevention compo-
nents that aid in identifying high-risk situations and then developing spe-
cific skills to be utilized in these settings to maintain drinking goals. CSTs
can include cue exposure as well as more general approaches to target
negative cognitions and daily social skills in an effort to better manage
triggers for alcohol use (Marlatt et al., 2012). Harm reduction psycho-
therapeutic approaches may often combine different aspects of cognitive
behavioral, motivational, and mindfulness-based techniques to achieve
risk-reduction goals.
Contingency Management
Contingency management, premised on operant conditioning, uses posi-
tive reinforcement to maintain desired treatment outcomes. Although
there has been support in the literature for contingency management, cost
and feasibility are limited given the frequency with which objective screen-
ing for alcohol use must be utilized for accurate detection. Nevertheless,
there may be benefit to reinforcing other positive outcomes, such as treat-
ment attendance and engagement (Marlatt et al., 2012).
Disulfiram
Disulfiram inhibits the enzyme acetaldehyde dehydrogenase, which con-
verts acetaldehyde formed from alcohol metabolism into acetic acid.
Inhibition of acetaldehyde dehydrogenase leads to accumulation of acetal-
dehyde in the body with associated severe hangover symptoms. Disulfiram
can thus be used to discourage alcohol consumption (Marlatt et al., 2012).
Disulfiram’s efficacy depends on medication adherence, and there is evi-
dence to suggest that without close monitoring adherence is quite low
(Barth & Malcom, 2010). Additionally, given the severity of physiologic
symptoms induced by alcohol in a person taking disulfiram, this medica-
tion is less suited to reduction in alcohol consumption than to complete
abstinence (Marlatt et al., 2012).
Naltrexone
Naltrexone is a mu-opioid antagonist that is used to reduce alcohol-induced
release of dopamine from the nucleus accumbens, thereby decreasing the
pleasurable effects of drinking (Marlatt et al., 2012). Naltrexone reduces
the positive reinforcement associated with alcohol use and is compatible
with both moderation and abstinence treatment goals.
Acamprosate
Acamprosate increases GABAergic inhibition through modulatory effects
on NMDA receptors, thereby reducing alcohol withdrawal symptoms
346 Substance Use Disorders

and the urge to use alcohol (Marlatt et al., 2012). Acamprosate is thus
complementary to naltrexone by mitigating the sensations that might lead
to alcohol use.
Tobacco
Nicotine—most commonly obtained by smoking tobacco—is one of the
most widely used substances worldwide. Smoking is a major cause of mor-
bidity and mortality and is responsible for one in five or approximately
443,000 deaths per year in the United States (CDC, 2012). Cigarettes have
been shown to be a strong risk factor in the development of lung disease,
including cancer, cardiovascular, and cerebrovascular disease. In addition
to personal disease-related harm associated with cigarette use, there is an
enormous cost to society. In 2004, tobacco use cost the United States an
estimated 193 billion dollars in lost productivity and health-related costs
(CDC, 2009).
Despite the well-established and publicized harms associated with ciga-
rettes, they are still widely used. In 2009, an estimated 46.6 million (20.6%)
adults aged 18 years and up were current smokers (CDC, 2009). In addi-
tion to being highly addictive, causing uncomfortable symptoms of with-
drawal in many users, nicotine is also a mild stimulant and can have the
effect of calming and focusing its users. Although the use of nicotine itself
is very low risk, it is the dominant method of obtaining the drug—smoking
cigarettes—that accounts for the enormous harms associated with its use
(Marlatt et al., 2012). Tobacco harm reduction (THR), then, is focused on
substituting alternate, low-risk systems for nicotine delivery for cigarette
smoking.
There is a variety of low-risk nicotine products whose use could
greatly decrease the individual and societal harms resulting from ciga-
rette use. These include pharmaceutical nicotine products that deliver
nicotine that has been removed from tobacco (e.g., patches, gum, loz-
enges, inhalers) as well as smokeless tobacco products (ST). These
include traditional chewing tobacco (snuff) and dry, powdered versions
for nasal use. There has also been a recent increase in electronic ciga-
rettes designed to produce low-risk nicotine containing vapor, closely
simulating the act of smoking.
THR strategies have not been widely implemented despite their great
potential to mitigate the enormous burden to individuals and society cre-
ated by smoking. In large part, this is the result of the widespread misper-
ception that ST use is itself a high-risk behavior (Marlatt et al., 2012). In
particular, there remains a persistent perception among medical pro-
viders and laypersons alike that ST is associated with significant risk for
oral cancers. Multiple epidemiological studies, including a 2004 review
article, have determined this risk to be minimal (Rodu & Jansson, 2004).
As noted by Phillips et al., a small increase in the risk for oral cancers—
already a rare disease in Western societies—is greatly outweighed by the
decreased risk for lung and cardiovascular disease directly attributable to
smoking (Marlatt et al., 2012). Furthermore, the widespread adoption of
THR has the potential to decrease the significant harms associated with
second-hand smoke.
 13 PREVENTION AND HARM REDUCTION INTERVENTIONS 347

Cannabis
Cannabis is the most commonly used illicit drug in the United States
(World Health Organization, 2008). Cannabis is widely regarded as a rela-
tively low-risk substance, and this perception has made it challenging to
address the potential harms associated with its use. Although for many
people infrequent use may be associated with very little harm to them-
selves and to society, more frequent users are at increased risk for depen-
dence and may be more susceptible to related harms. Indeed, as noted by
Roffman and Stevens, in discussing harm reduction related to cannabis, it
is crucial to keep in mind both extremes in the continuum of cannabis use
profiles and consequences (Marlatt et al., 2012).
Of particular importance to harm reduction with regard to cannabis is
use among adolescent and young adults. Rates of cannabis use are high-
est amongst individuals aged 18 to 25 years. Epidemiological studies have
raised concern that use among adolescents is associated with poorer psy-
chosocial outcomes. Given the drug’s acute effects on cognition, it is easy
to see how frequent users may be hampered by their use. Additionally,
cannabis use has clearly been associated with psychiatric consequences,
including acute panic reactions, depersonalization, and increased risk for
acute psychosis in susceptible individuals. Given that the most common
means of utilizing cannabis has been through smoking, use has also been
linked to respiratory and cardiovascular risks (Marlatt et al., 2012).
A harm reduction approach to cannabis use should take into account all
of what we know about the risks and benefits of cannabis use to help users
minimize the harm associated with their current patterns of use. Providing
objective information that neither exaggerates nor minimizes risks can avoid
alienating users while helping them make informed choices that decrease
the potential for associated harm (Marlatt et al., 2012). Brief “check-up”
interventions to assess use and provide feedback without pressure to
change may aid in engaging individuals whose use is problematic but who
might not have otherwise sought treatment (Walker et al., 2006). Treatment
approaches incorporating CST, motivational, and contingency management
approaches have shown efficacy in helping users decrease use and associ-
ated problems (Marlatt et al., 2012). Finally, encouraging lower-risk modes
of administration, such as ingestion or inhalation following vaporization, can
decrease adverse effects resulting from inhalation of smoke.
Cocaine
Cocaine and its derivative crack cocaine are powerful stimulants that
can be administered by a variety of methods, including injection, snort-
ing, smoking, and oral ingestion. Its use is associated with a number of
severe physical, mental, and social harms. Transmission of blood-borne
viruses like HIV and hepatitis C virus (HCV) is consistently associated with
stimulant use; in addition to engaging in risky sexual practices, users who
inject cocaine are more likely than heroin injectors to engage in particu-
larly risky behaviors surrounding use of equipment for drug preparation
and injection (Marlatt et al., 2012). Cocaine users are also at risk for a host
of other significant cardiovascular, pulmonary, neurologic, and infectious
complications. Harm reduction for cocaine use is focused on modifying
348 Substance Use Disorders

use patterns to minimize harmful effects on users’ physical, mental, and

social health.
Analogous to the implementation of needle and syringe exchange pro-
grams (NSEPs) for other intravenous drug–using groups, programs pro-
moting safer injection are a cornerstone of decreasing transmission of
blood-borne viruses among cocaine users. Provision of materials (needles,
syringes, water, containers for drug preparation) can reduce risk for viral
transmission. Rubber tips can be used on crack pipes to protect users
with cut or burnt lips who are sharing a pipe (Marlatt et al., 2012). In
addition to simply providing materials for safer injection, the possibility of
creating safe injection sites (“user rooms”) has been suggested as a harm
reduction strategy. User rooms would provide a controlled environment
in which users could prepare and inject drugs safely in the presence of
trained personnel who could assist in the event of an emergency (includ-
ing overdose). These sites would also function as a safe place to dispose
of drug-related paraphernalia, reducing public disorder associated with
intravenous use. Although the frequency with which cocaine users often
inject could pose a challenge to safe injection spaces, data from other
countries suggest positive outcomes associated with supervised injection
sites (Marlatt et al., 2012). Additionally, user rooms provide an interface
between marginalized substance users and providers of health care and
social services, facilitating education, risk reduction outreach, and referral
to a variety of related services (Tyndall et al., 2006).
A harm reduction approach that has been attempted with cocaine users
involves the use of peer health advocates to provide education regarding
harm reduction techniques for both drug use and high-risk sexual activ-
ity. This innovative approach harnesses preexisting peer networks, train-
ing active drug users in harm reduction techniques and allowing them to
disseminate information and skills throughout their communities. This
approach facilitates the spread of information and skills to a population
that might have never come in contact with providers. Additionally, infor-
mation might be better received coming from peers rather than provid-
ers. Study of one such program, the Risk Avoidance Partnership, suggests
positive outcome for both advocates and their peers (Weeks et al., 2006).
Although there have been controlled trials investigating possible phar-
maceutical interventions for cocaine use, studies to date have not discov-
ered a clinically useful “substitute” therapy. The quick-onset, pleasurable
effects experienced by cocaine users make the search for a reduced-risk
substitute that is acceptable to users challenging. Nevertheless, clinical
investigations in this area are ongoing.
Amphetamines
Amphetamines are a class of central nervous system (CNS) stimulants that
includes prescription medications (methylphenidate, dexamphetamine) as
well as illicit rugs (methamphetamine, MDMA). Administration routes
include snorting, oral ingestion, smoking, rectal administration, and injec-
tion. Harms associated with amphetamine use vary with the specific drug
in question but range from serious physical and mental effects (stroke,
seizures, myocardial infarction, psychosis) to consequences of behaviors
associated with use including injection and high-risk sexual behaviors
 13 PREVENTION AND HARM REDUCTION INTERVENTIONS 349

(DeSandre, 2006). Harm reduction techniques for amphetamine use are

tailored to the drug used as well as the population of users and circum-
stances surrounding use (Marlatt et al., 2012).
One of the prominent issues with MDMA (commonly known as
Ecstasy) in particular is the unpredictability of drug contents when pur-
chased on the street. While there is always the potential for the presence
of a number of different “fillers,” the dose and even chemical composition
of active substance found in different preparations can vary substantially
(Cole et al., 2002). Efforts to assess drug content have been proposed as
a harm reduction strategy. Test kits can be purchased or even found at
venues commonly associated with amphetamine use. Unfortunately, while
such kits can detect the presence of MDMA, their utility in determining
dose and other pill components is quite limited (Marlatt et al., 2012).
Harm reduction efforts regarding sexual risk associated with metham-
phetamine use have targeted men who have sex with men (MSM). Use of
methamphetamine during sex has been associated with high-risk sexual
behaviors across other subgroups, although the practice of pairing use
with sexual behavior (“party and play,” or PNP) is well established in
some MSM communities (Molitor et al., 1998). Harm reduction strategies,
including education, condom distribution, needle exchange, and sexually
transmitted infection testing, are likely to be effective at reducing harms in
this setting (Marlatt et al., 2012).
Finally, substitution therapy with prescribed pharmaceutical amphet-
amines has been attempted as a harm reduction approach. Particularly in
the setting of high-risk amphetamine use (injectors), research investigating
substitution therapy with oral dexamphetamine has shown potential for
positive outcomes including reductions in amount and frequency of injec-
tion amphetamine use (Shearer et al., 2001). Substitution therapy is not
widely used in clinical substance abuse treatment settings.
Opiates
Opiates—also commonly called narcotics—are a class of drugs that inter-
act with the human opioid receptors. Opiates are widely used for anal-
gesia, and some agents also have indications for cough suppression and
severe diarrhea (DEA, 2005). In addition to analgesia, opiates cause seda-
tion, euphoria, and respiratory depression. Cessation after chronic use can
produce severe, uncomfortable symptoms of withdrawal (NIDA, 2005).
These properties, combined with the high prevalence of both acute and
chronic pain disorders for which opiates may be prescribed, contribute to
the high rates of abuse that are seen with this class of drugs.
Illicit use of opiates spans a wide range of behaviors and patterns, from
the misuse of prescription pain medication to intravenous heroin use.
Intravenous heroin use carries the risks common to all intravenous drug
use (blood-borne viral transmission and other infectious complications)
as well as potential for fatal overdose given significant variation in drug
concentration. Nonmedical use of prescription opiates, however, also car-
ries significant risk. Users often modify prescription drugs in ways that
were not intended by the prescriber, including converting pill formula-
tions into powders for snorting or liquids for intravenous injection. These
practices, together with simultaneous use of other CNS depressant drugs
350 Substance Use Disorders

(alcohol, benzodiazepines, heroin), increase the potential for harm, includ-

ing overdose (Marlatt et al., 2012). Opiates are commonly implicated in
drug-related emergency department visits, and opiate misuse is the driver
for a significant economic burden to society (Strassels, 2009).
Opiates have proved to be the most amenable of the drugs of abuse
to harm reduction interventions based on pharmacologic substitutions.
Substitution-based therapies are based on the premise that by provid-
ing dependent individuals with a less harmful alternative under carefully
supervised conditions, withdrawal symptoms will be better controlled,
and patients will be equipped to engage in treatment, avoid illicit sub-
stance use, and build more productive and rewarding lives. Indeed, metha-
done maintenance programs have been shown to have better treatment
retention rates than abstinence-oriented interventions (Tapert et al.,
1998). Methadone maintenance programs have been shown to be effec-
tive in decreasing rates of intravenous drug use, decreasing needle sharing,
decreasing criminal activity, and increasing productivity among participants
(Maddux & Desmond, 1997).
Methadone and buprenorphine are comparable strategies for main-
taining opiate-dependent patients. Nevertheless, there are differences.
Methadone and buprenorphine (commonly prescribed in a formula-
tion combined with naloxone to discourage intravenous use) are dosed
daily and appear to be comparable in both efficacy and client satisfac-
tion (Marlatt et al., 2012). Additionally, there has not been a standard
established for maintenance therapy programs. The adjunctive services
available to individuals through different maintenance programs may vary
substantially, thus affecting outcomes. Nevertheless, the literature clearly
shows that maintenance programs are effective in reducing opiate-related
harm in large part by retaining clients in therapy even despite setbacks.
NSEPs are an important aspect of a harm reduction approach to all intra-
venous drug use, including opiates. These programs arose as an important
public health innovation in the wake of the AIDS epidemic in an effort to
curb transmission of blood-borne viruses spread by sharing of needles,
syringes, and other paraphernalia of intravenous drug use (Drucker et al.,
1998). In addition to reducing the amount of time any particular needle
or syringe circulates, NSEPs provide an important opportunity of interface
between often-marginalized intravenous drug users and medical, social,
and legal service providers. Thus, in addition to the actual exchange of
needles and other intravenous drug paraphernalia, NSEPs are crucial to
educating, engaging, and caring for intravenous drug users.
This page intentionally left blank
352 Substance Use Disorders

Harm Reduction Practices for

High-risk Sexual Behaviors and
Human Immunodeficiency Virus
Four percent of the estimated 56,300 new HIV infections each year have
occurred among MSM who also inject drugs. In addition, many infections
have occurred among MSM who use noninjection drugs such as metham-
phetamine, and such activity is frequently associated with high-risk sexual
behaviors (Ostrow et al., 2009). Moreover, substance abusers remain
an active source of new HIV cases through high-risk behavior (Abdala
et al., 2010; Santos et al., 2011). As targeted practices have been devel-
oped to address and reduce harms associated with high-risk drug use, a
similar framework has evolved to address high-risk sexual behaviors. The
fundamental strategies for preventing HIV transmission through sexual
contact—abstinence, monogamy, and condom use—are highly effective.
Nevertheless, for those individuals most vulnerable to HIV, these strate-
gies are often not utilized. This is reflected in the rising rate of new HIV
infections, particularly within marginalized social groups, including MSM
and women of color, despite the existence of highly effective prevention
strategies. Harm reduction with regard to sexual behavior recognizes the
rich complexity of variables that influence the degree of risk that may be
involved within a particular sexual encounter, and harness the concept of
relative risk in order to modify sexual risk through the preferential use of
lower risk behaviors.
Reducing the risk for sexually transmitted HIV begins with gaining
knowledge of one’s HIV serostatus through testing. There are data to sug-
gest that HIV-positive individuals who know their status are more likely
to engage in practices to reduce the risk for transmission to their sexual
partners (Parsons et al., 2005). Indeed, the rationale supporting Centers
for Disease Control and Prevention (CDC) recommendations for rou-
tine HIV screening is premised on the notion that offering treatment to
HIV-infected individuals can prevent the development of opportunistic
infections in those with HIV and may also reduce the likelihood of con-
tinued transmission through control of viremia, education, and behavioral
modification (Branson et al., 2006). Thus, increasing availability and imple-
mentation of HIV testing services within a variety of health care settings
can have important effects on both primary and secondary prevention.
The consistent use of latex condoms has proved highly effective in
reduction of HIV transmission. Condoms act as a barrier, preventing
exchange of semen and direct contact between fluids and mucous mem-
branes that can result in viral transmission. Availability of condoms and
other barrier devices such as dental dams may be limited in some settings,
leading to decreased use. Making such items available to high-risk indi-
viduals free of cost may increase their use. Still, there appear to be many
factors outside of cost and availability that lead to the underutilization of
effective protection of HIV transmission.
Epidemiological data have shown a trend toward higher rates of inten-
tional unprotected anal sex among MSM since the latter half of the 1990s
 13 PREVENTION AND HARM REDUCTION INTERVENTIONS 353

(Marlatt et al., 2012). The social, cultural, and psychological factors under-
lying the phenomena are quite complex. It is not difficult to see how pre-
vention programs that emphasize only condom use and HIV education
will be ineffective strategies to reduce harm within the setting of men
knowingly engaging in sexual activity that puts them at high risk for HIV
transmission. Similar to the way harm is conceptualized with regard to
drug use, a harm reduction approach views sexual risk-taking behaviors
along a continuum, with abstinence at one end and unprotected anal inter-
course at the other. Harm reduction techniques provide pragmatic ways
to reduce the risk for HIV transmission associated with a given sexual
encounter, while still acknowledging that risk may remain.
Advocating for sexual harm reduction behaviors has been controver-
sial because the associated risk of these behaviors is often still significant.
Nevertheless, the central harm reduction principle of autonomy posits
that people will make their own decisions regarding sexual risk taking.
Risk reduction techniques facilitate nonjudgmental discussion about risk
and thus may result in movement along the continuum toward safer sex
practices and decreased HIV transmission (Marlatt et al., 2012). If unpro-
tected anal intercourse is associated with the highest risk for HIV trans-
mission, it can be seen how other sex acts—including oral sex or mutual
masturbation—can be conceptualized as less risky. Limiting the exchange
of potentially infectious fluids and engaging in noninsertive sexual acts are
important ways to attain sexual satisfaction with minimal risk. Yet even
within the context of unprotected anal sex, risk for viral transmission can
be modified by a number of factors, including partner status (regular vs.
casual), HIV status, sexual positioning (insertive vs. receptive), and degree
of fluid exchange (Marlatt et al., 2012). Sexual harm reduction techniques
involve making active choices regarding these factors in an effort to reduce
risk for viral exposure and transmission.
Serosorting is a technique used to decrease the risk for HIV transmis-
sion through partner selection. Serosorting refers to the practice of having
sex only with people concordant with one’s own HIV infection status. The
effectiveness of serosorting as a harm reduction strategy depends on accu-
rate knowledge and honest disclosure of HIV status. CDC data suggest
that up to 44% of MSM testing positive for HIV were not aware of their
infection at the time of testing (CDC, 2009). Thus, the potential for inac-
curate sorting and resultant HIV transmission is high. Among HIV-positive
men, there is concern that serosorting may promote HIV superinfection
and contribute to drug resistance. There is also the potential to spread
other sexually transmitted infections. Nevertheless, serosorting as a harm
reduction strategy may encourage regular testing and knowledge of one’s
HIV status as well as facilitate discussions between partners about HIV
and risk reduction. There is evidence to suggest that serosorting is already
widely practiced amongst MSM despite clear data regarding its effective-
ness in reducing HIV transmission (Parsons et al., 2005).
Another harm reduction strategy used amongst MSM involves strate-
gic positioning. Because the receptive partner in anal sex faces a greater
risk for HIV transmission, strategic positioning places known positive indi-
viduals in the receptive position. The negative or unknown partner will
be insertive and thus at decreased risk for HIV transmission. Following a
354 Substance Use Disorders

similar logic, withdrawal before ejaculation can be used to limit exchange

of potentially infectious semen. There are data to suggest that some MSM
use the viral load status of their partners to make decisions regarding
sexual positioning and withdrawal. Indeed, high viral load is associated
with higher risk for transmission, although it has been established that
HIV transmission is possible even when viral load is undetectable (Marlatt
et al., 2012).
Finally, in addition to behavioral sexual harm reduction techniques,
recent years have seen the emergence of pharmacologically based harm
reduction. Antimicrobial topical preparations for use in the vagina or
rectum before sexual intercourse are currently under investigation for
their efficacy in preventing HIV transmission in women. Unlike condoms,
women could use this type of prevention strategy without the knowledge
of their sexual partners. This is crucial given the vulnerability of women
globally to disempowerment and sexual violence, factors important to
the spread of HIV transmission within this particular group. Additionally,
there is some evidence to support the daily use of oral antiretrovirals as
pre-exposure prophylaxis (PrEP) in high-risk groups. PrEP is not intended
to be used as a stand-alone method and may only be appropriate in
carefully selected patients (CDC, 2009). Further investigation into the
long-term safety and efficacy of these methods may result in more wide-
spread use as harm reduction techniques.
 13 PREVENTION AND HARM REDUCTION INTERVENTIONS 355

Acknowledgment
The preparation of this chapter was supported in part by the National
Institute on Drug Abuse grant #5U10DA020036-08.
356 Substance Use Disorders

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 359

Online Resources List for

Substance Use Disorders
and Co-occurring
Disorders
Prepared by Janis McDonald and Dennis
C. Daley, PhD of the A.T.S. Node of Clinical
Trials Network of NIDA

Table of Contents
1. Mutual Support Organizations
Page
1. Adult Children of Alcoholics 361
2. Al-Anon and Ala-Teen 361
3. Alcoholics Anonymous 362
4. Alcoholics for Christ 362
5. Alcoholics Victorious 363
6. Celebrate Recovery 363
7. Cocaine Anonymous 364
8. Crystal Meth Anonymous 365
9. Double Trouble in Recovery 365
10. Dual Recovery Anonymous 366
11. Emotions Anonymous 366
12. Families Anonymous 367
13. Gamblers Anonymous 367
14. LifeRing Secular Recovery 368
15. Men for Sobriety 369
16. Methadone Anonymous 369
17. Methadone Support 370
18. National Association for Children of Alcoholics 370
19. National Alliance for Medication Assisted Recovery 371
20. Nar-Anon Family Groups 371
21. Narcotics Anonymous 372
22. Overcomers Outreach 372
23. SMART Recovery 373
24. Secular Organizations for Sobriety 373
25. Women for Sobriety 374
360 Substance Use Disorders

2. Organizations for Professionals

1. American Academy of Addiction Psychiatry 375
2. American Association for the Treatment of Opioid Dependence 375
3. American Society of Addiction Medicine 376
4. Center for Substance Abuse Prevention/SAMHSA 376
5. Center for Substance Abuse Treatment/SAMHSA 377
6. Children of Alcoholics Foundation 377
7. College on Problems of Drug Dependency 378
8. National Association of Addiction Treatment Providers 379
9. National Clearinghouse for Alcohol and Drug Information 379
10. National Institute on Alcohol Abuse and Alcoholism 380
11. National Institute on Drug Abuse 381
12. National Organization on Fetal Alcohol Syndrome 382
13. Research Society on Alcoholism 382
14. State Associations of Addiction Services 383
15. Substance Abuse and Mental Health Services Administration 384
16. William L White Papers 385
1. Mutual Support Organizations
Organization/Contact Purpose Components
Information
1) Adult Children of • Adult Children of Alcoholics is an anonymous 12-Step, 12-Tradition • Group meetings
Alcoholics program of women and men who grew up in an alcoholic or • Telephone meetings
Phone 562–595-7831 otherwise dysfunctional home. • Online meetings/chat
http://www.adultchildren.org • We meet with each other in a mutually respectful, safe environment • Online forums
and acknowledge our common experiences. We discover how • Written materials
childhood affected us in the past and influences us in the present.
We take positive action.
• By practicing the 12 Steps, focusing on The Solution, and accepting a
loving Higher Power of our understanding, we find freedom from the

ONLINE RESOURCES LIST FOR SUDS

past and a way to improve our lives today.
2) Al-Anon and Ala-Teen • Since its founding in 1951, these have shared a single purpose: to help • Support for spouses and
http://www.al-anon.alateen. family and friends recover from the effects of someone else’s drinking. partners, adult children of
org/ • Members share their personal experiences and stories, and invite alcoholics, teens, parents,
1–888-425–2666 other members to “take what they like and leave the rest”—that is, to grandparents, and siblings
Western Pennsylvania decide for themselves what lesson they could apply to their own lives. affected by someone
Meetings: • The best place to learn how Al-Anon works is at a local meeting else’s drinking.
Phone: 800–628-8920 • Personal contact is an important element in the healing process. • Face-to-face meetings
http://www.pa-al-anon.org/ • Web page selections give encouragement to visit your first meeting. • Online and telephone
• Newcomers are often interested in learning from members whose meetings (call
personal situations most closely resemble theirs. 1–800-628–8920)
• After attending Al-Anon meetings, they begin to understand how
much they have in common with everyone affected by someone else’s
drinking, regardless of the specific details of their personal situation.
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1. Mutual Support Organizations (Continued)

Substance Use Disorders

Organization/Contact Purpose Components
Information
3) Alcoholics Anonymous • Alcoholics Anonymous is a fellowship of men and women who share • Regularly scheduled local
(AA) their experience, strength and hope to solve their common problem community meetings
http://www.aa.org/ and help others to recover from alcoholism. • Sponsors
A.A. World Services, Inc., • The only requirement for membership is a desire to stop drinking. • 12-Step programs
11th Floor 475 Riverside Dr. at• There are no dues or fees for AA membership; we are self- • Books/pamphlets, videos,
West 120th St. New York, NY supporting through our own contributions. and periodicals related to
10115 (212) 870-3400 • AA is not allied with any sect, denomination, politics, organization, recovery
or institution; does not wish to engage in any controversy; neither • Opportunities for service
endorses nor opposes any causes. • Recovery events
• Our primary purpose is to stay sober and help other alcoholics to
achieve sobriety.
4) Alcoholics for Christ • AC is an interdenominational, nonprofit, Christian fellowship that • Face-to-face meetings
www.alcoholicsforchrist.com ministers to 3 groups: substance abusers, family members, and adult • Newsletters
Email: office@ children raised in alcoholic, substance abuse, or dysfunctional families. • Children and family
alcoholicsforchrist.com • AC ministries is dedicated to the propagation of the gospel of Jesus programs
Telephone: 248-399-9955 Christ, as well as sharing His burden for the lost and hurting individuals. • Prison/jail ministries
Fax: 248-399-1099 • This fellowship uses the Word of God as its primary source of direction.
Address: 1316 N. Campbell • Our chief goal is to direct and restore the alcoholic or substance
Rd. abuser, the family member, and the adult child to a sincere and
dedicated relationship with Jesus Christ.
Royal Oak, MI 48067
• We encourage that persons stay active in their local A/C, AA, NA,
ACOA, or other support group and continue to worship within their
own body of believers.
5) Alcoholics Victorious • AV is a network of Christian support groups for addicted persons. • Community Christian
(AV) We believe that alcoholism is an addiction, and that the alcoholic is support group meetings
http://www. an individual who cannot, as a matter of will power alone, control • Use of 12 Steps and
alcoholicsvictorious.org the dependency. Alcoholics Victorious
phone: 816-561-0567 • Some groups also sponsor meetings for the spouses and concerned Creed
friends of addicts. • Some meetings held to
• We are devoted to: support and education about addictive benefit family and friends
problems, reconciliation to GOD and family, and encouragement and of addicts
support of one another through fellowship in recovery.

ONLINE RESOURCES LIST FOR SUDS

• In AV meetings, both the 12 Steps and the Alcoholics Victorious Creed
are used.
6) Celebrate Recovery • A Christ-centered recovery program: Over 700,000 people have • Christ-centered recovery
http://www.celebraterecovery. gone through the Celebrate Recovery program in more than 17,000 program
com churches worldwide. • Use of 8 Recovery
email: info@celebraterecovery.• Celebrate Recovery is a program designed to help those struggling Principles, “The Road to
com with hurts, hang-ups, and habits by showing them the loving power Recovery” based on the
of Jesus Christ through the recovery process. Beatitudes
• Use of “Life’s Healing
Choices in Step Studies”
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Substance Use Disorders
1. Mutual Support Organizations (Continued)

Organization/Contact Purpose Components

Information
7) Cocaine Anonymous • CA is concerned solely with the personal recovery and continued • Regularly scheduled
(CA) sobriety of individual drug addicts who turn to our Fellowship for meetings
http://www.ca.org/ help. • Focus on 12-Step
W. Pennsylvania Contact: • CA is open to all persons who state a desire to stop using cocaine, philosophy
Phone: Tom 412-874-0667 including “crack” cocaine, as well as all other mind-altering substances. • Reading materials related
http://www.caofpa.org • There are no dues or fees for membership. Our expenses are to addiction and recovery
supported by the voluntary contributions of our members — we
respectfully decline all outside contributions. We are not allied with
any sect, denomination, politics, organization, or institution.
• Like AA (with which we are not affiliated), we use the 12 Step
recovery method, which involves service to others as a path toward
recovery from addiction.
• We feel that one addict talking to another can provide a level of
mutual understanding and fellowship that is hard to obtain through
other methods.
• We hold regular meetings to further this fellowship and to allow new
members to find us and, perhaps, the answers they seek.
8) Crystal Meth Anonymous • CMA is a fellowship of men and women who share their experience, • 12 Steps and 12
(CMA) strength, and hope with each other so that they may solve their Traditions
http://www.crystalmeth.org common problem and help others to recover from addiction to • Regularly scheduled
crystal meth. meetings in selected areas
4470 W. Sunset Blvd, Suite
107 PMB 555 • The only requirement for membership is a desire to stop using. of the country
Los Angeles, CA 90027-6302 • There are no dues or fees for CMA membership; we are self- • Sponsors
Phone: 213-488-4455
supporting through our own contributions. • Literature and readings
• CMA is not allied with any sect, denomination, politics, organization,
or institution; does not wish to engage in any controversy; and
neither endorses nor opposes any causes.
• Our primary purpose is to lead a sober life and to carry the message
of recovery to the crystal meth addict who still suffers.
9) Double Trouble in • DTR is designed to meet the needs of the dually diagnosed and • 12-Step based

ONLINE RESOURCES LIST FOR SUDS

Recovery is clearly for those having addictive substance problems as well as • Recovery group meetings
http://www. having been diagnosed with a psychiatric disorder. • Online access to reading
bhevolution.org/public/ • DTR follows a 12-Step approach to recovery. materials, pamphlets, etc.
doubletroubleinrecovery • Working the DTR 12 Steps and regular attendance at DTR and other related to dual diagnosis
Double Trouble in Recovery appropriate self-help groups will help us gain the rewards of sanity, and recovery
c/o MH Empowerment Project serenity, and freedom from addictions.
271 Central Ave, • There are no dues or fees for DTR membership; they are self-
supporting through contributions.
Albany NY 12209
518-434-1393
MyIndependentLiving.org
(meeting list not available)
(continued)

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1. Mutual Support Organizations (Continued)

Substance Use Disorders

Organization/Contact Purpose Components
Information
10) Dual Recovery • DRA is a 12-Step program for individuals who experience both • Group meetings
Anonymous (DRA) addiction and an emotional or psychiatric illness. Men and women • Follows 12-steps and
http://draonline.org/dual_ who currently use psychiatric medications under a doctor’s care, or 12-traditions
diagnosis.html who have done so in the past, are welcome to participate. • Bookstore, DD-related
Dual Recovery Anonymous • The primary purpose of DRA is to help one another achieve dual downloads, etc.
World Network Central recovery, to prevent relapse, and to carry the message of recovery • Sponsors
Office P.O. Box 8107, Prairieto others who experience dual disorders.
Village, Kansas, 66208 • DRA has two requirements for membership: a desire to stop using
E-mail: draws@draonline.org alcohol and other intoxicating drugs, and a desire to manage our
Phone: 913-991-2703 emotional or psychiatric illness in a healthy and constructive way.
(9-5 Central) • DRA is a nonprofessional self-help program. The DRA fellowship has
no opinion on matters of diagnosis, treatment, medication, or other
issues related to the health care professions.
11) Emotions Anonymous • EA is a 12-Step organization, similar to AA. • EA book, which features
(EA) • Our fellowship is composed of people who come together in writings on the Steps and
PO Box 4245 weekly meetings for the purpose of working toward recovery from personal recovery stories,
emotional difficulties. our daily meditation book
St. Paul, MN 55104-0245 Today, and program-
651-647-9712 • EA members are from many walks of life and are of diverse ages,
economic status, and social and educational backgrounds. approved literature.
www.emotionsanonymous.org
• The only requirement for membership is a desire to become well • Weekly face-to-face
emotionally. meetings
• Online discussion
12) Families Anonymous • FA is a 12-Step fellowship for the families and friends who have • Online Meeting Without
(FA) known a feeling of desperation concerning the destructive behavior Walls group
PO Box 3475 of someone very near to them, whether caused by drugs, alcohol, or • National and international
Culver City, CA 90231-3475 related behavioral problems. face-to-face meetings
800-736-9805 • When you come into our rooms you are no longer alone, but among • Literature, CDs, group
friends who have experienced similar problems. materials available online
www.familiesanonymous.org
• Any concerned person is encouraged to attend our meetings, even if
there is only a suspicion of a problem.
13) Gamblers Anonymous • GA is a fellowship of men and women who share their experience, • 12-Step program

ONLINE RESOURCES LIST FOR SUDS

(GA) strength and hope with each other that they may solve their • U.S. face-to-face meetings
International Service Office common problem and help others to recover from a gambling • U.S. hotlines
problem.
PO Box 17173 • Intergroup mail addresses
• The only requirement for membership is a desire to stop gambling.
Los Angeles, CA 90017 • Gam-Anon help for family
• There are no dues or fees for Gamblers Anonymous membership; and friends
213-386-8789 we are self-supporting through our own contributions.
www.gamblersanonymous.org • Gamblers Anonymous is not allied with any sect, denomination, • Sponsors
politics, organization, or institution; does not wish to engage in any
controversy; neither endorses nor opposes any cause. Our primary
purpose is to stop gambling and to help other compulsive gamblers
do the same.
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Substance Use Disorders
1. Mutual Support Organizations (Continued)
Organization/Contact Purpose Components
Information
14) LifeRing Secular • The “3-S” Philosophy: “3-S” is short-hand for the fundamental • Face-to-face meetings
Recovery (LSR) principles of LifeRing: Sobriety, Secularity, and Self-Help. • Practice the “Sobriety
http://lifering.org/ • Sobriety. In LifeRing it always means abstinence. Priority”
LifeRing Service Center • The basic membership requirement is a desire to remain abstinent • On-line forums
1440 Broadway, Suite 312 from alcohol and “drugs.”
Oakland, CA 94612-2023 • LifeRing welcomes people regardless of their “drug of choice.”
• Secularity. LifeRing Recovery welcomes people of all faiths and none.
• You get to keep whatever religious beliefs you have, and you are
under no pressure to acquire any if you don’t.
• Participants’ spiritual or religious beliefs or lack thereof remain
private.
• Self-help in LifeRing means that the key to recovery is the individual’s
own motivation and effort.
• The main purpose of the group process is to reinforce the
individual’s own inner strivings to stay clean and sober.
• LifeRing is a permanent workshop where individuals can build their
own Personal Recovery Plans.
15) Men for Sobriety (MFS) • MFS is a non-profit organization dedicated to helping men overcome • Men’s sobriety programs
PO Box 618 alcoholism and other addictions. (access thru WFS
Quakertown, PA 18951-0618 • Our “New Life” Program helps achieve sobriety and sustain ongoing website)
Phone: 215-536-8026 recovery. • Self-help meetings
Fax: 215-538-9026 • MFS is based on a 13-Statement Program of positivity that encourages • 13-Statement program of
emotional and spiritual growth. positivity
http://womenforsobriety.org/
beta2/ Note: Men’s Groups in Canada Only
Men’s brochure: http://www.
womenforsobriety.org/
Brochure/Brochure-%20

ONLINE RESOURCES LIST FOR SUDS

Men%20&%20Addictions.pdf
16) Methadone • AFIRM is a group of methadone maintenance treatment providers, • Community/consumer
Anonymous (MA) consumers, and other interested parties. We support methadone advocates
(AFIRM: Advocates for the maintenance as treatment and as an effective tool of recovery.
Integration of Recovery and • We believe that methadone is a successful form of treatment that
Methadone, Inc) can be enhanced by the integration of other treatment approaches.
http://www. • Our mission includes the education and training of health providers
methadoneanonymous.org/ and the community regarding the benefits of methadone treatment.
• We promote the development and proliferation of MA and other
12-Step fellowships, clinical treatment alternatives, public relations
initiatives, and other political advocacy.

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Substance Use Disorders
1. Mutual Support Organizations (Continued)

Organization/Contact Purpose Components

Information
17) Methadone Support • A nonprofit support organization/website for “Medication Assisted • Group meetings
(MSO) Treatment” (MAT) . . . . those addicted or dependent on opiates for • Online forums
http://www. any reason, from substance abuse to chronic pain. • Publications
methadonesupport.org/ • A 12-step fellowship that gives support to those on MAT, a member
of the Center for Substance Abuse Treatment (CSAT) Patient
Support and Community Education Project (PSCEP), and focus on
the basic needs and rights of both patients and providers.
18) National Association for • NACoA believes that none of these vulnerable children should grow • Periodic online and print
Children of Alcoholics up in isolation and without support. newsletters
(NACoA) • A national nonprofit organization working on behalf of children of • Videos, booklets, posters,
Phone 888-554-2627 alcohol- and drug-dependent parents. educational materials
301-468-0985 • Our mission is to eliminate the adverse impact of alcohol and drug • Send information packets
use on children and families: to all who ask
http://www.nacoa.org
We work to raise public awareness. • Maintain a toll-free phone
We provide leadership in public policy at the national, state, and available to all
local levels.
We advocate for appropriate, effective, and accessible education
and prevention services.
We facilitate and advance professional knowledge and
understanding.
19) National Alliance For • An organization composed of medication-assisted treatment patients • Function as consumer
Medication-Assisted and health care professionals who are supporters of quality opiate advocates
Recovery (NAMA agonist treatment.
Recovery) • The primary objective is to advocate for the patient in treatment
by destigmatizing and empowering medication-assisted treatment
http://www.methadone.org patients.
Phone: 212-595-6262 • We confront the negative stereotypes that affect the self-esteem
and worth of many medication-assisted treatment patients with a
powerful affirmation of pride and unity.
20) Nar-Anon Family • A worldwide fellowship for those affected by someone else’s • Nar-Anon groups hold

ONLINE RESOURCES LIST FOR SUDS

Groups addiction. meetings in the United
http://nar-anon.org • A 12-Step program designed to help relatives and friends of addicts States, Canada, and
Nar-Anon Family Group HQ recover from the effects of living with an addicted relative or friend. worldwide.
22527 Crenshaw Blvd #200B • The only requirement is that there is a problem of drugs or addiction • Literature and other
in a relative or friend. materials are available at
Torrance, CA 90505 Nar-Anon meetings.
310-534-8188 or 800-477-6291 • Not affiliated with any other organization or outside entity. • Use Nar-Anon’s 12 Steps
For info about online • Whether the addict is using or not, Nar-Anon offers hope and
recovery to all people affected by the addiction of a loved one or and 12 Traditions
meetings:
friend.
http://nar-anon.org

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1. Mutual Support Organizations (Continued)

Substance Use Disorders

Organization/Contact Purpose Components
Information
21) Narcotics Anonymous • NA is a nonprofit fellowship or society of men and women for • 12-Step program
(NA) whom drugs have become a major problem. • Regularly scheduled
http://www.na.org/ • We are recovering addicts who meet regularly to help each other meetings
NA Main Office PO Box stay clean. • Regional 24-hour helpline
9999 Van Nuys, California • The 12 Steps of NA are the basis of our recovery program. • Resources and literature
91409 Telephone (818) 773- • NA gives members a place to share recovery with other addicts. related to narcotics
9999 Fax (818) 700-0700 • If you are not an addict, look for an open meeting, which welcomes addiction
nonaddicts. • Sponsors
• Discussion meetings allow members to take turns sharing.
• Speaker meetings allow one or more members to share for an
extended period of time.
22) Overcomers Outreach • An international network of Christ-centered 12-Step support groups • Support groups using the
(OO) which ministers to individuals, their families, and their loved ones 12 Steps and scriptures
http://overcomersoutreach. who suffer from the consequences of any addictive behavior. • Groups are structured
org/ • We exist to serve as a bridge between traditional 12-Step recovery to be sharing groups, not
12828 Acheson Drive groups and churches of all denominations. therapy groups
Whittier, CA 90601 • We recover together as we meet to study and grow in God’s Word.
1–800-310-3001 • Our ministry is all-welcoming, regardless of age, race, lifestyle,
background, or belief.
Phone: 562-698-9000
Fax: 562-698-2211
Email: info@
overcomersoutreach.org
23) SMART Recovery • SMART Recovery is the leading self-empowering addiction recovery • Face-to-face meetings
http://www.smartrecovery.org/ support group. • Daily online meetings
7537 Mentor Ave, Suite 306 • Participants learn tools for addiction recovery based on the latest • Online message board
Mentor, OH 44060 scientific research and participate in a worldwide community that • Publications
includes free, self-empowering, science-based mutual help groups.
Phone: 440-951-5357
• The SMART Recovery 4-Point Program helps people recover from
Toll Free: 866-951-5357 all types of addiction and addictive behaviors, including: drug abuse,
Fax: 440-951-5358 drug addiction, substance abuse, alcohol abuse, gambling addiction,
cocaine addiction, and addiction to other substances and activities.
• SMART Recovery sponsors face-to-face meetings around the world,
and daily online meetings. Our online message board and 24/7 chat
room offer excellent recovery forums.

ONLINE RESOURCES LIST FOR SUDS

24) Secular Organizations • An alternative recovery method for alcoholics or drug addicts who • Nonreligious alternative
for are uncomfortable with the spiritual content of 12-Step programs. to 12-Step
Sobriety (SOS) • SOS takes a reasonable, secular approach to recovery and maintains • State-wide group
http://www.cfiwest.org that sobriety is a separate issue from religion or spirituality. meetings
4773 Hollywood Blvd. • SOS credits the individual for achieving and maintaining sobriety, • E-group meetings
Hollywood, Ca 90027 USA without reliance on any “Higher Power.” • Quarterly newsletter
Phone (323) 666-4295 • SOS respects recovery in any form regardless of the path used • Scheduled special events
Fax (323) 666-4271 Email: • SOS supports healthy skepticism and encourages the use of the
sos[at]cfiwest.org scientific method to understand alcoholism.
• SOS is a nonprofit network of autonomous, nonprofessional local
groups dedicated to helping individuals achieve and maintain sobriety.

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Substance Use Disorders
1. Mutual Support Organizations (Continued)
Organization/Contact Purpose Components
Information
25) Women for Sobriety • A nonprofit organization dedicated to helping women overcome • Sobriety programs
(WFS) alcoholism and other addictions. It is, in fact, the first national self- • Self-help meetings
PO Box 618 help program for women alcoholics. • 13-Statement program of
Quakertown, PA 18951-0618 • Our “New Life” Program helps achieve sobriety and sustain ongoing positivity
Phone: 215-536-8026 recovery.
Fax: 215-538-9026 • WFS has been providing services to women alcoholics since July
http://womenforsobriety.org/ 1976.
beta2/
• This program grew out of one woman’s search for sobriety.
• WFS self-help groups are found all across this country and abroad.
Based on a 13-Statement Program of positivity that encourages
emotional and spiritual growth, the “New Life” Program has been
extremely effective in helping women overcome their addictions and
embrace a new positive lifestyle.
2. Organizations for Professionals
Organization/Contact Purpose Components
Information
1 ) American Academy of • AAAP is an international professional membership • Promote high-quality treatment
Addiction Psychiatry organization of psychiatrists, faculty at various academicfor all
(AAAP) • Educate the public to influence
institutions, medical students, residents and fellows, and
related health professionals making a contribution to the public policy
www.aaap.org/ field of addiction psychiatry. • Provide continuing education for
addiction professionals
• Encourage research on the
etiology, prevention, identification,

ONLINE RESOURCES LIST FOR SUDS

and treatment of addiction
2) American Association for • AATOD was founded in 1984 to enhance the quality of • Promote the growth and
the Treatment of Opioid patient care in treatment programs by promoting the growth development of opioid treatment
Dependence (AATOD) and development of comprehensive opioid treatment services
www.aatod.org/
services throughout the United States. • Support programs and services
related to prevention of substance
abuse
• Advise members as to changes in
applicable laws and advancements
in opioid treatment

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Substance Use Disorders
2. Organizations for Professionals (Continued)
Organization/Contact Purpose Components
Information
3) American Society of • ASAM is a professional society representing physicians • Increase access to and quality of
Addiction Medicine dedicated to increasing access and improving quality of addiction treatment
(ASAM) addiction treatment, educating physicians and the public, • Educate physicians, other health
supporting research and prevention, and promoting the care providers, and the public
www.asam.org appropriate role of physicians in the care of patients with• Support research and prevention
addictions.
• Promote the appropriate role
of the physician in the care of
patients with addiction
4) Center for Substance • CSAP provides national leadership in the federal effort to • Promote youth development
Abuse Prevention/ prevent alcohol, tobacco, and other drug problems. To help • Reduce risk-taking behaviors
SAMHSA (CSAP) Americans lead healthier and longer lives, CSAP promotes a • Build assets and resilience
structured, community-based approach to substance abuse
www.samhsa/.gov/centers/csap/ prevention through the Strategic Prevent Framework (SPF). • Prevent problem behaviors across
csap.html individuals’ life spans
5) Center for Substance • CSAT promotes the quality and availability of community- • Initiatives and programs based on
Abuse Treatment/ based substance abuse treatment services for individuals and research findings and the general
SAMHSA (CSAT) families who need them. consensus of experts in the
www.samhsa.gov/centers/csat/ • CSAT works with states and community-based groups to
addiction field
csat/html improve and expand existing substance abuse treatment • Promote the idea that treatment
services under the Substance Abuse Prevention and and recovery work best in a
Treatment Block Grant Program. community-based, coordinated
• CSAT also supports SAMHSA’s free treatment referral system of comprehensive services
service to link people with the community-based substance • Support the nation’s effort to
abuse services they need. provide multiple treatment

ONLINE RESOURCES LIST FOR SUDS

modalities, evaluate treatment
effectiveness, and use results to
enhance treatment and recovery
approaches
6) Children of Alcoholics • COAF’s mission is to help children of all ages from alcoholic • Develops curriculum and other
Foundation (COAF) and substance-abusing families reach their full potential by educational materials
www.coaf.org breaking the cycle of parental substance abuse and reducing • Writes reports, provides
the pain and problems that result from parental addiction. information about parental
COAF is a national nonprofit that provides a range of substance abuse for the general
educational materials and services to help professionals, public
children, and adults • Trains professionals
• Promotes research

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Substance Use Disorders
2. Organizations for Professionals (Continued)
Organization/Contact Purpose Components
Information
7) College on Problems of • CPDD is the longest standing group in the U.S. addressing • Annual scientific meeting
Drug Dependency problems of drug dependence and abuse. • Special conferences on topics of
(CPDD) • CPDD functions as an independent body affiliated with other interest
www.cpdd.vcu.edu scientific and professional societies representing various • Sponsors of the journal, Drug and
disciplines concerned with problems of drug dependence Alcohol Dependence
For Information contact: and abuse.
Martin W. Adler, PhD • Timely policy statements and fact
• CPDD has over 700 members and serves as an interface sheets available through website
Center for Substance Abuse among governmental, industrial, and academic communities
Research maintaining liaisons with regulatory and research agencies
Temple University School of as well as educational, treatment, and prevention facilities in
Medicine the drug abuse field.
3400 North Broad Street
Philadelphia, PA 19140-5104
Phone: 215-707-3242
Fax: 215-707-1904
Email: baldeagl@temple.edu
8) National Assoc. of • NAATP promotes, assists, and enhances the delivery of • Represents nearly 275 providers
Addiction Treatment ethical, effective, research-based treatment for alcoholism • Has acted as the voice of private
Providers (NAATP) and other drug addictions by providing its members and treatment programs throughout
the public with accurate, responsible information and other the U.S., including Congress, in
www.naatp.org resources related to the treatment of these diseases. the insurance industry, in the
• Advocates for increased access to and availability of quality utilization review arena, and in the
treatment for those who suffer from alcoholism and other treatment field
drug addictions.
• Works in partnership with other organizations and
individuals that share NAATP’s mission and goals.
9) National Clearinghouse • SAMHSA’s NCADI is a one-stop resource for information • About 1,000 downloadable text
for Alcohol and Drug about substance abuse problems. NCADI’s public library and graphic files concerning

ONLINE RESOURCES LIST FOR SUDS

Information has more than 80,000 journals, newspapers, magazines, and substance abuse prevention
https://preventionplatform.
reference books, plus equipment for reviewing audiotapes • Access to information specialists
and videotapes. • Public forums for posting
samhsa.gov/
• The clearinghouse also provides access to 11 computer questions and comments
data bases, including the Educational Resources Information • Online access to CSAP-developed
Center (ERIC) of the U.S. Department of Education, the training courses for professionals
ETOH data base of the National Institute on Alcohol Abuse and the public
and Alcoholism, and the bibliographic data base of the
Centers for Disease Control and Prevention’s Office on
Smoking and Health.
• NCADI’s own Prevention Materials Data Base lists
more than 8,000 prevention products, such as curricula,
videocassettes, posters, brochures, specialty items, and
educational material.

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2. Organizations for Professionals (Continued)

Substance Use Disorders

Organization/Contact Purpose Components
Information
10) National Institute On • NIAAA conducts and supports research in a wide range • Basic research on medications
Alcohol Abuse and of scientific areas including genetics, neuroscience, development for alcohol use
Alcoholism (NIAAA) epidemiology, health risks and benefits of alcohol disorders
www.niaaa.nih.gov consumption, prevention, and treatment • Genetic studies of vulnerability to
• Coordinates and collaborates with other research institutes alcohol
and federal programs on alcohol-related issues • Long-term, community-based
• Collaborates with international, national, state, and local prevention of alcohol problems at
institutions, organizations, agencies, and programs engaged in specific life stages
alcohol-related work • Multisite, collaborative initiative on
• Translates and disseminates research findings to health care fetal alcohol syndrome
providers, researchers, policymakers, and the public • Women, HIV/AIDS, and alcohol
NIAAA’s webpage provides: • Training the next generation of
• Most recent NIAAA news releases and advisories, exhibit investigators
schedules, and alcohol research updates • News highlights
• Access to publications, including Alcohol Alert, Alcohol • Underage drinking research
Research & Health, newsletters, pamphlets, professional initiative
education manuals
• Access to data base resources and statistical tables, related
websites, research guidelines, and resources
• Access to extramural and intramural research conducted at
NIAAA
• Clinical trials information for patients, physicians, and NIAAA
studies seeking patients
11) National Institute on • NIDA’s mission is to lead the nation in bringing the power of • Drugs of abuse
Drug science to bear on drug abuse and addiction. This charge has • Publications
Abuse (NIDA) two critical components. • Funding opportunities and
www.nida.nih.gov • The first is the strategic support and conduct of research information
across a broad range of disciplines. • News and events
• The second is ensuring the rapid and effective dissemination • AIDS research
and use of the results of that research to significantly
improve prevention and treatment and to inform policy as it • Clinical Trial Network
relates to drug abuse and addiction. • NIDA Notes
NIDA’s webpage provides: • Information on treatment
• Extensive information on drugs, drug problems, and research

ONLINE RESOURCES LIST FOR SUDS

treatment • Selected NIDA publications
• Updates on current research and information on funding
opportunities
• Information about the Clinical Trials Network national
research project
• Information about NIDA’s AIDS research program
• Information on medical and health care professionals (e.g.,
drug screening tools, curriculum resources)
• Information relevant to the questions and concerns of
patients and families
• Information relevant to the needs of parents and teachers
(continued)

381
 382
2. Organizations for Professionals (Continued)

Substance Use Disorders

Organization/Contact Purpose Components
Information
12) National Organization • NOFAS seeks to create a global community free of alcohol- • Communicate the significant risk
on Fetal exposed pregnancies and a society supportive of individuals and harm of prenatal alcohol
Alcohol Syndrome already living with FASD. exposure
(NOFAS) • NOFAS effectively increases public awareness and mobilizes • Promote national policies that
www.nofas.org grassroots action in diverse communities and represents the enhance knowledge of FASD and
interests of persons with FASD and their caregivers as the ensure services for families
liaison to researchers and policymakers. • Extend reach through partnerships
• By ensuring that FASD is broadly recognized as a and coalitions
developmental disability, NOFAS strives to reduce the • Diversify and increase the
stigma and improve the quality of life for affected individuals revenue streams and resources to
and families. accomplish our mission
13) Research Society on • The RSA provides a forum for communication among • Online resources for researchers
Alcoholism (RSA) researchers, who share common interests, in alcoholism. • Education materials
http://www.rsoa.org The Society’s purpose is to promote research that can lead
the way toward prevention and treatment of alcoholism.
• Events and meetings of interest
7801 N. Lamar Blvd, Suite D89
• Membership consists of regular scientific members,
• Treatment and advocacy
Austin TX 78752-1038 resources
postdoctoral fellows, associate members and student members.
Phone: 512-454-0022 The current membership of over 1,800 is drawn from countries • Research grants/awards available
Fax: 512-454-0812 throughout the world, with the majority from the U.S.
• The annual scientific conference provides a meeting place for
scientists and clinicians from across the country, and around
the world, to interact. The meeting gives members and
nonmembers the chance to present their latest findings in
alcohol research through abstract and symposia submissions.
14) State Associations of • SAAS is a nonprofit organization whose membership • Ensure health care reform
Addictions Services consists of state associations of addiction treatment and requires SUD coverage equal to
www.saasnet.org prevention providers. These associations represent programs that of other illnesses
of all sizes and treatment and prevention approaches. • Include SUD prevention and
• SAAS is the only national organization of state alcohol screening in health reform
and drug addiction treatment and prevention provider • Include SUD in workforce
associations. development initiatives
• Through our member associations, SAAS has a direct link to • Increase federal funding for SUD
thousands of prevention and treatment programs that are services and research

ONLINE RESOURCES LIST FOR SUDS

the core of the publicly supported addiction services system.
• SAAS serves as an information broker and advocate, linking
state associations with national developments such as
evidence-based practices and providing input to federal
organizations on the needs of community-based services
providers and their clients.

(continued)

383
 384
2. Organizations for Professionals (Continued)

Substance Use Disorders

Organization/Contact Purpose Components
Information
15) Substance Abuse and • SAMHSA’s mission is to reduce the impact of substance SAMHSA plays a unique role in
Mental Health Services abuse and mental illness on America’s communities. advancing service delivery systems
Admin (SAMHSA) • In order to achieve this mission, SAMHSA has identified 8 and community-wide strategies
Strategic Initiatives to focus the Agency’s work on improving that improve health status and
www.samhsa.gov lives and capitalizing on emerging opportunities. well-being by providing:
• To accomplish its work SAMHSA administers a combination • Leadership and voice
of competitive, formula, and block grant programs and data • Funding
collection activities. • Surveillance and data
NAMHSA’s webpage provides: • Public awareness and education
• Access to major topic areas and programs covered by • Regulation and oversight
SAMHSA, including substance abuse & mental health
prevention, treatment, recovery, grants and funding • Practice improvement in
opportunities, agency administrative information, and contacts community-based, primary, and
• FY 2012 grant announcements specialty care
• Publications related to topics that include Children of
Alcoholics, Managing Chronic Pain, Enhancing Motivation for
Change in Substance Abuse Treatment, etc.
• Access to the Substance Abuse and Mental Health Data
Archive (SAMHDA), which allows access to the nation’s
preeminent substance abuse and mental health research data
• Access to Uniform Reporting System (URS) output tables;
other mental health statistics reports
• Access to the National Registry of Evidence-Based Programs
and Practices (NREPP) searchable online registry of more
than 160 interventions
16) William L White Papers • This site contains the full text of more than 200 articles, 7 Site offers free access to:
http://www. monographs, 30+ recovery tools, 9 book chapters, 3 books, • Papers
williamwhitepapers.com/ and links to an additional 13 books written by William White • Books and monographs
and coauthors over the past four decades.
• Book reviews
• The purpose of this site is to create a single location where
• Leadership interviews
such material may be accessed by those interested in the

ONLINE RESOURCES LIST FOR SUDS

history of addiction treatment and recovery in the United • Friends and favorites
States. • Chronologies
• Those papers selected for inclusion contain all of the articles • Presentations
and monographs authored by William White on the new • Recovery toolkit
recovery advocacy movement, recovery management, and • RM and ROSC library
recovery-oriented systems of care. • Get involved
• It is hoped that this resource library will serve present and • Biographical info
future generations of addiction professionals, recovery
coaches, and recovery advocates.

385
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 387

Index

attention deficit case vignettes, 162–163,

A hyperactivity disorder 181, 218, 262–263
absorption (ADHD), 330 Clinical Institute
alcohol, 98 bipolar disorder, 330 Withdrawal
benzodiazepines, 108 case vignettes, 318, 322, Assessment of
cannabis, 125 326, 331 Alcohol Scale, Revised
heroin, 112 cognitive and behavioral (CIWA-Ar), 100,
LSD (lysergic acid interventions, 103–105t
diethylamide), 127 324–326 detoxification, 99
PCP (phencyclidine) and comorbid psychiatric intoxication, 98, 99t
ketamine, 129 disorders, 329 medication-assisted
pharmacokinetics, 96 conduct disorder, 330 treatments, 261–262
stimulants, 123 developmental medications approved for
abuse, 160 considerations, 320 treatment of SUDs, 171t
acamprosate (Campral) diagnosis, 318 medications for
alcohol, 345–346 family interventions, 325 detoxification, 105–108
alcohol dependence, group interventions, metabolism, 175
171t, 174 325–326 pharmacology, 98
alcoholism, 21 level of care, 320–321 pharmacotherapy for
COMBINE study with major depressive adolescents, 328
naltrexone, 177 disorder, 329 relapse prevention, 257
typical dose and effects, motivational enhancement substance use, 344–346
178t therapy (MET), 322 treatment approach, 182
Ackerman, Nathan, 65 nicotine craving and withdrawal, 99, 100t, 328
action, transtheoretical withdrawal, 328–329 Withdrawal Assessment
model (TTM) of pharmacotherapy for, Scale (WAS), 100,
change, 35 328–330, 335 101–102t
addict, 144 prevalence, 5 withdrawal assessment
addicted brain, 24f psychosocial treatment, scales, 100, 105
addiction, 7, 30 321 alcohol dependence
chronic brain illness, 18 rates, 5, 313 acamprosate, 174,
circuitry model, 23–24 risk factors, 313, 314 345–346
neurobiology, 32–33 screening, 315 baclofen, 180
neurobiology of initiation substance use disorders disulfiram, 174–175, 345
of, 20–22 (SUDs), 10, 312 FDA-approved
neuroplasticity, 20, 22 treatment, 320–321, 332 medications, 174–177
principles of effective Adult Children of gabapentin, 180
treatment, 42t Alcoholics, 361 medications dose and
progressive disease, 32 adults, prevalence and effects, 178–179t
transition from reward rates of substance use naltrexone, 175–177, 345
to, 22–23 disorders, 4–5 ondansetron, 181
addiction career, 51 advice, interventions, 39 promising medications,
Addiction Severity Index African Americans 177, 180–181
(ASI), 155 case vignette, 86–87 topiramate, 177
addictive, 7 substance use disorders, alcohol detoxification
adolescents 78–79 anticonvulsants, 107
alcohol aversion agonist therapy, 8 antipsychotics, 107
pharmacotherapy, 328 Al-Anon, 52, 85, 87, 217, barbiturates, 108
alcohol craving, 328 301, 361 benzodiazepines, 105–107
alcohol withdrawal, 328 Alateen, 233, 301, 361 beta-adrenergic antagonists
anxiety disorders, Alatots, 301 and alpha-adrenergic
329–330 alcohol, 291 agonists, 107
assessment of substance abuse tests, 154 medications for, 105–108
use disorders (SUDs), addiction, 6, 261–262 thiamine and magnesium,
316–317 adolescents, 313, 328 107
388 INDEX

alcoholic, 144 pharmacology, 123–124 benzodiazepines, 170

alcoholics, children of, 68 substance use, 348–349 alcohol detoxification,
Alcoholics Anonymous amygdala (Amyg), brain, 105–107
(AA), 38, 52, 54, 55, 170, 20, 21f case vignette, 130–131
214, 233, 258, 297 anticonvulsants, alcohol detoxification from,
adolescents, 325 detoxification, 107 109–110
case vignettes, 263, antiepileptic drugs (AEDs), pharmacology, 108
307–308 alcohol detoxification, protracted withdrawal
organization information, 107 of, 110
362 antipsychotics, alcohol symptoms of intoxication,
twelve-step philosophy, detoxification, 107 108–109
237 antiretroviral therapy withdrawal symptoms, 109
Alcoholics for Christ (AC), (ART), human beta-adrenergic antagonists,
362 immunodeficiency virus alcohol detoxification,
Alcoholics Victorious (HIV), 277 107
(AV), 363 antisocial personality biopsychosocial illness, 33
alcoholism, 54 disorders, 286 bipolar disorder, 231,
alcohol use, prevalence anxiety disorders, 286, 330
rate, 2 adolescents, 329–330 blood alcohol concentration
Alcohol Use Disorders aripiprazole, 181, 202 (BAC), 98, 99, 156,
Identification Test Asians, substance use 162–163
(AUDIT), 152, 154, 315 disorders, 81 boosting, 187
all-or-nothing thinking, 225 assessment borderline personality
alpha-adrenergic agonists, co-occurring disorders disorder (BPD),
alcohol detoxification, (CODs), 292–293 228–229, 232, 286
107 domains, 158–159 Bowen, Murray, 65
alprazolam, 54, 108 opening process of, 142 brain, major regions, 20, 21f
American Academy of substance use disorders breath alcohol
Addiction Psychiatry (SUDs), 157 concentration, clinical
(AAAP), 120, 170, 375 SUDs in adolescents, effects, 99t
American Academy of 316–317 brief interventions, alcohol,
Child and Adolescent assisted recovery, 28 344–345
Psychiatry, 312 atenolol, alcohol brief strategic family therapy
American Association for withdrawal, 107 (BSFT), 229
the Treatment of Opioid attention deficit Bronfenbrenner, Urie,
Dependence (AATOD), hyperactivity disorder 64, 65
375 (ADHD), 150, 314, 329, buprenorphine, 8
American Indian/Native 330, 331 metabolism, 190
Alaskan, substance use attitudes and beliefs, lapse methadone vs., 190–191
disorders, 80 or relapse, 252–253 opioid dependence, 171t,
American Osteopathic autonomy, motivational 188–190, 350
Academy of Addiction interviewing (MI), 40 opioid detoxification,
Medicine, 120 aversion therapy, 175 120–121
American Psychiatric buprenorphine-naloxone,
Association (APA), 2, opioid dependence, 171t,
30, 292 B 188–190
American Society of baclofen, alcohol buprioprion SR
Addiction Medicine dependence, 171t, 180 (Wellbutrin), 54, 172t,
(ASAM), 120, 170, 376 barbiturates, alcohol 200, 202
continuum of care, detoxification, 108 buspirone (Buspar),
220–222 Bath Salts, 290 cannabis dependence,
example of adult ASAM Beck, Aaron, 53 172t, 204
criteria, 45–46 behavioral change,
framework, 220–222, transtheoretical model
292–293 (TTM), 34–35 C
Patient Placement Criteria behavioral consequences, Caduceus (society of
for the Treatment of 158 physicians caring for
Substance-Related behavioral couples therapy physicians), 55
Disorders, 28, 44 (BCT), 224 CAGE tool, alcohol abuse,
amotivational syndrome, behavioral marital therapy 154
150 (BMT), relapse cannabis
amphetamines prevention, 257 illicit use, 347
 INDEX 389

intoxication symptoms, clinical recommendations, cognitive distortions,

126 adolescents with SUDs, recovery and relapse
medications approved for 334–335 risk, 258–259
treatment of SUDs, clinician collaboration, motivational
172t, 204 African Americans, 79 interviewing (MI), 40
pharmacology, 125–126 Asians, 81 College on Problems of
withdrawal symptoms, case vignettes, 85–87 Drug Dependency
9–10, 126–127 discontinuation of use, (CPDD), 378
carbamazepine 72, 73 commitment language,
alcohol dependence, elderly and substance use motivation, 38–39
171t, 181 disorders, 82 community, recovery, 50–51
alcohol detoxification, ethnicity and substance community reinforcement
107 use disorders, 79, approach (CRA),
benzodiazepine 80, 81 226–227
withdrawal, 111t gay/lesbian/bisexual/ community reinforcement
carbohydrate-deficient transgender (GLBT) approach and family
transferrin (CDT), 156 and substance use, 83 training (CRAFT),
carisoprodol (Soma), 64 Hispanics, 80 227, 315
catastrophizing, 225 Native Americans, 80 comorbidities. See also
Celebrate Recovery, 363 ongoing recovery, 76 co-occurring disorders
Center for Substance Abuse recognition of disorder, (CODs)
Prevention/SAMHSA 70, 71 human immunodeficiency
(CSAP), 376 treatment and early virus (HIV), 277
Center for Substance Abuse recovery, 74, 75 compliance, 46
Treatments (CSAT), 250, women and substance use conditional cues, lapse or
255, 257, 377 disorders, 84 relapse, 253
Centers for Disease clonazepam, 54, 108, 187 conduct disorder, 314, 330
Control and Prevention clonidine, 172t, 189 confidentiality
(CDC) alcohol withdrawal, 107 health care information,
hepatitis C virus (HCV), nicotine dependence, 140–141
272 172t, 199 SUDs in adolescents,
human immunodeficiency opioid detoxification, 316–317
virus (HIV), 276, 352 118–119, 161 contemplation,
Children and Youth cocaine, 290, 291 transtheoretical model
Services, 28 medications approved for (TTM) of change, 34–35
Children of Alcoholics treatment of SUDs, contingency management,
Foundation (COAF), 377 172t 227, 316, 321, 345
chlordiazepoxide pharmacology, 123–124 continued care, 221,
alcohol detoxification, substance use, 347–348 227–228, 304
105, 106t Cocaine Anonymous (CA), continuum of care, 32
metabolism, 108 233, 297, 364 Controlled Substances Act
cigarettes. See also nicotine cocaine dependence (1970), 184
adolescents, 313 case vignette, 218 co-occurring disorders
nicotine, 346 medications for, 172t, (CODs), 253, 284, 285
circuitry model, addiction, 200–201 adolescents, 329
23–24 cocaine vaccine, 172t, 201 assessment and treatment
Clinical Institute Narcotic Code of Federal Regulations of, 47
Assessment (CINA), (CFR), 140 case vignettes, 305–308
116, 117–118t Codependents Anonymous, components of
Clinical Institute Withdrawal 233, 301 assessment, 292–293
Assessment for Alcohol cognitive behavioral concerns of family
Scale (CIWA-Ar), 45–46 skills-based treatments members, 300–301
Clinical Institute Withdrawal (CSTs), alcohol, 345 continuing care, 304
Assessment of cognitive behavioral therapy family effects, 300–302
Alcohol Scale, Revised (CBT), 224–226 integrated treatment, 231
(CIWA-Ar), 100, adolescents, 324–326 integrated treatment for,
103–105t Beck, 53 294–298
clinical obstacles, motivation, 41 lapse or relapse, 253
psychological relapse prevention, prevalence and
assessment, 46–47 255–256 consequences, 286
Clinical Opioid Withdrawal cognitive consequences, principles and strategies
Scale (COWS), 113–116 158 for helping families, 302
390 INDEX

co-occurring disorders dextroamphetamine, alcohol dependence, 171t,

(CODs) (Cont.) methamphetamine 174–175
promoting recovery, dependence, 172t, 203 cocaine dependence, 172t,
304–305 dextromethorphan (DXM), 200–201
psychosocial treatments, 128 typical dose and effects,
294 Diagnostic and Statistical 178t
relapse prevention, 261, Manual of Mental disulfiram-alcohol reaction,
298, 304–305 Disorders (DSM) 175
relationships between classification of substance divalproex sodium
substance use use disorders, 6–11 (Depakote)
disorders (SUDs) and, DSM-I, 6 alcohol dependence,
290–291 DSM-II, 6 171t, 181
role of medications in DSM-III, 6 cannabis dependence,
treating, 295–296 DSM-IV, 6, 161, 318 172t, 204
strategies to help patients DSM-IV-TR (text revision), Dole, Vincent, 184
with, 296–298 6, 160, 286, 292, 341 dopamine, reinforcing
subtypes of, 287 proposed changes from addiction, 20, 21f
SUDs and psychiatric DSM-IV to DSM5, Double Trouble in
disorders, 159 6–11 Recovery (DTR), 297,
theories of, 288 section changes, 7 307, 365
types of family treatment, severity specifiers and drinking, natural change, 36
301 criteria changes, 7–8 drinking and driving, case
coping skills training (CST), substance use and vignettes, 162–163
228 addictive disorders dronabinol (Marinol),
counseling, relapse general section, 9–10 cannabis dependence,
prevention, 257 substance use disorders in 172t, 204
craving, 8 elderly people, 10–11 drug abuse, 30
alcohol, 328 Diagnostic and Statistical Drug Abuse Screening Test
managing, 258 Manual of Mental (DAST), 144, 292
nicotine, 328–329 Disorders (DSM) 5th drug addiction,
Crystal Meth Anonymous edition, 2, 30, 318 neurobiology, 18
(CMA), 233, 365 proposed changes from drug addicts, children of, 68
cue-triggered relapse, 23 DSM-IV, 6–11 Drug Enforcement
diagnostic orphans, 7 Administration (DEA),
dialectical behavioral 120, 189
D therapy (DBT), 228–229 drug poisonings, deaths,
Dartmouth Assessment diazepam, 187 28–29
of Lifestyle Inventory alcohol detoxification, drug-specific “not elsewhere
(DALI), 292 105, 106t classified” diagnoses, 9
deaths, drug poisonings, 28–29 metabolism, 108 drug-triggered relapse, 23
delta-9- diazetylmorphine. See drug use, 30
tetrahydrocannabinol heroin harm reduction principles,
(THC), 156. See also dimensional disorder, 161 342–343
cannabis diphenoxylate/atropine, Drug Use Disorders
pharmacology, 125–126 opioid withdrawal, 119t Identification Test
Department of Health dissociative drugs, (DUDIT), 154
and Human Services 128–129 drug use self-reports, 148
(DHHS), 66 distribution Dual Recovery Anonymous
dependence, 7, 30, 160 alcohol, 98 (DRA), 297, 307, 366
depot naltrexone, 8 benzodiazepines, 108
desipramine (Norpramin), cannabis, 125
cocaine dependence, heroin, 112 E
172t, 200 LSD (lysergic acid early recovery, family
desire, motivation, 38 diethylamide), 127 impact, 74, 75
detoxification, 94 PCP (phencyclidine) and ecstasy
from benzodiazepines, ketamine, 129 (3,4-methylenedioxy-
109–110 pharmacokinetics, 96 N-methylamphetamine;
goals, 99 stimulants, 123 MDMA), 127, 348–349
opioids, 118–122, 161 disulfiram (Antabuse), 170 elderly people, substance
development stage, family alcohol, 345 use disorders, 10–11, 82
and substance use alcohol aversion elimination
disorder, 70, 71 pharmacotherapy, 328 alcohol, 98
 INDEX 391

benzodiazepines, 108 discontinuation of use, gay/lesbian/bisexual/

cannabis, 126 72, 73 transgender (GLBT),
heroin, 112 education groups, 233 substance use disorders,
LSD (lysergic acid enabling, 70 83
diethylamide), 127 impact of substance use general systems theory, 65
PCP (phencyclidine) and disorders, 66–67 genetic epidemiology, 5
ketamine, 129 influence on SUDs, 68 genetic vulnerability,
pharmacokinetics, 97 interventions for addiction, 18
stimulants, 123–124 adolescents, 325 glutamate, reinforcing
emotional states and ongoing recovery, 76 addiction, 20, 21f
moods, relapse principles and strategies gradual taper, detoxification
prevention, 260–261 for helping, 301 from benzodiazepines,
Emotions Anonymous psychosocial interventions, 109–110
(EA), 366 229–230 group treatment
empathy, 138 recognition of disorder, adolescents, 325–326
interventions, 40 70, 71 psychosocial interventions,
maintaining, 144–145 social ecological model, 230
enabling, family and 64–65 relapse prevention, 257
substance use disorder, treatment and early guanfacine, opioid
70, 300 recovery, 74, 75 detoxification, 119
entacapone (Comtan), types of treatment, 301
cannabis dependence, family systems theory,
172t, 204 65, 74 H
environmental causes, lapse family therapy, 74, 301 habitual excessive drinking,
or relapse, 253 feedback 6
Epidemiologic Catchment general systems theory, 65 hallucinogen persisting
Area (ECA), 290 interventions, 39 perception disorder, 128
epidemiology fixed dosing, hallucinogens
genetic, 5 benzodiazepines, 106 intoxication symptoms,
substance use disorders, fluoxetine, 54 127–128
4–5 fortune telling, 225 pharmacology of LSD, 127
episodic excessive FRAMES (feedback, withdrawal symptoms, 128
drinking, 6 responsibility, advice, haloperidol, 107
escalation, illicit substance menu of alternative HALT (don’t get too hungry,
use, 36 change, empathy, angry, lonely or tired),
eszopiclone, 108 self-efficacy), brief 12-step programs, 261
ethanol dependence, 54 interventions, 39–40 hangover, 10
ethnicity/race functional analysis, 159 harm reduction
African Americans, 78–79 functional assessments of alcohol, 344
American Indian/Native behaviors (FABs), 226 amphetamines, 348–349
Alaskan, 80 cannabis, 347
Asians, 81 cocaine use, 347–348
case vignette, 86–87 G high-risk sexual behaviors,
Hispanics, 79, 80 gabapentin (Neurontin), 352–354
substance use disorders, 107, 171t, 180, 202 human immunodeficiency
78 Gamblers Anonymous virus (HIV), 352–354
evocation, motivational (GA), 367 opiates, 349–350
interviewing (MI), 40 gambling, 10 principles of, 342–343
experimentation, 10 gambling disorder, 9 tobacco, 346
gamma-aminobutyric acid hazardous use, 7
(GABA) health recovery, 50
F benzodiazepines, 108 hedonic dysregulation, 20
facilitating sharing, 143 reinforcing addiction, hepatitis B virus (HBV), 272
Fagerstrom Test for 20, 21f hepatitis C virus (HCV),
Nicotine Dependence, gamma-glutamyl transferase 270, 272–275
155 (GGT), 174 barriers to treatment,
Families Anonymous (FA), gamma-glutamyl 275
367 transpeptidase (GGTP), cocaine use, 347
family 156 progression of infection,
co-occurring disorders gas chromatography–mass 273–274
(CODs), 297, 300–302 spectrometry (GC–MS), screening, 273
development stage, 70 155 transmission, 272
392 INDEX

hepatitis C virus (HCV) integrated treatment, Maternal Opioid Treatment:

(Cont.) co-occurring disorders Human Experimental
treatment for chronic (CODs), 231 Research (MOTHER),
infection, 274, 275t intensive outpatient 188, 190
heredity, addiction, 18 programs (IOPs), 221 matrix model, stimulant
heroin, 111–112 intoxication abuse or addiction,
pharmacology of, 112–113 alcohol, 98, 99t 232–233
high-risk situations, relapse benzodiazepines, 108–109 mechanism of action
prevention, 259 cannabis, 126 alcohol, 98
Hispanics, substance use dissociative drugs, 129 benzodiazepines, 108
disorders, 79, 80 hallucinogens, 127–128 cannabis, 126
historic recurrent bipolar opioid, 113 heroin, 113
depression, 54 stimulants, 124 LSD (lysergic acid
homeostasis, general diethylamide), 127
systems theory, 65 PCP (phencyclidine) and
hospital-based J ketamine, 129
detoxification, 220 jumping to conclusions, 225 stimulants, 124
human immunodeficiency medical consequences, 158
virus (HIV), 270, medical marijuana, 125
276–278, 338 K medical stabilization, 48
cocaine use, 347 medical trainee, treatment
comorbidities, 277 K2, 125 roles, 216–217
harm reduction practices, ketamine, 128, 129 medication-assisted
352–354 treatment (MAT),
hepatitis C virus motivation, 41
transmission, 272
L medications
integrated treatment, lamotrigine, 54, 55 alcohol dependence, 171t,
277–278 lapse, 252 174–177, 345–346
medical complications, 277 causes of, 252–255 approved for treatment of
scope of problem, managing, 262 SUDs, 171–172t
276–277 Latinos. See Hispanics co-occurring disorders
hydroxyzine, legal difficulties, criteria, 8 (CODs), 295–296
benzodiazepine LifeRing Secular Recovery opioid dependence, 171t,
withdrawal, 111t (LSR), 368 184–192
hydroxyzine pamoate, liquid chromatography–mass relapse prevention, 257,
119t, 189 spectrometry (LC–MS), 261–262
155 medication-supported
lofexidine, opioid recovery (MSR),
I detoxification, 119 motivation, 41
ibuprofen, opioid long-term residential medication-supported
withdrawal, 119t programs, 221 treatment (MST), 28
illicit drug use loperamide, opioid medication use, 30
prevalence rate, 2 withdrawal, 119t memantine, alcohol, 21
use and escalation, 36 lorazepam Men for Sobriety (MFS), 369
imipramine, benzodiazepine alcohol detoxification, menu of alternative change
withdrawal, 111t 105, 106t options, interventions,
individual drug counseling metabolism, 108 39–40
(ICD), 230–231 lysergic acid diethylamide men who have sex with
infection (LSD), pharmacology, 127 men (MSM)
hepatitis C virus (HCV), human immunodeficiency
273–274 virus (HIV), 276,
human immunodeficiency M 353–354
virus (HIV), 277 magnesium, alcohol methamphetamine use,
treatment for chronic, detoxification, 107 349
274, 275t maintenance, mephedrone, 123
injection drug users (IDUs), transtheoretical model meta-analysis of clinical
270 (TTM) of change, 35 trials, relapse prevention,
hepatitis B virus (HBV), 272 maintenance therapy, 8 256–257
human immunodeficiency major depressive disorder, metabolism
virus (HIV), 276, 277 314, 329 alcohol, 98, 175
inpatient detoxification, marijuana, adolescents, 313, benzodiazepines, 108
benzodiazepines, 110 316, 331 buprenorphine, 190
 INDEX 393

cannabis, 126 motivational interviewing National Comorbidity

heroin, 112 (MI), 28, 40 Survey Replication
LSD (lysergic acid alcohol, 344–345 (NCS-R), 4–5
diethylamide), 127 facilitating sharing, 143 National Epidemiological
PCP (phencyclidine) and psychosocial intervention, Survey on Alcohol and
ketamine, 129 234–235 Related Conditions
pharmacokinetics, 96–97 motivation for change, 28 (NESARC), 4
stimulants, 123 multidimensional family National Institute of Health
methadone, 8 therapy for adolescents (NIH), 290
common adverse effects (MDFT), 229 National Institute on
of, 187t multisystemic therapy Alcohol Abuse and
medications with potential (MST), 229 Alcoholism (NIAAA), 4,
interactions, 186t mutual support 154, 181, 255, 315, 380
metabolism, 185 organizations, 359 National Institute on Drug
opioid dependence, mutual support programs, Abuse (NIDA), 2, 23,
184–188, 350 237–239, 326 42, 119, 155, 255, 277,
opioid detoxification, 338, 381
119–120 National Organization on
risk for overdose, 187 N Fetal Alcohol Syndrome
vs. buprenorphine, naloxone with (NOFAS), 382
190–191 buprenorphine, opioid National Survey on
Methadone Anonymous detoxification, 120–121 Drug Use and Health
(MA), 369 naltrexone (Revia), 8, 170 (NSDUH), 78
Methadone Support (MSO), alcohol, 345 natural change, process
370 alcohol dependence, 171t, of, 36
methamphetamine 175–177 natural recovery, 28, 36, 53
medications approved for opioid dependence, 171t, need, motivation, 38
treatment of SUDs, 191–192 needle and syringe exchange
172t, 202–203 typical dose and effects, programs (NSEPs),
pharmacology, 123–124 178t, 179t 348, 350
substance use, 348–349 naproxen, 54, 119t neonatal abstinence
methylenedioxy- Nar-Anon, 87, 217, 301 syndrome (NAS), 188
pyrovalerone (MDPV), Nar-Anon Family Groups, neurobiology
pharmacology, 123–124 371 drug addiction, 18
methylone, 123 Narcotic Addict Treatment reward, 20, 21f
Michigan Alcoholism Act (1974), 184 neuroplasticity, addiction,
Screening Test (MAST), Narcotics Anonymous 20, 22
154, 292 (NA), 52, 131, 170, 214, neurotransmitters
mind reading, 225 233, 254, 258, 297 initiation of addiction,
Minuchin, Salvadore, 65 adolescents, 325 20–22
mirtazapine, 172t, 202 organization information, reinforcing effects on
modafinil (Provigil) 372 drugs of abuse, 22–23
cocaine dependence, twelve-step philosophy, 237 nicotine
172t, 200 National Alliance for medications approved for
methamphetamine Medication-Assisted treatment of SUDs,
dependence, 172t, 202 Recovery (NAMA 171–172t, 261–262
Monitoring the Future Recovery), 371 pharmacotherapy for
Survey (MTF), 4, 313 National Alliance of the adolescents, 328-329
motivation Mentally Ill (NAMI), tobacco use, 346
brief interventions, 39–40 301, 307 nicotine dependence
concept of, 38 National Association for bupropion SR (Zyban),
dimensions of, 38–39 Children of Alcoholics 172t, 196–198
motivational interviewing (NACoA), 370 clonidine, 172t, 199
(MI), 40 National Association of FDA-approved
readiness for change, 158 Addiction Treatment medications, 196–198
science-based treatments, Providers (NAATP), 379 nicotine replacement
41–42 National Clearinghouse therapy, 171t, 196, 197t
ways to influence, 39–42 for Alcohol and Drug NicVAX, 171t, 199
motivational enhancement Information, 379 non-FDA-approved
therapy (MET), 28, National Comorbidity medications for
233–234, 322 Survey-Adolescent smoking cessation,
motivational incentives, 227 Supplement (NCS-A), 5 171t, 172t, 199
394 INDEX

nicotine dependence (Cont.) case vignette, 131–132 pharmacotherapy

nortriptyline, 171t, 199 Clinical Institute Narcotic adolescents, 328–330
varenicline (Chantix), Assessment (CINA), guiding principles, 205
172t, 198 116, 117–118t phencyclidine (PCP), 128,
nicotine vaccines, 171t, 199 Clinical Opioid 129, 290
NM-ASSIST (Modified Withdrawal Scale polysubstance users, 4
Alcohol, Smoking, and (COWS), 113–116 positron emission
Substance Involvement heroin, 111–112 tomography (PET),
Screening Test), 155 medications approved for buprenorphine-
non-addicted brain, 24f treatment of SUDs, naloxone, 190
nortriptyline, nicotine 171t, 184–192 post-traumatic stress
dependence, 171t, 199 pharmacology of heroin, disorder (PTSD), 148,
nucleus accumbens (NAcc), 112–113 163, 231, 232
brain, 20, 21f pregnancy, 116 precontemplation,
Nyswander, Marie, 184 prescription, 112 transtheoretical model
signs and symptoms of (TTM) of change, 34
intoxication, 113 predisposition, addiction,
O signs and symptoms of 32–33
olanzapine, alcohol withdrawal, 113 prefrontal cortex (PFC),
dependence, 171t oral naltrexone, 8 brain, 20, 21f
ondansetron (Zofran), 202 outcome measures, pregnant women. See also
alcohol dependence, recovery, 50 women
171t, 181 outpatient, 221 methadone maintenance,
opioid withdrawal, 119t outpatient detoxification, 185
ongoing recovery, family benzodiazepines, 110 opioids and pregnancy,
impact, 76 Overcomers Outreach 116
opiates. See also opioids (OO), 372 substance use disorders,
harm reduction, 350 overlearning, drug 83–84
illicit use, 349–350 acquisition behaviors, 22 preparation, transtheoretical
opioid addiction, oxazepam, alcohol model (TTM) of change,
medication-assisted detoxification, 105, 106t 35
treatments for, 261–262 oxycodone, 193 prevention, 338
opioid dependence indicated, interventions,
buprenorphine and 341
buprenorphine- P selective, 340–341
naloxone, 171t, Parents Groups, 301 substance use behavior,
188–190 partial hospital (PH) 340–341
case vignette, 193–194 programs, 221 universal, 340
FDA-approved Patient Placement Criteria prevention paradox, 338
medications, 171t, for the Treatment of problematic use, 30
184–192 Substance-Related proclorperazine maleate,
methadone, 184–188 Disorders opioid withdrawal, 119t
methadone vs. American Society of professional organizations,
buprenorphine, Addiction Medicine 360
190–191 (ASAM), 28, 44 progressive disease,
naltrexone, 171t, 191–192 levels of care, 44–45 addiction, 32
opioid detoxification peer-assisted recovery, 53 promethazine, opioid
buprenorphine, 120–121 Percocet, 131 withdrawal, 119t
clonidine, 116, 118–119 personal recovery, 53 propranolol, benzodiazepine
guanfacine, 119 pharmacodynamics, 94 withdrawal, 111t
lofexidine, 119 pharmacokinetics, 94, 96–97 protracted withdrawal,
methadone, 119–120 pharmacology benzodiazepines, 110
naloxone with alcohol, 98 psilocybin (“shrooms”), 127
buprenorphine, basic principles of, 96–97 psychiatric disorders.
120–121 benzodiazepines, 108 See also co-occurring
rapid and ultrarapid, 122 cannabis, 125–126 disorders (CODs)
tramadol, 121–122 heroin, 112–113 case vignette, 163–164
opioid-induced androgen LSD (lysergic acid co-occurring, 159
deficiency (OPIAD), 186 diethylamide), 127 role of medication, 295
opioid peptides, reinforcing PCP (phencyclidine) and psychological assessment,
addiction, 20, 21f ketamine, 129 clinical obstacles, 46–47
opioids stimulants, 123–124 psychology
 INDEX 395

relapse prevention (RP),

macro, of addressing
substance use disorder,
Q 248, 249
32–33 quetiapine (Seroquel) models of, 255–256
treatment and recovery, cannabis dependence, research support for,
44–48 172t, 204 256–257
psychosocial consequences, opioid withdrawal, 119t relapse prevention therapy
158 (RPT), 235–236
psychosocial interventions, relationship, addiction or
214 R substance dependence, 56
adolescents, 312, 321 race. See ethnicity/race research, adolescents with
behavioral couples therapy randomized trials, relapse SUDs, 334
(BCT), 224 prevention, 256 Research Society on
case vignette, 218 Rational Recovery, 217, 297 Alcoholism (RSA), 382
case vignettes, 218, 232 reasons, motivation, 38 responsibility, interventions,
cognitive behavioral recognition, family and 39
therapy (CBT), substance use disorder, reward
224–226 70, 71 neurobiology, 20, 21f
community reinforcement recovery, 28, 56, 250 transition from, to
approach (CRA), check-ups, 227–228 addiction, 22–23
226–227 continuing care, 304 reward circuitry, brain,
community reinforcement co-occurring disorders 20, 21f
approach and family (CODs), 297–298 reward cravings, 176
training (CRAFT), 227 early, 48, 74, 75 rimonabant, cannabis
contingency management, evolving definitions, 50–51 dependence, 172t, 204
227 family and ongoing, 76 risk factors, adolescents,
continued care and interventions aiding, 312, 314
recovery check-ups, 257–262 robotripping,
227–228 natural, 28, 36, 53 dextromethorphan, 128
co-occurring disorders outcome measures, 50 Rogers, Carl, 144
(CODs), 294 problem severity, 51, 52t
coping skills training promoting, 304–305
(CST), 228 psychology of, 44–48 S
dialectical behavioral psychosocial issues, 240, safety, treatment, 140–141
therapy (DBT), 241t “scared straight” approach,
228–229 recovery-focused care, 51 adolescents, 322
family approaches, relapse prevention (RP), Schedule for Affective
229–230 304–305 Disorders and
group approaches, 230 recovery capital, 51, 52t Schizophrenia for
individual drug counseling recovery-focused treatment, School-Age Children
(IDC), 230–231 52–53, 54–55 (K-SADS), 316
integrated treatment for recovery-oriented cognitive schizophrenia, 231, 286
CODs, 231 therapy (CBT-R), 53 screening
matrix model, 232–233 recovery-oriented systems adolescents, 315
motivational incentives, of care, 52 biological measures,
227 recovery support services, 155–156
motivational interviewing 52 clinical questions, 154
(MI), 234–235 recovery with illness hepatitis C virus (HCV),
motivation enhancement management, 53 273
therapy (MET), reflective listening, 144 importance of valid,
233–234 rehabilitation programs, 220 150–151
mutual support programs, reinstatement paradigms, instruments, 154–155
237–239 craving and relapse substance use disorders
relapse prevention therapy triggers, 23 (SUDs), 152
(RPT), 235–236 relapse, 248, 252 tools and instruments,
role of medical trainee in causes of, 252–255 154–156
treatment, 216–217 identifying warning signs, screening, brief intervention,
therapeutic community 259–260 and referral to treatment
(TC), 236–237 interventions reducing risk (SBIRT), 220
treatment and recovery, of, 257–262 Secular Organizations for
240, 241t managing, 262 Sobriety (SOS), 217, 373
twelve-step facilitation prevention groups, 233 selective prevention,
therapy (TSF), 237 reinstatement paradigms, 23 340–341
396 INDEX

selective serotonin reuptake stress-triggered relapse, 23 therapeutic community

inhibitors (SSRIs), 110, Suboxone, buprenorphine (TC), 236–237
171t, 172t, 202, 295 with naloxone, 120, 191, therapeutic index, 97
self-change, process of, 36 193–194 therapeutic window, 97
self-efficacy, interventions, substance abuse, 6 thiamine, alcohol
40 Substance Abuse and detoxification, 107
self-reports, validity of, 148 Mental Health Services tobacco, nicotine, 346
serosorting, HIV Administration tobacco harm reduction
transmission, 353 (SAMHSA), 80, 189, 384 (THR), 346
Services Administration substance dependence, tolerance, 10
for Mental Health prevalence rates, 2 topiramate (Topamax),
and Substance Abuse substance use, cost and 202
(SAHMSA), 4, 47 effects of, 31 alcohol dependence, 171t,
severity specifiers, substance use disorders 177, 180–181
diagnostic criteria, 7–8 (SUDs). See also cocaine dependence,
short-term residential co-occurring disorders 172t, 201
rehabilitation programs, (CODs) typical dose and effects,
220–221 adolescents, 10 179t
SMART Recovery, 217, assessment domains, tramadol, opioid
297, 373 158–159 detoxification, 121–122
SMAST (short version of case vignettes, 162–164 transparency, 146–147
Michigan Alcoholism diagnostic approaches, transtheoretical model
Screening Test), 154 160–161 (TTM)
smokeless tobacco products elderly people, 10–11 behavioral change, 34
(ST), 346 epidemiology, 4–5 stages of change, 34–35
smoking cessation, 1–800– impact on family system trazodone
QUIT–NOW, 341 and members, 66–67 benzodiazepine
social anxiety, 238 importance of valid withdrawal, 111t
social ecological model, 74 screenings, 150–151 opioid withdrawal, 119t
Bronfenbrenner, 64–65 macro psychology of treatment
exo-system, 64 addressing, 32–33 adolescents with SUDs,
macro-system, 64 prevalence and rates in 320–321, 332
meso-system, 64 U.S., 4–5 chronic hepatitis C virus
micro-system, 64 prevalence rates, 2 infection , 274, 275t
social pressures roles of medical trainee in confidentiality, 140–141
lapse or relapse, 254 treatment, 216–217 co-occurring disorders
resisting, 260 treatment history, 159 (CODs), 294–298
social support network, Subutex, buprenorphine, empathy, 144–145
159. 233 120 focusing transition
societal blueprint, 64 suicide, 47 between levels of
sociodemographic data, support system, developing care, 262
prevalence and rates and utilizing, 260 human immunodeficiency
of substance use surrender, acceptance, 46 virus (HIV), 277–278
disorders, 5 symptomatic, 65 medication-assisted,
sodium valproate, symptom-triggered dosing, 170–172
benzodiazepine benzodiazepines, 106 opening assessment
withdrawal, 111t process, 142
spice, 125 outcomes of, 255
spiritual illness, T principles of effective, 42t
biopsychosocial, 33 tapered dosing, psychology of, 44–48
spiritual issues, lapse or benzodiazepines, psychosocial issues, 240,
relapse, 254 106–107 241t
spouses, relapse prevention, technology of acceptance, safety, 140–141
257 229 strategies for facilitating
State Associations of technology of change, sharing, 143
Addictions Services 228, 229 therapeutic alliance, 139
(SAAS), 383 temazepam, metabolism, transparency, 146–147
stimulants 108 validity of self-reports, 148
pharmacology, 123–124 test-retest reliability, treatment-assisted recovery,
symptoms of intoxication, DSM-IV, 7 53
124 therapeutic alliance, treatment stress, lapse or
stress, lapse or relapse, 254 treatment, 139 relapse, 254–255
 INDEX 397

tricyclic antidepressants U.S. Food and Drug William L. White Papers,

(TCAs), 199, 295 Administration (FDA), 385
triggers 119, 170 Witaker, Carl, 65
identification, 258 approved for alcohol withdrawal
lapse or relapse, 253 dependence, alcohol, 328
trimethobenzamide, opioid 174–177 cannabis, 9–10
withdrawal, 119t approved medications for nicotine, 328–329
triple diagnosis, patients, 276 opioid dependence, opioid, 113
twelve-step facilitation 184–188 Withdrawal Assessment
therapy (TSF), 237 approved or studied Scale (WAS), alcohol,
twelve-step programs, 258. medications for 100, 101–102t
See also Alcoholics substance use withdrawal symptoms
Anonymous (AA); disorders, 171–172t alcohol, 99, 100t
Narcotics Anonymous medication for hepatitis C benzodiazepines, 109
(NA) virus, 274 cannabis, 126–127
Cocaine Anonymous US WorldMeds, 119 dissociative drugs, 129
(CA), 233, 297, 364 hallucinogens, 128
Codependents opioids, 113
Anonymous, 233, 301 V stimulants, 124–125
Crystal Meth Anonymous valproic acid, alcohol withdrawal syndromes,
(CMA), 233, 365 detoxification, 107 9–10, 94
Dual Recovery varenicline women. See also pregnant
Anonymous (DRA), alcohol dependence, women
297, 307, 366 171t, 181 case vignette, 85
Emotions Anonymous nicotine dependence, methadone maintenance,
(EA), 366 172t, 198 188
Families Anonymous ventral tegmental area substance use disorders,
(FA), 367 (VTA), reward circuitry, 83, 84
HALT (don’t get too 20, 21f Women for Sobriety (WFS),
hungry, angry, lonely Veterans Administration 217, 297, 374
or tired), 261 (VA), 170 World Health Organization
Methadone Anonymous Vicodin, 55, 131 (WHO), 154
(MA), 369 Volkow, Nora, 23–24

U Y
ultrarapid detoxification W youth. See adolescents
procedure, opioids, 122 warning signs, lapse or
United Nations, Drug relapse, 259–260
Control Program, 340 Wernicke encephalopathy, Z
universal prevention, 340 107 zaleplon, 108
urine drug testing (UDT), Wernicke–Korsakoff ziprasidone, 54, 55
155–156 syndrome, 107 zolpidem, 108