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Evidence-Based Intensive Outpatient Treatment Programs. For Substance Use Disorders. Definition and Diagnoses of Substance Use Disorders. DSM-IV-TR CRITERIA

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definition and diagnoses of substance use disorders
Definition and Diagnoses of Substance Use Disorders

Substance Abuse: a maladaptive pattern of substance use leading to clinically significant impairment or distress occurring in any of the following areas, within a 12-month period

  • Failure to fulfill major obligations at work, school, or home
substance abuse dx cont
Substance Abuse Dx – Cont.
  • Recurrent substance use in hazardous situations, such as driving or operating heavy machines while impaired by the substance use
  • Substance-related legal problems
  • Social and interpersonal problems caused by or exacerbated by the substance
substance dependence dx
Substance Dependence Dx

A syndrome characterized by a maladaptive

pattern of substance use leading to clinically

significant impairment or distress, as manifested

by at least 3 of the following and occurring in a

12-month period:

  • Tolerance
  • Withdrawal
  • Substance is taken in larger amounts or for longer periods than intended (overdosing)
substance dependence dx cont
Substance Dependence Dx – Cont.
  • Persistent desire or unsuccessful efforts to cut down or control substance use
  • A significant amount of time is spent in activities to obtain, use, and recover from the substance
  • Important social, occupational, or recreational activities are given up or reduced
  • Continued substance use despite knowledge of having a persistent or recurrent physical or psychological problem
definition of addiction
Definition of Addiction

American Society of Addiction Medicine defines it as:

A primary, chronic, neurobiologic disease with genetic, psychosocial, and environmental factors influencing its development and manifestations. Addiction is characterized by behaviors that include one or more of the following: impaired control over drug use, compulsive use, continued use despite harm, and craving (Graham et al., 2003).

u s statistics on drinking and substance use disorder rates
U.S. Statistics on Drinking and Substance Use Disorder rates:

NIAA 2001-2002 National Epidemiologic Survey on Alcohol and Related Conditions

  • 72% Never exceed the daily or weekly limits
  • 16% Exceed only the daily limit
  • 10% Exceed both daily and weekly limits
csat 2006 data
CSAT 2006 data
  • 50% Americans age 12 and older report drinking alcohol
  • 30% American adults drink at levels that increase their risk for physical, emotional, and social problems. Of these heavy drinkers, about 1 in 4 currently has an alcohol abuse or dependence disorder
  • More men report being current drinkers than do women
  • The rate of alcohol dependence is also lower for women than for men
n ssats 2005
N-SSATS 2005
  • The survey showed that on March 31, 2005, 1.08 million people were enrolled in substance abuse treatment, an 8 percent increase from 1 million in 2000.
  • Of them, 34 percent were in treatment for drug abuse only, up from 29 percent in 2000.
  • In contrast, patients enrolled in treatment only for alcohol abuse declined from 23 percent in 2000 to 19 percent in 2005.
n ssats 2005 cont
N-SSATS 2005 – Cont.
  • The proportion of patients in treatment for both drug and alcohol abuse made up nearly half of all patients (47 percent).
  • The 2005 national survey reported that the number and proportion of patients receiving methadone increased from 17 percent of all patients in 2000 to 22 percent in 2005.
n ssats 2005 cont1
N-SSATS 2005 – Cont.
  • The survey also indicated that opioid treatment programs, which focus on treating addiction to heroin and prescription narcotic pain medications, were available in 8 percent of all substance abuse treatment programs.
  • http://wwwdasis.samhsa.gov/05nssats/nssats2k5web.pdf
samhsa s national survey on drug use and health nsduh 2006
SAMHSA's National Survey on Drug Use and Health (NSDUH) 2006
  • In 2003, of the estimated 25 million veterans (93% were male) living in the United States, 8.4% were between the ages of 17 and 34; 30.1% between the ages of 35 and 54; 42.3% between the ages of 55 and 74; and 19.2% were aged 75 or older.
  • SAMHSA's National Survey on Drug Use and Health found that in 2003, an estimated 3.5% of veterans used marijuana in the past month compared with 3.0% of their nonveteran counterparts.
nsduh 2006 cont
NSDUH 2006 – Cont.
  • Past month heavy use of alcohol was more prevalent among veterans (7.5%) than nonveterans (6.5%).
  • Estimated rates of dependence on alcohol and/or illicit drugs did not differ significantly between veterans and nonveterans. Rates of those dependent on alcohol and/or illicit drugs but who did not receive treatment in the past year were also comparable.
nsduh 2006 cont1
NSDUH 2006 – Cont.
  • An estimated 0.8% of veterans received specialty treatment for a substance use disorder (alcohol or illicit drugs) in the past year compared with 0.5% of nonveterans.
1996 veterans affairs report
1996 Veterans Affairs Report
  • Among veterans with drug diagnoses treated in specialized inpatient substance abuse units 65% abuse cocaine, 19% abuse opiates, and 35% have co-existing psychiatric diagnoses.
veterans with hepatitis c
Veterans with Hepatitis C

Source: HCV Clinical Case Registry

veterans with cirrhosis
Veterans with Cirrhosis

33% increase in annual unique patients (HCV+ or -) with a diagnosis of cirrhosis from 2000-2006.

Source: VA Liver Disease Database

Risk of HCC increases with increasing alcohol intake but is greater in the presence of HCV infection

Donato et al. Am J Epidemiol 2002;155:323

brief alcohol intervention initiative
Brief Alcohol Intervention Initiative
  • Challenge:

Need evidence-based alcohol reduction interventions to help HCV patients reduce or eliminate alcohol consumption

  • Response:

Implement effective brief-intervention strategies and tools for providers to address heavy alcohol use in HCV clinical settings

principles of effective iop programs
Principles of Effective IOP Programs
  • Utilize evidence-based practices
      • Motivational Interviewing (Miller and Rollnick, 1991)
      • Relapse Prevention (Marlatt and Gordon, 1985;


      • NIDA Matrix Model of IOP 20 year project
  • (Rawson et al. 1995)
      • Stages of Change

(DiClemente and Prochaska, 1998)

      • Harm Reduction model
  • ( Sobell and Sobell, 1993b, 1993, 1998, 1999)
evidence based practices cont
Evidence-Based Practices – Cont.
  • Brief Alcohol Interventions in primary care settings (Project TREAT (Trial for Early Alcohol Treatment), 1997; World Health Organization Brief Intervention Study, 1996; and TIP 24 A Guide to Substance Abuse Services for Primary Care Clinicians)
  • Cognitive-Behavioral Therapy (i.e. relapse prevention –Gorski, Marlatt & Gordon, Najavits - Seeking Safety)
evidence based practices cont1
Evidence-Based Practices – Cont.
  • SAMHSA/CSAT Treatment Improvement Protocols (TIPS 8, 13, 33 and 35 for IOP programs)
websites for evidence based practices
Websites for Evidence-based Practices
  • www.hepatitis.va.gov
  • www.modelprograms.samhsa.gov
  • www.nrepp.samhsa.gov
  • www.mentalhealthpractices.org
  • tie.samhsa.gov/Externals/tips.html
  • www.nida.nih.gov/PubCat/PubsIndex.html
  • www.niaaa.nih.gov/publications/guides.html
principles of effective iop cont
Principles of Effective IOP – Cont.
  • A continuum of care is more cost efficient care.
  • A multidisciplinary approach
  • Cross-trained Staff
  • Integration of treatment is essential.
  • Treatment should be individualized.
components of iop treatment group topics
Components of IOP TreatmentGroup Topics
  • The neurochemistry of addiction and the addiction process
  • The role and process of treatment and recovery
  • Medical aspects of addiction - PAWS symptoms
  • The importance of abstinence from alcohol and all other drugs
  • Appropriate use of prescribed and over-the-counter drugs
  • Powerlessness and unmanageability of AOD use
components of iop cont group topics
Components of IOP – Cont.Group Topics
  • Maximizing the use of self-help and support groups
  • Spirituality and the development of an externalized source of support
  • The roles of nutrition, exercise, leisure, and recreation in recovery
  • Experiencing emotions and feelings without AODs
  • Relationship skills
  • Conflict resolution and communication skills
components of iop cont group topics1
Components of IOP – Cont.Group Topics
  • Family dynamics of addiction
  • Healthy relationships and family functioning
  • Relapse management skills
  • AOD refusal skills
  • Avoiding and defusing triggers for craving and relapse
  • Minimizing risks for HIV, AIDS, and sexually transmitted disease
core and enhanced services for iop programs
Core and Enhanced Services for IOP programs
  • High quality leadership and administrative support
  • Comprehensive biopsychosocial screening and assessment
  • Program orientation and intake procedures
  • Routine and random urine drug screening
  • Individual treatment planning and review
  • 24-hour crisis management
  • Pharmacotherapy and medication management
  • Medical treatment
core and enhanced services for iop programs cont
Core and Enhanced Services for IOP programs – Cont.
  • Individual counseling
  • Group therapy
  • Education about AOD issues
  • Family education and counseling
  • Self-help and support group orientation
  • Case management services
  • Discharge and transitional service planning
core and enhanced services for iop programs cont1
Core and Enhanced Services for IOP programs – Cont.
  • Program and outcome evaluation
  • Adult education
  • Adjunctive therapies
  • Transportation services
  • Housing and food
  • Smoking cessation treatment
  • Aftercare
  • Specialty groups
model programs and evidence based practices
Model Programs and Evidence-Based Practices
  • Brief Interventions/Motivational Interviewing for Hazardous Drinking
brief interventions motivational interviewing for hazardous drinking
Brief Interventions/Motivational Interviewing for Hazardous Drinking
  • Strengths:
  • Uses Motivational Interviewing

-Uses change talk

-Roadmap for BI

brief interventions motivational interviewing for hazardous drinking1
Brief Interventions/Motivational Interviewing for Hazardous Drinking
  • Uses feedback to raise readiness
  • Discuss change options with patients
  • Solution-Focused
  • Structured
  • Harm Reduction
brief interventions for hazardous drinking
Brief Interventions for Hazardous Drinking
  • Weaknesses:
  • Is not a pancea for every difficult or unmotivated patient
  • (see Ten Things Motivational Interviewing is not by Miller & Rollnick, 2009)
raise importance
Raise importance
  • On a scale of 0-10, how important is it for you to change your drinking?
  • Why did you give it a (patient’s number) and not a lower higher number?
  • What would it take to give it a higher number?
  • I m p o r t a n c e
  • 0 1 2 3 4 5 6 7 8 9 10

Rollnick, Health Behavior Change, 1999

build confidence
Build confidence
  • On a scale of 0-10, how confident are you that you can change your drinking?
  • Why did you give it a (patient’s number) and not a lower higher number?
  • What would it take to give it a higher number?
  • C o n f i d e n c e
  • 0 1 2 3 4 5 6 7 8 9 10
  • Rollnick, Health Behavior Change, 1999
drinking diary card
Drinking Diary Card
  • Measuring behavior is an intervention
  • Good for patients in early stages of change
  • Self-monitoring can reveal:
    • Drinking patterns
    • Social/emotional contexts
    • Antecedents/consequences (A, B, C’s)
  • Can promote harm reduction
change plan template
Change Plan Template
  • For patients who appear ready to attempt behavior change
  • Goals most likely successful when they are:
    • Explicit (measurable)
    • Achievable (realistic)
    • Public (verbal commitment)
  • Facilitates problem-solving, identifying resources & support
model programs and evidence based practices1
Model Programs and Evidence-Based Practices
  • 12-Step Facilitation Approach

"Minnesota Model“

12 step facilitation model
12-Step Facilitation Model
  • Strengths:
  • 12-Step meetings are a free, widely available, ongoing source of support.
  • The 12-Step approach emphasizes an array of recovery tasks in cognitive, spiritual, and health realms.
  • The 12-Step approach is effective with patients from diverse backgrounds (Tonigan 2003).
12 step facilitation model1
12-Step Facilitation Model
  • Weaknesses:
  • It can be difficult to monitor accurately patients' compliance with assigned step tasks, including meeting attendance.
  • 12-Step groups' emphasis on a higher power may be unacceptable to some patients.
  • Some communities may not be large enough to sustain 12-Step meetings or appropriate meetings for people with significant psychiatric disorders.
model programs and evidence based practices2
Model Programs and Evidence-Based Practices
  • Cognitive Behavioral Therapy


cognitive behavioral therapy cbt
Cognitive Behavioral Therapy (CBT)
  • Strengths:
  • CBT actively engages patients in therapy and experiential learning.
  • Numerous manuals on CBT are available.
  • CBT is suitable for patients from diverse backgrounds and with varying histories of alcohol and drug use.
  • CBT provides structured methods for understanding relapse triggers and preparing for relapse situations.
  • Weaknesses:
  • Patients with poor reading or cognitive skills may need alternatives to written assignments.
  • The approach requires counselor training in CBT principles and techniques.
  • Patient motivation is critical because of the extent of homework assignments.
  • CBT was developed as an individual, not group, counseling approach.
motivational approaches
Motivational Approaches
  • Strengths
  • MI and MET are patient centered and relevant to patients' personal interests.
  • MI and MET focus on realistic, attainable goals.
  • MI and MET encourage patient self-efficacy and self-sufficiency.
  • MI and MET emphasize positive, empathic support that does not undermine or elicit anger from patients.
motivational approaches cont
Motivational Approaches – Cont.
  • Weaknesses:
  • MI and MET rely heavily on patients' capabilities and level of self-awareness.
  • Commonly used problem-oriented assessment instruments are incompatible with a motivational approach.
  • Although MET provides some guidance about effective interpersonal strategies for treating ambivalent patients, the approach does not specify session content.
motivational approaches cont1
Motivational Approaches – Cont.
  • Motivational approaches require significant staff training, reorientation, and ongoing supervision.
  • Motivational approaches may be difficult to combine with disease- or therapeutic community-oriented approaches that expect adherence to program-imposed goals.
  • MI and MET were developed as individual approaches; their effectiveness for use with groups is unproved.
motivational approaches cont2
Motivational Approaches – Cont.
  • MET was developed for, and has been effective with, patients exhibiting varying severities of alcohol-related problems. Court-mandated patients appear to benefit as much from MET as do self-referred patients.
the matrix model
The Matrix Model
  • Strengths
  • The model integrates a cognitive-behavioral approach with family involvement, psychosocial education, 12-Step support, and urine testing.
  • The model follows a manual, providing therapists with specific instructions and practical exercises. A version of the Matrix materials is available free from NCADI (CSAT 2006c,2006d).
  • The model has been used extensively with people dependent on stimulants and has been shown to be effective.
the matrix model cont
The Matrix Model – Cont.
  • Weaknesses:
  • Some materials may need to be modified for patients whose cognitive functioning is impaired.
  • The program requires special staff training and supervision.
  • The highly structured content may not appeal to all patients.
  • The tight structure and schedule may not leave time for identification and stabilization of other non-drug-specific problems.
controlled drinking
controlled drinking research sternberg 2005
Controlled Drinking Research (Sternberg, 2005)
  • Some alcohol-dependent individuals choose and achieve moderation even while participating in abstinence-based treatment programs.
  • Studies of abstinence-based treatment outcomes consistently report reduced, moderated, or non-problematic drinking among participants of these programs. Long-term moderate consumption appears to be as prevalent as continuous abstinence.
controlled drinking research cont
Controlled Drinking Research – Cont.
  • The combined evidence from multiple studies finds that 20-40% of patients report long-term abstinence or stable moderate-drinking following treatment.
  • When given a choice between controlled-drinking or abstinence treatment goals, many problem drinkers choose abstinence.
  • On the other hand, other individuals who start out with the goal to achieve moderate drinking, eventually choose to become abstinent.
controlled drinking research cont1
Controlled Drinking Research – Cont.
  • Sobell and Sobell recommend that patients be treated in a stepwise fashion. For those who have substance abuse rather than dependence, work towards moderate drinking (if patient desires this), if patient is unable to achieve moderation then focus on abstinence and more intensive interventions.
  • Permitting a choice of treatment goals (e.g., controlled drinking vs. abstinence) increases recruitment and lowers attrition, without increasing the rate of relapse.
controlled drinking research cont2
Controlled Drinking Research – Cont.
  • Numbers of studies have found several factors to be associated with controlled drinking success – including psychological and social stability, steady employment, higher levels of education, and fewer pre-treatment periods of abstinence.
  • Generally, speaking patients with more severe alcohol problems tend to fare better in abstinence-oriented programs.