Chapter 18: Treating Substance Abuse and Dependence

Treatment for substance abuse and dependence may include both behavioral and psychosocial approaches as well as the use of various medications.  The goals and approaches of different treatments reflect different theories about substance abuse. For example, if one views alcohol dependence as a biological disease, then the only acceptable treatment goal is complete abstinence.  If, on the other hand, one views alcohol dependence as one end of a continuum of drinking, then controlled social drinking might be an appropriate treatment outcome.

Many of today's psychosocial treatment programs are heavily influenced by the philosophy developed by Alcoholics Anonymous.  These programs are often collectively referred to as 12-step programs.  The disease model inherent in AA's approach removes the blame for problem drinking from the individual; it does not, however, eliminate the individual's responsibility for dealing with the problem. Group support and a buddy system are key features of AA's approach.

Motivational interviewing is another behavioral approach to treatment.  It is usually used in conjunction with stages of change theory, to help move people from one stage to another in the process of quitting.  Contingency management, another behavioral approach, has been shown to be effective, but programs based on this approach can be expensive because of the emphasis on providing rewards for people who remain drug-free.  Combining cognitive therapy with behavioral skills training has also been shown to help prevent relapse.

In addition to psychosocial and behavioral approaches, medications are a key feature of substance abuse treatment. Medications are often used to ease withdrawal during the initial detoxification stage. Medications may also help people maintain abstinence; these medications for maintenance therapy can be divided into three general groups. The first group is agonist or substitution drugs, which are used to induce cross-tolerance to the abused drug; agonist agents typically have safer routes of administration and/or diminished psychoactive effects compared to the abused drug.  The second group is antagonists, which prevent the user from experiencing the reinforcing effects of the abused drug. Finally, punishment agents produce an aversive reaction following ingestion of the abused drug; these punishment drugs are generally not effective because patients often choose not to taken them as recommended.

For treatment of alcohol dependence, benzodiazepines are typically given to reduce the potentially dangerous withdrawal symptoms.  Disulfiram is a drug that may be used for maintenance therapy; it interferes with alcohol metabolism and produces illness if the patient uses alcohol.  Naltrexone and acamprosate are also available to assist in preventing relapse.

For nicotine dependence, there are five nicotine replacement products approved by the FDA that can be used for maintenance therapy.  In addition, the antidepressant drug bupropion may be used alone or in combination with nicotine replacement therapy to aid smoking cessation.  These agents have been shown to increase quit rates, although the relapse rate is high.

For opioid dependence, methadone is the drug most commonly used during both detoxification and maintenance therapy. Long-term methadone substitution therapy is viewed as preferable to heroin dependence.  The drug buprenorphine is now also available for use in substitution therapy.  Another potential medication, naltrexone, blocks the effects of opioids, but it has not been as effective as methadone in helping people abstain from heroin or other abused opioids.  Rapid opioid detoxification is a short-term method to avoid experiencing withdrawal symptoms, but it carries significant medical risks.

No drugs have yet been approved for treatment of cocaine dependence or cannabis dependence.  However, the use of oral THC, which relieves cannabis withdrawal symptoms, shows promise as a potential treatment for cannabis dependence.

Overall, substance abuse treatment programs are considered to be effective because they do help many people abstain, sometimes only for a few months, but often for many years.  The benefits in terms of reduced crime, reduced mortality, and increased employment far exceed the costs of providing the programs.