Therapies in substance abuse disorder-converted.pptx

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1. THERAPIES IN SUBSTANCE ABUSE DISORDER PRESENTED BY-DR SALONI(JR2) MODERATED BY-DR A.Q JILANI(MD,DNB,DM)

2. Introduction The use of substances that alter mood, behavior, or cognition has been a part of human life across numerous social contexts throughout history. Invariably, there are some individuals whose use of such substances may lead to abuse and eventual psychological, social or physical harm. Although some people use drugs safely, most encounter problems.

3. Assessment Sound assessment is required that will determine the choice of treatment - goal and content. Information should be attained on the Evolution of drug/alcohol intake Family history Patterns of current use Degree of dependency The extent of drug and alcohol related problems Reinforcement parameters maintaining the behavior Opportunities within the client’s environment for developing more adaptive responses.

4. Assessment It is also important to assess the extent of any co-existing psychopathology. There are numerous scales that have been developed for the assessment of various aspects of drug and alcohol abuse.

5. Assessment Gossop (1996) has provided examples of treatment goals which include: Reduction of psychosocial or physical problems either directly or indirectly related to the drug problem. Reduction of risky behavior associated with the use of the drug. Attainment of controlled or nondependent use. Attainment of abstinence from the problem drug. Attainment of abstinence from all drugs.

6. Psycho education Psychoeducation of patient and family with special emphasis on harm minimization. Def. as the policies, programmes and practices that aim primarily to reduce the adverse health, social and economic and legal consequences of the use of legal and illegal psychoactive drugs without necessarily reduction in drug consumption. AIM to keep drug user alive Well and productive until treatment works or they grow out of their drug use Can be integrated in society Often applied to reduce harm associated with IV drug users i.e. HIV/AIDs.

7. Brief intervention MILLER AND SANCHEZ 1994 F – FEEDBACK of personal risk and impairment R – RESPONSIBILITY for change A – ADVICE to change M – MENU of alternative change options E – EMPATHY on the behalf of the practitioner S – SELF-EFFICACY or optimism in the client facilitated by the practitioner

8. Motivational enhancement therapy Given by Miller in 1999. Brief therapy which uses an empathic, non-judgemental and supportive approach to examine the patient’s ambivalence about changing substance behaviours. 5 stages model – Precontemplation Contemplation Preparation Action Maintenance

9. STAGES STRATEGIES PRECONTEMPLATION ESTABLISH RAPPORT ESTABLISH PATIENT’S PERCEPTION OF PROBLEM GIVE INFORMATION ABOUT RISK OF SUBSTANCE USE EXPRESS CONCERN AND KEEP DOOR OPEN CONTEMPLATION NORMALIZE AMBIVALENCE CHANGE EXTRINSIC AND INTRINSIC MOTIVATION EMPHASIZE THE CHOICE OF RESPONSIBILITY AND SELF EFFICACY ELICIT SELF MOTIVATIONAL STATEMENTS OF INTENT AND COMMITMENT PREPARATION CLARIFY PATIENT’S OWN GOAL AND STRATEGIES FOR CHANGE OFFER MENU OF OPTIONS AND WITH PERMISSION GIVE ADVICE HELP PATIENT ENLIST SOCIAL SUPPORT EXPLORE EXPECTANCIES AND PATIENT’S ROLE ASSIST THE PATIENT TO NEGOTIATE FINANCES, CHILD CARE, WORK OR OTHER

10. STAGE STRATEGIES ACTION ENGAGE PATIENT IN TREATMENT AND REINFORCE THE IMPORTANCE OF REMAINING IN RECOVERY ACKNOWLEDGES DIFFICULTIES IN EARLY STAGES OF CHANGE HELP IDENTIFY HIGH RISK SITUATIONS AND DEVELOP APPROPRIATE COPING STRATEGIES HELP ASSESSING STRONG FAMILY AND SOCIAL SUPPORT MAINTAINENCE HELP IN IDENTIFYING AND SAMPLE DRUG FREE SOURCES OF PLEASURE SUPPORT LIFE STYLE CHANGE ASSIST IN PRACTICING THE USE OF NEW COPING STRATEGIES TO AVOID RETURN TO DRUG USE MAINTAIN SUPPORTIVE CONTACT DEVELOP A ‘FIRE ESCAPE’ PLAN IF PATIENT RESUMES SUBSTANCE USE

11. Relapse prevention therapy (RPT): There are three primary areas of focus in RPT: (1) coping skills training, (2) cognitive therapy interventions, and (3) behavioral techniques/lifestyle changes. Two models are available: Marlott’s and Gorski’s CENAPS Model of RPT. RPT is to be done postdetoxification

12. Relapse prevention therapy (RPT): The model by Marlatt and Gordon presented relapse prevention as a set of principles broadly based on social learning theory. In this program, individuals are taught to recognize the possibility of relapse. Essentially the client constructs a personal behavioral analysis and receives training in specific coping strategies. These can include broad-based skills training (behavioral rehearsal, assertiveness training), cognitive reframing (coping imaginary, reframing reactions to lapse), and lifestyle interventions (relaxation and exercise enhancement).

13. Relapse prevention therapy (RPT): Clients are taught to recognize early warning signals and made aware of apparently irrelevant decisions that can increase the possibility of relapse. Emphasis is placed on the modification of cognitive distortions and the challenging of faulty beliefs or dysfunctional assumptions. The abstinence violation effect is a distorted redefinition of lapse as relapse, so undermining the effectiveness of future coping behavior. The Marlatt and Gordon relapse prevention program is therefore a combination of skills training, self-management, and cognitive interventions and the client is encouraged to practice these strategies using rehearsal, role play and homework tasks.

14. Relapse prevention therapy (RPT): The relapse prevention model of Annis and Davis(1989) draws more explicitly on self-efficacy theory. The emphasis of this approach is on performance based methods, notably the exposure to increasingly high-risk situations with continuing self-monitoring of efficacy expectations. In guiding the client through the high- risk situations four factors are taken into account. First, the situation is challenging; second, to succeed in mastering the situation a moderate degree of effort is needed; third, the client is responsible and external help is kept to a minimum; and fourth, the success is described as part of improved performance.

15. Cognitive behavior therapy (CBT) CBT for substance abuse has typically been delivered in 45- to 60- minute individual or group counseling sessions. The overall focus is the teaching of coping skills relevant to quitting marijuana and coping with other related problems that might interfere with good outcome. Such coping skills include functional analysis of marijuana use and cravings, development of self-management plans to avoid or cope with drug-use triggers, drug refusal skills, problem-solving skills, and lifestyle management. Each session involves coping skill, role-playing, interactive exercises, and practice assignments. The duration of CBT has ranged from 6 to 14 sessions.

16. 12 step facilitation therapy Among the contemporary multimodal treatment packages for alcohol abuse, Alcoholics Anonymous is a community self-help group founded by Bill Wilson and Dr. Bob Smith in 1935. The principles of change described by AA are based on a religious organization in the Protestant tradition which emphasized self-examination, the public admission of character deficits, restitution, pledge taking and bible reading. The AA belief system is articulated in the 12 steps mediated by fellowship meetings conducted by formerly drug-dependent persons, which include the requirement of a searching personal inventory, commitment to a greater power, making amends to other people, and carrying the message to other alcoholics. It also takes in to account motivation enhancement by proximal goals, role modeling, relapse management in terms of alternative activity and new social networks. AA emphasizes that helping other members is an essential component of one’s o wn recovery.

17. Contingency management (CM) systematic application of reinforcing or punishing consequences in order to achieve therapeutic goals. CM most commonly involves the systematic application of positive reinforcement to increase abstinence from drug use , an approach referred to as abstinence reinforcementtherapy, but also to facilitate other therapeutic changes, including retention in treatment, attendance at therapy sessions, and compliance with medication regimens. CM is not a replacement for motivational enhancement or skill building, but can be used to augment the decisional balance among patients who would not otherwise be ready to address their substance use.

18. Contingency management (CM) interventions/ motivational incentives: It includes voucher-based reinforcement and prize incentives approaches. It incorporates providing patients tangible rewards in order to enhance positive behaviors like remaining abstinent to substances. It has been shown to be effective in alcohol, stimulants, opioids, marijuana, and nicotine dependence

19. Community reinforcement approach plus vouchers: This outpatient therapy utilizes a range of familial,social, vocational and recreational reinforcers and pertinent material incentives to make substance use less rewarding than non-drug use lifestyle. This intensive program is geared towards cocaine and alcohol users.

20. The matrix model: In this approach, a structure is provided for engagement in treatment of stimulant users and helping them to achieve abstinence.

21. Therapeutic community Therapeutic communities (TCs) and social model recovery programs emphasize on giving back to the community a way to facilitate one’s own and others’ recovery. Experienced residents help orient new residents, take on job responsibilities to maintain the facility, and volunteer to participate in a residents’ council or client government that helps manage program operations. Descriptions of social model recovery homes have described an ethic of volunteerism as a hallmark of that modality. In TC treatment, the role modeling for other clients during daily activities and treatment groups is an essential component of one’s treatment

22. Network Therapy Three key elements are introduced into the Network Therapy technique. Cognitive behavioral approach to relapse prevention. Emphasis in this approach is placed on triggers to relapse and behavioral techniques for avoiding them. Support of the patient’s natural social network is engaged in treatment e.g., peer support, family, friends and spouses. Drug-free rehabilitation is provided by mobilization of resources.

23. Family and Marital Therapy Family therapy is appropriate and helpful throughout the process of recovery. The model follows different stages. One generally starts by working with the most motivated family member or members, convening other family members when needed. The problem is defined and a contract negotiated. The case for a chemical free life, with the involvement of family members is then established. The crisis faced by family members when they go through the change is managed and help given in stabilizing the family.

24. Family and Marital Therapy Family reorganization and recovery is 5 Psychosocial Treatment in Substance Use Disorder the next stage where the roles are balanced and assistance is given in couple or family issues of power and control. The family unit is helped to achieve closeness and intimacy. Treatment comes to an end when client and therapist(s) mutually agree to stop meeting regularly.

25. Skills training Skills building can be broadly conceptualized as targeting interpersonal, emotion regulation, and organizational/problem-solving deficits. Clinical trials examining the addition of coping and communication skills training have demonstrated positive outcomes and are common components of CBT for substance abuse. The use of strategies should be based on case conceptualization, building from patient report and behavioral observation of such deficits. Interpersonal skills building exercises may target repairing relationship difficulties, increasing the ability to use social support, and effective communication. For patients with strong support from a family member or significant other, the use of this social support in treatment may benefit both goals for abstinence and relationship functioning In addition, the ability to reject offers for substances can be a limitation and serves a challenge to recovery. Rehearsal in session of socially-acceptable responses to offers for alcohol or drugs provides the patient with a stronger skill set for applying these refusals outside of the session.

26. Skills training Emotion regulation skills can include distress tolerance and coping skills. use of problem-solving exercises and the development of a repertoire for emotion regulation, the patient can begin to both determine and utilize non-drug use alternatives to distress. Strategies for coping with negative affect, such as using social supports, engaging in pleasurable activities, and exercise can be introduced and rehearsed in the session. The development of pleasurable sober activities is of particular importance given the amount of time and energy that is often taken for substance use activities (i.e., obtaining, using, and feeling the effects of substances). When reducing substance use, patients can be left with a sense of absence where time was dedicated to use, which can serve as an impediment to abstinence. Thus, concurrently increasing pleasant and goal-directed activities while reducing use can be crucial for facilitating initial and maintained abstinence.

27. Skills training Finally, goal-setting deficits can be targeted within the session as part of treatment. Guiding patients in setting treatment goals can serve as a first practice of this skill building.

28. Other therapies Cue exposure and Relaxation training Involves exposing a patient to cues that induce craving while preventing actual substance use. Paired with relaxation techniques. Aversion Therapy Involves coupling substance use with an unpleasant experience such as mild electric shock or pharmacologically induced vomiting.

29. Conclusion Research shows relapse prevention procedures are clearly useful for smokers, moderately effective for alcohol abusers, and have some variable effect, as a treatment for cocaine abuse. In the primary care setting the need for brief interventions and motivational interviewing would be a useful technique since many patients enter these programs unwillingly or at best with motivation to deal with the immediate crisis and placate those responsible for getting them into treatment.

30. The issue of cost effectiveness of treatment is discussed at length rather than the need of the individual. Thus it has been emphasized that it would be best to remind the treatment providers that it would be justified to work on the need for caring of this population rather than cost-benefit analysis.

31. References Substance use disorder by RK lal 1 st edition Clinical practice guidelines for the assessment and management of substance use disorders by pk dalal Comprehensive textbook of psychiatry 10 th edition