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Chapter 17

Chap 17-Treatments for Substance.doc

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Department
Psychology
Course
PSY240H5
Professor
Ayesha Khan
Semester
Winter

Description
Treatments for Substance-Related Disorders • The treatments for substance-related disorders have been based on the disease model, which views these disorders as medical diseases • The disease model suggests that biological treatments are most appropriate. • It also suggests that people with these disorders have no control over their use of substances because of their disease and, thus, must avoid all use of the substances • Alcoholics Anonymous, a self-help group, focuses on helping alcoholics accept that they have a disease and abstain completely from drinking. • Psychological interventions have been based on a harm-reduction model of treatment o Proponents of this approach focus on the psychological and sociocultural factors that lead people to use substances inappropriately and on helping people gain control over their use of substances through behavioural and cognitive interventions o Does not presume that people must avoid all use of substances —for example, that alcoholics must never take another drink— although it is strongly recommended that people with substance use disorders restrict their exposure to substances • A clinician will most often recommend detoxification as the first step in any treatment program o Individuals are assisted in stopping their use of the substance and then the substance is eliminated from the body o Many detoxification programs are in hospitals and clinics so that physicians can monitor individuals through their withdrawal from the drug, making them more comfortable and intervening if their life is in danger o Detoxification is especially important when the substance being used can cause permanent organ or brain damage or is frequently lethal, such as cocaine, amphetamines, and inhalants. • Once people stop using the substance and are through the withdrawal process, a variety of biological and psychosocial therapies are used to help them prevent relapse. • These therapies are often combined in comprehensive substance treatment programs • People check themselves into these programs, where they remain for a few weeks or months until they feel they have gained control over their substance use and dependence. • Research on trans-theoretical stages of change demonstrates that before people begin treatment for substance-related disorders, they go through a process in which change occurs in increments: from an initial precontemplation stage, in which the person is not considering change; to contemplation, in which the person actively evaluates the pros and cons of changing; to the preparation stage, in which planning and commitment to change are consolidated. • Although the specific interventions may have different treatment targets, the process of change appears to be the same across different interventions • New techniques focused on motivational interviewing are also commonly implemented to help the person struggling with changing addictive behaviours to negotiate the barriers that emerge at each stage of change and to facilitate forward movement through the different stages Biological Treatments: Antianxiety Drugs, Antidepressants, and Antagonists o For people who are alcohol dependent, a benzodiazepine, which has depressant effects similar to those of alcohol, can be prescribed to reduce the symptoms of tremor and anxiety, to decrease pulse and respiration rates, and to stabilize blood pressure. o The dosage of the drug is decreased each day, so that a patient withdraws from the alcohol slowly but does not become dependent on the benzodiazepine. o Antidepressants are also used to help people weather the withdrawal syndrome and continue abstaining from substance use o The selective serotonin reuptake inhibitors (SSRIs) can help reduce the impulsive consumption of and craving for alcohol. o Antidepressant drugs are sometimes used to treat alcoholics or other drug addicts who are depressed, but the efficacy of these drugs in treating either the alcohol or other drug problems or the depression in the absence of psychotherapy has not been consistently supported o Antagonist drugs block or change the effects of the addictive drug, reducing the desire of the addict for the drug. o Naltrexone and naloxone are opioid antagonists—they block the effects of opioids, such as heroin o Heroin dependants are also given other drugs that reduce the reinforcing effects of heroin and thus reduce their desire for it o If a person takes heroin while on naltrexone or naloxone, he or she will not experience the positive effects of the heroin o This, theoretically, can reduce the desire for the drug and, therefore, use of the drug. o Naltrexone has also proven useful in blocking the high that can be caused by alcohol o Naltrexone may block the effects of alcohol and opioids because it blocks the effects of the release of endorphins during drinking. o Alcoholics on naltrexone report that their craving for alcohol is diminished and they drink less o The drug acamprosate affects glutamate and GABA receptors in the brain, which in turn are involved in the craving for alcohol. o Preliminary studies have suggested that alcoholics who are prescribed acamprosate stay abstinent longer and may crave alcohol less than alcoholics given placebo o Just having one drink can make a person taking disulfiram feel sick and dizzy and can make him or her vomit, blush, and even faint. o People must be very motivated to agree to remain on disulfiram, and it works to reduce alcohol consumption only as long as they take it. o In the pharmacological treatment of nicotine dependence, there are two general approaches: o The first and most common is nicotine replacement therapy— the use of nicotine gum, the nicotine patch, nicotine nasal spray, or the nicotine inhaler to prevent withdrawal effects for a user who wants to stop smoking o It is hoped that the individual will gradually reduce his or her use of the nicotine replacements, weaning off the physiological effects of nicotine slowly o The other approach is to prescribe a medication that reduces the craving for nicotine o The only medication currently approved for this use is bupropion (marketed for smoking cessation as Zyban), which is an antidepressant. o The ways in which bupropion helps people stop smoking are not currently clear but may involve changes in the neurotransmitter dopamine Methadone Maintenance Programs o Gradual withdrawal from heroin can be achieved with the help of the synthetic drug methadone o This drug itself is an opioid, but it has less potent and longer-lasting effects than heroin when taken orally o The person dependent on heroin takes methadone while discontinuing the use of heroin. o The methadone helps reduce the extreme negative symptoms of withdrawal from heroin. o Individuals who take heroin while on methadone do not experience the intense psychological effects of heroin, because methadone blocks receptors for heroin o Although the goal of treatment is eventually to withdraw individuals from methadone, some patients continue to use methadone for years, under physicians' care, rather than taper off their use o These methadone maintenance programs are controversial. o Some people believe that they allow the heroin dependant simply to transfer dependency to another substance that is legal and provided by a physician. o Methadone maintenance is the only way to keep some heroin dependants from going back on the street and becoming re-addicted. o Studies following patients in methadone maintenance programs do find that they are much more likely than patients who try to withdraw from heroin without methadone to remain in psychological treatment, and they are less likely to relapse into heroin use or to become reinvolved in criminal activity Behavioural and Cognitive Treatments: o Several behavioural and cognitive techniques are used in the treatment of substance use disorders, and several studies have shown these treatments to be quite effective o The first is to motivate the individual to stop using the drug. o People who enter treatment are often ambivalent about stopping use, and they may have been forced into treatment o The second goal is to teach new coping skills to replace the use of substances to cope with stress and negative feelings o The third is to change the reinforcements a person has for using substances—for example, an individual may need to disengage from social circles in which drug use is part of the culture. o The fourth is to enhance the individual's supports from non-using friends and family o The final goal is often to foster adherence to pharmacotherapies the person is using in conjunction with psychotherapy. Behavioural Treatments o Behavioural treatments based on aversive classical conditioning are sometimes used to treat alcohol dependency and abuse, either alone or in combination with biological or other psychosocial therapies o Eventually, through classical conditioning, they develop conditioned responses to the alcohol—namely, nausea and vomiting. They then learn to avoid the alcohol, through operant conditioning, to avoid the aversive response to it o Studies have shown such aversive conditioning to be effective in reducing alcohol consumption, at least in the short term o Booster sessions are often needed to reinforce the aversive conditioning, however, because it tends to weaken with time. o An alternative is covert sensitization therapy, in which people who are alcohol dependent use imagery to create associations between thoughts of alcohol use and thoughts of highly unpleasant consequences of alcohol use o Covert sensitization techniques seem effective in creating conditioned aversive responses to the sight and smell of alcohol and in reducing alcohol consumption. o Some people who are alcohol dependent develop classically conditioned responses to the environmental cues often present when they drink o These conditioned responses increase the risk for relapse among people who are abstinent or trying to quit drinking. A behaviour therapy known as cue exposure and response prevention is used to extinguish this conditioned response to cues associated with alcohol intake o Clients are exposed to their favourite types of alcohol, are encouraged to hold glasses to their lips, and are urged to smell the alcohol, but they are prohibited from or strongly encouraged not to drink any of the alcohol o This procedure reduces the desire to drink and increases the ability to avoid drinking when the opportunity arises o The procedure should be coupled with strategies for coping with and removing oneself from tempting situations Cognitive Treatments o Interventions based on the cognitive models of alcohol abuse and dependency help clients identify the situations in which they are most likely to drink and to lose control over their drinking and their expectations that alcohol will help them cope better with those situations o Therapists then work with clients to challenge these expectations by reviewing the negative effects of alcohol on their behaviour o The therapist might have the client recount the embarrassing and socially inappropriate behaviours he engaged in while intoxicated, to challenge the notion that the alcohol helped him cope effectively with his party anxiety o Therapists also help clients learn to anticipate and reduce stress in their lives and to develop more adaptive ways of coping with stressful situations, such as seeking the help of others or engaging in active problem solving o The therapist then helps the client evaluate the potential effectiveness of each option and anticipate any potential negative consequences of each action. o Therapists using th
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