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Clinical Interventions


Non-Medication Interventions


Counseling

Counseling is a general term to describe talk therapy with a professional whose chief aim is to help the patient stop their drug use. It may also deal with practical patient needs for services to support their drug abstinence. There are different counseling techniques such as cognitive behavioral therapy, motivational interviewing, twelve-step facilitation, and contingency management which can be provided by a licensed addictions counselor, a mental health therapist, a nurse, a psychologist, a physician, or social worker. Counseling can occur in various settings including a physician’s office, a clinic, an intensive outpatient treatment, a partial hospitalization program, or during inpatient treatment. It may accompany methadone maintenance treatment, office based buprenorphine treatment, or smoking cessation treatment. The amount of counseling provided relates to the level of intensity of the substance abuse program.

Group Therapy

Group therapy brings patients together on a regular basis to discuss drug use and efforts at maintaining abstinence. This type of therapy is led by a professional who keeps the group focused, maintains the rules, and limits individuals who try to monopolize the group’s time and attention.  But the patients in the group have the primary role in the therapeutic process. Using their own experience, they can confront other patients’ behavior as peers. The best groups have a stable cadre of participants who develop and mature together and provide mutual support.  Group therapy can occur in inpatient and outpatient settings, both short and long-term.

Family and Couples Counseling

Counseling for the families and partners of patients being treated for substance abuse disorders can be very useful under the proper circumstances and is often provided in the context of other modes of treatment such as methadone maintenance or partial hospitalization.  The family of an adolescent in treatment is often critical. And a spouse or partner can provide key support to help the patient achieve or maintain abstinence.  Family and couples counseling is best provided by professionals who specialize in this type of counseling.


Medications for Opioid Dependence or Addiction


Opioid Withdrawal Syndrome

Opioid withdrawal is a distressing and uncomfortable experience for the patient but it is usually not life-threatening.  It occurs when a person who is physically dependent on opioids stops or markedly decreases the amount of opioid they are taking. Not all of the signs and symptoms of for a person going through withdrawal, but some of these will typically occur:

Diarrhea

Perspiration

Restlessness

Dysphoria (depression)

Poor sleep

Runny eyes

Feeling tired

Pupillary dilation

Runny nose

Gooseflesh

Loss of appetite

Sweating

Irritability

Muscle cramps

Vomiting

Joint aches

Nausea

Yawning

Methadone

Methadone is a medication approved for use in the treatment of opioid dependence or addiction. It can help prevent very distressing and uncomfortable opioid withdrawal symptoms. It blocks the effects of other opioids so the patient doesn’t experience a ‘high’ if another opioid is substituted. And it decreases the craving that a person feels to use opioids.  It is also a very effective pain medication.

When used for opioid dependence,  methadone is used for both opioid withdrawal (detoxification) or for maintenance of opioid abstinence. If an opioid-dependent patient relapses after several attempts at withdrawal they will enroll in methadone maintenance treatment. 

Methadone is swallowed, often given in liquid form, and provided through special clinics (opioid treatment programs or OTPs) when it is used to treat opioid dependence.  When used for opioid addiction, methadone is taken once a day, beginning with daily visits to an OTP, and later receiving doses to take at home. 

Methadone treatment at an OTP is usually accompanied by non-medication treatment such as counseling. While methadone alone can be useful for some patients, a combination of treatments types improves the outcome for the patient. 

Buprenorphine

Buprenorphine is a medication approved for use in the treatment of opioid dependence. Like methadone, buprenorphine can help prevent very distressing and uncomfortable opioid withdrawal symptoms. It blocks the effects of other opioids so the patient doesn’t experience a ‘high’ if another opioid is substituted. And it decreases the craving that a person feels to use opioids. It is also a pain medication usually administered by injection in a hospital setting for pain treatment. When used to treat opioid dependence, it is given as a tablet that dissolves under the tongue, or a soluble film (like a breath film strip) that is put in the mouth. Buprenorphine can be used for either opioid withdrawal (detoxification) or maintenance treatment. 

In contract to methadone, buprenorphine can be prescribed by a physician who is trained and certified to prescribe it to treat opioid dependence, saving the patient travel to a special clinic for treatment. Buprenorphine has a relatively long duration of effects. It is usually taken once a day but, for some patients, the frequency can stretch to every other day or every third day.

Sometime buprenorphine itself is abused by dissolving the tablet or film and injecting it. In order to prevent this, it is often blended with another medication called naloxone, which makes the abuser ill if injected.  

Oral Naltrexone

Naltrexone is a medication approved for use in the treatment of both opioid dependence and alcoholism. Unlike methadone and buprenorphine, naltrexone is not used for the treatment of pain. The oral form is swallowed in tablet form, and is taken from once a day up to three times a week (for what purpose? Maintenance?).  It is important that a person with opioid dependence be completely withdrawn from opioids before taking naltrexone, otherwise it can precipitate opioid withdrawal syndrome.  Naltrexone also blocks the intoxicating effects of other opioids similar to methadone and buprenorphine.  It can be prescribed by a physician (no special certification is required) saving a patient the need to go to a special clinic. 

Injectable Naltrexone

In addition to the oral form of naltrexone, an injectable form is available to treat opioid dependence and  alcoholism. The injectable form is administered once per month and can be prescribed by a physician without special certification. Again, the patient does not need to go to a special clinic.


Medications for Alcoholism


Disulfiram

Disulfiram is approved for the treatment of alcoholism and has been used for decades.    It works to block an enzyme (acetaldehyde dehydrogenase) that is involved in the metabolism of alcohol.  When a person taking disulfiram drinks alcohol, their body doesn’t effectively metabolize the acetaldehyde that is produced from the alcohol (and the acetaldehyde builds up in them).  This results in what is called a ‘disulfiram reaction’ which is unpleasant.  The person can experience  nausea, vomiting, flushing, headache, and shortness of breath. Not all of these symptoms may occur, but in some cases the reaction can be quite severe.

Disulfiram is meant to help motivate the person to not drink. Ideally, the person taking disulfiram never feels the effects of it.  Disulfiram can be prescribed by a physician without specialized training, and the patient does not need to attend a special clinic.

Oral Naltrexone

Naltrexone is a medication approved for use in the treatment of alcohol dependence as well as  opioid dependence.  It is swallowed in a tablet form, and can be taken from once a day up to three times per week. 

It is not exactly clear why naltrexone is effective when it is used to treat alcoholism and not everyone will find it effective, but multiple studies have shown that it can be helpful for many. 

Naltrexone can be prescribed by a physician with specialized training and the patient does not need to go to a special clinic. 

Injectable Naltrexone

In addition to the oral form of naltrexone, there is an injectable form of this medication that can be used for the treatment of both alcohol and opioid dependence . This form of naltrexone is administered once per month and can be prescribed by a physician without specialized training, saving trip so to a special clinic. 

Acamprosate

Acamprosate is approved for the treatment of alcoholism. Again, how this medication works is not well understood but studies have shown effectiveness in helping a person abstain from alcohol.  Acamprosate is taken by mouth three times per day.  It can be prescribed by a physician with no specialized training.


Self-Help Programs


Probably the most commonly known self-help programs are Alcoholics Anonymous (AA) and its variant, Narcotics Anonymous. AA and its associated programs are often called ‘twelve-step programs’, because they feature twelve steps that participants take in their process of recovery from addiction. While the twelve-step programs are generally well-known, there are other programs as well ---- SMART Recovery, Women for Sobriety, Secular Organizations for Sobriety/Save Our Selves, and Moderation Management. 

A distinguishing feature to these programs is that they are run by the participants in the program, unlike group therapy, where a professional leads the group. While professionally delivered services such as individual and group therapy cost the patient, there is no charge for attending an AA or NA meeting. 

Self-help programs can have an important role in recovering from a substance abuse problem.  Countless persons have succeeded in maintaining abstinence from a drug through the sole use of such groups. In addition, self-help programs often are coordinated with treatment-based services such as an intensive outpatient or a partial hospitalization. While attending a self-help program may not be right for everyone, these programs serve an invaluable role in helping persons achieve and maintain abstinence. 

 

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