Psychosocial Approaches to Substance Use Disorder Management

DEFINITIONS OF TERMS RELATING TO MODELS OF CARE

Centralized model of care: Substance use disorder (SUD) treatment is integrated and offered in a single location, frequently delivered by the primary care physician with an addiction specialist providing support.

Distributive model of care: SUD treatment is delivered with a focus on case management to maximize access to care for a wider selection of community services.

Universal programs: SUD treatment interventions designed to reach a whole section of the general population, such as interventions to get all the students in a given school district.

Family-based programs: SUD treatment interventions that are focused on addressing risk factors and protective factors for the development of SUD. Such programs involve supporting parents in how to best communicate and discipline their children to promote drug abstinence and healthy lifestyles.

Selective programs: SUD treatment interventions that target at-risk population groups. For example, interventions that target school dropouts are described as selective programs.

Indicated programs: SUD treatment interventions that target specific at-risk individuals. For example, interventions reduce subsequent drug use for a specific teenager suspended from school after LSD was found in his backpack.

LONG-TERM PSYCHOSOCIAL PROGRAMS FOR THE CARE OF PERSONS WITH SUD

The phrase “residential rehabilitation program” is not a discrete and well-defined intervention; instead, it refers to a long-term residential setting for persons with subacute SUD treatment needs in which a variety of services may be offered. Treatment programming varies widely but often follows the 28-day traditional “Minnesota Model.” Residential rehabilitation programs are frequently followed by intensive outpatient programs. As discussed in Chapter 1, the American Society of Addiction Medicine (ASAM) patient placement criteria (PPC-2R) specifies which type of services and treatment settings are most appropriate for a given patient with SUD, with Level III referring to residential programs:

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  Level III.1: Clinically managed low-intensity residential services

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  Level III.3: Clinically managed medium-intensity residential treatment

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  Level III.5: Clinically managed high-intensity residential treatment

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  Level III.7: Medically monitored intensive inpatient treatment

The term “clinically managed” describes facilities with on-site skilled clinical staff but no on-site physician. Using the PPC-2R framework, individuals in need of Level III services are those with minimal withdrawal and biomedical needs who require maintenance SUD services in a 24-hour monitored recovery environment.

Therapeutic communities (TC) are a type of residential treatment facility that is traditionally longer-term (typically 6 to 12 months) and utilizes every aspect of the residential community as part of the treatment experience and an opportunity to provide services. The treatment goal is to promote resocialization of the person with SUD and use every community member, including staff and other residents, as active components of treatment. The program focuses on accountability, responsibility, and structuring a socially productive life. The TC model has been adapted to correctional settings. When combined with community-based TC on release from incarceration, such models are associated with improved substance use and criminal justice outcomes.

Overall, the clinical outcomes from residential rehabilitation treatment programs are mixed, ranging from no effect to modest or moderate benefit compared to alternative modes of treatment, such as intensive outpatient programs, and methodological issues limit many research studies. Some studies show that length of stay correlates with abstinence success rates.

COMMUNITY MUTUAL-SUPPORT GROUPS AND 12-STEP PROGRAMS

Mutual-support groups, including 12-step programs, such as AA or Narcotics Anonymous, are peer-led groups traditionally facilitated by persons with SUD in recovery as self-directed leadership aiming to foster supportive and mentoring peer relationships. Groups are focused on a problem shared by group members, are free of charge, and encourage mutual aid. Techniques used to promote change rely on experiential learning, building structure, learning coping strategies, and strengthening social networks. The goals of such a group include promoting self-efficacy and a new identity.

We will use AA as a model for this discussion on 12-step–based mutual-support groups. AA meetings involve an opening ritual, group members sharing their experiences, and a closing ritual. Members are encouraged to “work through” the 12 steps of AA; surrender to a higher power; and select a sponsor who can provide mentorship, guidance, and support to help the member work through the steps. AA principles include taking responsibility, finding humility, and using honesty. AA uses tools based on psychological principles, including stimulus control and cue reactivity (surrounding oneself with sober social connections and avoiding people, places, and things associated with alcohol use), reconditioning (or counterconditioning: learning healthier behaviors for managing urges and substituting addictive behaviors such as seeking support from a sponsor, desensitization, assertion, and cognitive counters to irrational assertions), and positive reinforcement (offering “chips” to celebrate the duration a member has been sober).

Although many persons with alcohol use disorder find AA meetings extremely helpful, many do not. Indeed, although abstinence is not mandated to attend AA meetings, all participating members have to agree to a goal of total and complete abstinence. Setting harm reduction goals (such as reducing one’s drinking rather than lifelong abstinence) is inconsistent with the AA ideology. People seeking to moderate their drinking are unlikely to benefit from AA. Similarly, persons with alcohol use disorder who cannot accept the concept of a “higher power” (loosely defined in modern AA teachings to fit a range of beliefs including a god, nature, or even the support of group fellowship) or the “alcoholic” label cannot meaningfully participate in AA.

For such persons finding AA unsuitable to their needs, organizations such as SMART Recovery, Secular Organizations for Sobriety, Moderation Management, and LifeRing serve as an alternative to the spiritually oriented AA. We will use SMART Recovery as a model for this discussion alternative to 12-step-based mutual-support groups.

Self-Management and Recovery Training (SMART) Recovery aims to teach persons with SUD coping strategies and a logical approach to thinking and acting. Groups utilize trained facilitators and seek to change maladaptive behaviors leading to substance use. The program lists four core tenets:

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  Building and maintaining motivation to abstain

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  Learning how to cope with urges

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  Managing feelings, thoughts, and maladaptive behaviors

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  Balancing immediate and long-term rewards (monetary and enduring satisfactions

SMART Recovery offers in-person and online programs, both of which are of equal effectiveness in achieving abstinence or reducing drinking and substance-related problems. Similarly, Moderation Management applies cognitive behavioral therapy (CBT) techniques in a peer-support context with a member-elected goal of either abstinence or moderation of drinking. Moderation Management promotes self-control, responsibility, choice, rational thinking, and insight into drinking behaviors.

The 12 steps of AA:

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  I can’t (We are powerless over alcohol, and our lives have become unmanageable.)

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  God can (Power greater than ourselves can restore us to sanity.)

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  Let God (Turn our will and our lives over to the care of God as we understood Him.)

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  Look within (Made a searching and fearless moral inventory of ourselves.)

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  Admit wrongs (Admitted to God, to ourselves, and to another human being the exact nature of our wrongs.)

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  Ready self for change (Were entirely ready to have God remove all these character defects.)

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  Seek God’s help (Humbly asked Him to remove our shortcomings.)

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  Become willing (Made a list of all persons we had harmed, and became willing to make amends to them all.)

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  Make amends (Made direct amends to such people wherever possible, except when to do so would injure them or others.)

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  Daily inventory (Continued to take personal inventory, and when we were wrong, promptly admit it.)

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  Pray and meditate (Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and power to carry that out.)

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  Give it away (Having had a spiritual awakening due to these steps, we tried to carry this message to alcoholics, and to practice these principles in all our affairs.)

HALT (Hungry, Angry, Lonely, or Tired) is an AA mnemonic for triggers and emotional states that promote relapse.

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  Relapse prevention strategies in 12-step–based programs use Marlatt Relapse Prevention model. The model defines intrapersonal determinants of relapse as:

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    Self-efficacy

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    Outcome expectancies (beliefs about the consequences one can anticipate as a result of substance use)

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    Craving

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    Motivation

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    Coping

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    Emotional states

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  For persons with SUD in treatment, the earlier in the course of treatment that they are referred to mutual-support group meetings, the more likely they are to attend.

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  Effectiveness studies show that attending AA meetings is most likely to be associated with abstinence in persons attending two or more groups per week.

SPECIFIC PSYCHOTHERAPIES

Various evidence-based psychotherapies effectively treat SUD, including CBT, motivational interviewing (MI), twelve-step facilitation (TSF), contingency management (CM), and mindfulness-based interventions.