Psychosocial Treatment of Substance use Disorder
Substance use disorder is a bio-psycho-social condition and requires a multi-pronged approach for its management. It is fairly established from research in the area of substance abuse that the effective treatment of substance use disorder requires comprehensive management. This includes management of physical complications resulting from the cessation of drug use. It involves addressing broader issues of motivation, lifestyle adjustment, reducing risk behavior, and developing skills to cope with factors that could trigger drug use or to prevent an occasional lapse from becoming a full-blown relapse to regular drug use. Donovan and Wallace (1986) have articulated a bio-psycho-social model in addictive behaviors. This has been the most often used model for the treatment of substance use disorder. It addresses the issue of substance use disorder from biological, psychological, and social perspectives. The components include:
1. Biomedical modalities focus on improved detoxification regimens, anti-craving medication, antagonist medication, substitution treatment, and other pharmacological approaches.
2. Psychological treatment modalities range from addiction counseling to psychodynamic and cognitive-behavioral treatment modalities, including insight-oriented psychotherapy, behavior therapy, family therapy and motivational intervention.
3. Socio-cultural treatment modalities include the community reinforcement approach, therapeutic communities, vocational rehabilitation and culturally specific interventions.
Very often a combination of components of psychological treatments and socio-cultural treatment is done. Psychosocial interventions include a broad range of psychological and behavioral strategies used either alone or in combination with pharmacotherapy and other medical or social interventions.
Psychosocial interventions may be delivered in the context of abstinence-based treatments or in conjunction with pharmacological approaches. The level of intensity, frequency, and duration of these interventions may vary depending upon approach and settings (outpatient, partial hospitalization, inpatient, or residential based treatment settings). Modes of delivering psychosocial intervention also differ and may be delivered in individual, or group sessions and may also include family members, or peer groups. Psychosocial intervention increases the effectiveness of pharmacological approaches and is more effective than either alone.
Important Psychosocial Interventions
Many of the psycho-social interventions can be easily practiced with some training. Choice of intervention may be influenced by the stage of treatment, nature of drug use, treatment setting, and availability of trained manpower. An overview of some of the major interventions is being provided. Models of delivering these interventions can be therapist mediated or based on a self-help approach or through peer group (peer-led interventions).
Brief or time-limited intervention is an effective intervention approach with harmful or hazardous substance users. It can be used at specialist drug abuse treatment settings as well as other opportunistic settings such as primary health care emergency departments by trained health care professionals. Brief intervention is generally conducted to achieve a specific short term goal like facilitating referral to specialized treatment setting, reducing frequency and quantity of substance use, reducing risk associated with substance use, etc. It has been found effective in decreasing alcohol use for at least one year in non-dependent drinkers in primary care clinics, managed care settings, hospitals, and research settings, with similar effect sizes for men and women and for all age groups over 18, including older adults. It can reduce health care utilization as measured by reductions in emergency room visits and hospital days, reductions in hospital readmissions, and reductions in physician office visits. Brief interventions may reduce mortality, health care, and societal costs.
Motivation Improvement Therapy
Motivation has been described as a prerequisite for treatment, without which the clinician can do little. Similarly, lack of motivation has been used to explain the failure of individuals to begin, continue, comply with and succeed in treatment. Motivation can be understood not as something that one has but rather as something one does. It involves recognizing a problem, searching for a way to change, and then beginning and sticking with that change strategy. There are many ways to help people move toward such recognition and action. Motivational interventions are based on principles of motivational psychology; it is a therapist mediated, patient-centered intervention. Studies over the past 10 years have demonstrated that motivational interventions are moderately successful in initiating change among a variety of individuals with alcohol-related problems.
Research has shown that motivation enhancing approaches are associated with greater participation in treatment and positive treatment outcomes. Such outcomes include a reduction in consumption, increased abstinence rates, social adjustment, and successful referrals to treatment.
Principles for Effective Substance Use Disorder Treatment
Inter-individual variance has been linked to the efficacy of outcome in substance use disorder treatment. But certain issues have universal applicability and should form the basis for the management plan. The guiding principles for effective intervention according to NIDA (1999) are:
- No single treatment is effective for all individuals: The treatment should be culture and gender-specific and geared towards addressing the individualized needs of the patient.
- Treatment must be readily available: Patients entering treatment from waiting lists generally have poorer outcomes.
- Treatment to be effective should attend to the multiple needs of the patient and include case management services: To be effective, treatment must address the individual’s drug use and associated medical, psychological, social, vocational, and legal problems.
- Counseling and other behavioral treatment are critical components of substance use disorder treatment: The treatment which focuses on motivation, relapse, lifestyle change, and problem-solving ability yields better outcome results.
- Pharmacological intervention, when combined with psychosocial intervention, has proved to be more efficacious.
- To be successful, treatments must address aspects of the patient’s post-treatment environment and offer a continuum of care.
- The patient’s progress in treatment should be closely monitored, particularly substance use and treatment plans modified as needed.
- Treatment does not need to be voluntary to be effective. Patients who enter treatment out of coercion fare equally well in terms of outcome.
- Retention in treatment is positively linked to the outcome. It is fairly established in substance use disorder treatment that the longer the retention in treatment, the better the outcome. Research has shown that treatment duration (at least 3 months) is related to better outcomes.
- Treatment to be effective should be flexible and strive for quality improvement.
- Complete abstinence from substance use is a long term process and may require multiple episodes of treatment.