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Treatment and Prevention of Substance Use Disorders

Treatment and Prevention of Substance Use Disorders. Lecture Overview Nature and treatment of alcoholism Tobacco Treatments and Prevention Relapse Prevention. Prevalence of Substance Disorders. Lifetime Prevalence of DSM-III-R Substance Abuse Disorders.

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Treatment and Prevention of Substance Use Disorders

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  1. Treatment and Prevention of Substance Use Disorders • Lecture Overview • Nature and treatment of alcoholism • Tobacco Treatments and Prevention • Relapse Prevention Substance Abuse

  2. Prevalence of Substance Disorders Substance Abuse

  3. Lifetime Prevalence of DSM-III-R Substance Abuse Disorders Source: Tsuang et al (1998). Archives of General Psychiatry, 55, 967-972. Data based on 3372 Male Twin Pairs Substance Abuse

  4. Conditional Probabilities of Drug Use Co-occurrence SOURCE: Tsuang et al (1998). Archives of General Psychiatry, 55, 967-972.Data based on 3372 Male Twin Pairs Substance Abuse

  5. Lifetime Prevalence of DSM-III-R Drug Use and Dependence Source: Warner et al (1995). Archives of General Psychiatry, 52, 219-228. Data from National Comorbidity Study Substance Abuse

  6. Pharmacological Treatment for Alcohol Dependence • Disulfiram • Lithium • Naltrexone • Acamprosate? Substance Abuse

  7. Effects of Naltrexone in Reducing Relapse SOURCE: Volpicelli et al (1992). Archives of General Psychiatry, 49, 876-880. Substance Abuse

  8. Effects of Naltrexone in Reducing Relapse SOURCE: O’Malley et al (1992). Archives of General Psychiatry, 49, 881-887. Substance Abuse

  9. Effects of Naltrexone in Reducing Relapse SOURCE: O’Malley et al (1992). Archives of General Psychiatry, 49, 881-887. Substance Abuse

  10. Behavioral Approaches to Alcoholism • Aversion Methods • Chemical • Electrical • Imaginal Substance Abuse

  11. Behavioral Approaches to Alcoholism • Cue Exposure • Rationale Substance Abuse

  12. Cue Exposure:Treatment Components • Continuous exposure to an opened alcohol beverage • Focus on the sight and smell of the beverage • Focus on imaginal drinking cues (high risk situations) • Guided practice in specific coping skills to reduce urges to drink during in vivo and imaginal exposures Substance Abuse

  13. Efficacy Studies: Cued Exposure Monti et al, 1993 Substance Abuse

  14. Cue Exposure With Coping Skills Training SOURCE: Monti et al (1993). JCCP, 61, 1011-1019. CET = Cue Exposure + Skills Training CC = Control Condition Substance Abuse

  15. Efficacy Studies: Cued Exposure Sitharthan et al, 1993 Substance Abuse

  16. Efficacy of Cued Exposure in Moderation Drinking SOURCE: Sitharthan et al, (1993). JCCP, 65, 878-882. Data presented are for the 6-mo follow-up. Frequency = Drinks per month Substance Abuse

  17. Behavioral Approaches to Alcoholism • Relapse Prevention Training • Rationale Substance Abuse

  18. Approaches for Preventing Relapse • Booster session method • Shot gun method • Self-control method • Analyses of relapse process Substance Abuse

  19. Marlatt's Relapse Prevention Model • Major components of the model • High-risk situation Substance Abuse

  20. Triggers for Relapse • Intrapersonal • Coping with negative emotional states • Coping with negative physical/physiological states • Enhancement of positive emotional state • Testing personal control • Giving in to urges Substance Abuse

  21. Triggers for Relapse • Interpersonal triggers • Coping with interpersonal conflict • Social pressure • Enhancement of positive emotional state Substance Abuse

  22. Most Common High-risk Situations • Coping with negative emotional states (37%) • Coping with social pressures (24%) • Coping with interpersonal conflict (15%) Substance Abuse

  23. Marlatt's Relapse Prevention Model • Major components of the model • High-risk situation • Ability to engage in adaptive coping response Substance Abuse

  24. Marlatt’s Relapse Prevention Model • Major components of the model • High-risk situation • Ability to engage in adaptive coping response • Positive outcome expectancies about the substance Substance Abuse

  25. Marlatt’s Relapse Prevention Model • Major components of the model • High-risk situation • Ability to engage in adaptive coping response • Positive outcome expectancies about the substance • Abstinence violation effect (AVE) Substance Abuse

  26. Major Treatment Components of Relapse Prevention Training • Learning to identify high risk situations via self-monitoring • Specific skill training to build effective coping responses • General lifestyle skill training to increase patients' general coping and sense of personal control • Development of leisure activities that do not involve alcohol • Information to counter positive outcome expectancies • Training in coping with slips and the AVE Substance Abuse

  27. Controlled Efficacy Data on Relapse Prevention Training • Description of controlled outcome studies • Number of studies • Type of substance • Abstinence initiation vs. Maintenance of abstinence • Types of comparison groups Substance Abuse

  28. Controlled Efficacy Data on Relapse Prevention Training • Major findings • Comparison to minimal or no treatment • Comparison to attention controls • Comparison to alternative active treatments Substance Abuse

  29. Research on Treatment Matching Substance Abuse

  30. Treatment Matching • Rationale Substance Abuse

  31. Treatment Matching • Conditions for which matching is most appropriate • No single treatment has been shown to be superior • Evidence to suggest that significant subject heterogeneity exists • When evidence suggests that treatment outcome is a function of the interaction between subject characteristics and type of treatment delivered Substance Abuse

  32. Treatment Matching • Practical obstacles to treatment matching • Lack of alternative treatments • Need to specify the treatments along a number of therapy-relevant dimensions • Need to specify the client characteristics at which the treatments are targeted • Practical impact of the increased workload associated with the necessary assessments and treatments • Need to determine the best methods for matching clients and treatments Substance Abuse

  33. Treatment Matching • Observed moderator effects • Social skills (Kadden et al (1992) • Level of craving (Jaffe et al, 1996) • Religiosity (Craig et al, 1977) Substance Abuse

  34. Project Match Substance Abuse

  35. Project MATCH • Primary aim • To assess the benefits of matching alcohol dependent patients to three different treatments based on selected patient characteristics Substance Abuse

  36. Project MATCH • Design • Two parallel but independent 3-arm multisite (10 sites) randomized clinical trials, one with outpatients (N = 952) and one with patients receiving aftercare treatment following intensive inpatient treatment (N = 774) • Treatment conditions (12 individual sessions) • Cognitive-behavior therapy (CBT) • Twelve-step facilitation therapy (12-step) • Motivational enhancement therapy (MET) Substance Abuse

  37. Project MATCH • Apriori matching variables • Severity of alcohol involvement (Edwards & Lader, 1994) • Cognitive impairment (Cooney et al, 1991) • Client conceptual level (McLachlan, 1972) • Gender (Cronkite & moos, 1983) • Meaning seeking (brown et al, 1993) • Readiness to change (DiClemente and Hughes, 1990) • Psychiatric severity ((Kadden et al, 1989) • Social support for drinking (Longabaugh e al, 1993; 1995) • Sociopathy (Cooney et al, 1991) • Typology (Litt et al, 1992) Substance Abuse

  38. Project MATCH • Primary treatment outcome measures • Percent days abstinent (PDA) • Measures drinking frequency • Drinks per drinking days (DDD) • Measures drinking severity Substance Abuse

  39. Project MATCH – Study Findings • Treatment outcome • All three treatments led to significant reductions in PDA and DDD • The improvements on alcohol indices were largely maintained over a 15-month period • The majority of patients did not maintain complete abstinence over thee study period • In general, there were no significant differences between the three treatments for either the aftercare trial or the outpatient trial Substance Abuse

  40. Project MATCH – Study Findings • Matching findings • None of the apriori matching hypotheses were significant for the aftercare sample for either PDA or DDD • One matching hypothesis (psychiatric severity) was significant in the outpatient sample Substance Abuse

  41. Differential Effects of Psychiatric Severity Substance Abuse

  42. Project MATCH – Study Findings • Other moderator effects • For the aftercare sample • Male gender was associated with poorer outcome on PDA • Male gender, higher alcohol involvement, higher social support for drinking was associated with poorer outcome on DDD • Outpatient sample • Higher pretreatment motivation and lower scores on social support for drinking were each associated with a more favorable outcome Substance Abuse

  43. Prevention of Substance Abuse Substance Abuse

  44. Epidemiology • Prevalence of substance use among adolescents • Trends over time • Effects of age, gender, and ethnicity on prevalence • Relationship between cigarette smoking and other drug use Substance Abuse

  45. Prevalence of Substance Use Among Adolescents 12-17 Source: 1995 National Household Survey on Drug Abuse Substance Abuse

  46. Gender Breakdown of Substance Use Among Adolescents 12-17 Source: 1995 National Household Survey on Drug Abuse Substance Abuse

  47. Racial Breakdown of Substance Use Among Adolescents 12-17 Source: 1995 National Household Survey on Drug Abuse Substance Abuse

  48. Cigarette Smoking • Scope of the problem • Mortality • Costs to society • Adverse effects on pregnancy • Adverse effects of environmental tobacco smoke Substance Abuse

  49. Substance Abuse

  50. Substance Abuse

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