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An integrated system of care that guides and tracks a person over time through a comprehensive array of health services appropriate to the individual's need. A continuum of care may include prevention, early intervention, treatment, continuing care, and recovery support. Mild substance use disorders can be identified quickly and reliably in many medical and social settings. To address the spectrum of substance use problems and disorders, a continuum of care provides individuals an array of service options based on need, including prevention, early intervention, treatment, and recovery support Figure 4.

Traditionally, the vast majority of treatment for substance use disorders has been provided in specialty substance use disorder treatment programs, and these programs vary substantially in their clinical objectives and in the frequency, intensity, and setting of care delivery. This chapter describes the early intervention and treatment components of the continuum of care, the major behavioral, pharmacological, and service components of care, services available, and emerging treatment technologies:.

Early intervention services can be provided in a variety of settings e. The goals of early intervention are to reduce the harms associated with substance misuse, to reduce risk behaviors before they lead to injury, 18 to improve health and social function, and to prevent progression to a disorder and subsequent need for specialty substances use disorder services. Early intervention services may be considered the bridge between prevention and treatment services. For individuals with more serious substance misuse, intervention in these settings can serve as a mechanism to engage them into treatment.

Early intervention should be provided to both adolescents and adults who are at risk of or show signs of substance misuse or a mild substance use disorder. Other groups who are likely to benefit from early intervention are people who use substances while driving and women who use substances while pregnant.

In , an estimated , women consumed alcohol while pregnant, and an estimated , pregnant women used illicit drugs. Available research shows that brief, early interventions, given by a respected care provider, such as a nurse, nurse educator, or physician, in the context of usual medical care for example, a routine medical exam or care for an injury or illness can educate and motivate many individuals who are misusing substances to understand and acknowledge their risky behavior and to reduce their substance use.

Regardless of the substance, the first step to early intervention is screening to identify behaviors that put the individual at risk for harm or for developing a substance use disorder. Positive screening results should then be followed by brief advice or counseling tailored to the specific problems and interests of the individual and delivered in a non-judgmental manner, emphasizing both the importance of reducing substance use and the individual's ability to accomplish this goal.

In addition, research shows that SBI can be cost-effective. For example, a randomized study compared SBI to screening alone for alcohol and drug use disorders among patients covered by Medicaid in eight emergency medicine clinics in the State of Washington. Ideally, substance misuse screening should occur for all individuals who present in health care settings, including primary, urgent, psychiatric, and emergency care. Professional organizations, including the American College of Obstetricians and Gynecologists, the American Medical Association, the American Academy of Family Physicians, and the American Academy of Pediatrics recommend universal and ongoing screening for substance use and mental health issues for adults and adolescents.

Within these contexts, substance misuse can be reliably identified through dialogue, observation, medical tests, and screening instruments. Table 4. Brief interventions or brief advice range from informal counseling to structured therapies. They often include feedback to the individual about their level of use relative to safe limits, as well as advice to aid the individual in decision-making. Motivational interviewing MI is a client-centered counseling style that addresses a person's ambivalence to change.

A counselor uses a conversational approach to help their client discover their interest in changing their substance using behavior. The counselor asks the client to express their desire for change and any ambivalence they might have and then begins to work with the client on a plan to change their behavior and to make a commitment to the change process. The main purpose of MI is to examine and resolve ambivalence, and the counselor is intentionally directive in pursuing this goal.

In such cases, the care provider makes a referral for a clinical assessment followed by a clinical treatment plan developed with the individual that is tailored to meet the person's needs. Although the screening and brief intervention components of SBIRT are the same as SBI, referral to treatment helps the individual access, select, and navigate barriers to substance use disorder treatment.

The literature on the effectiveness of drug-focused brief intervention in primary care and emergency departments is less clear, with some studies finding no improvements among those receiving brief interventions. Trials evaluating different types of screening and brief interventions for drug use in a range of settings and on a range of patient characteristics are lacking. Recently, efforts have been made to adapt SBIRT for adolescents and for all groups with substance use disorders. Despite the fact that substance use disorders are widespread, only a small percentage of people receive treatment.

Of those who needed treatment but did not receive treatment, over 7 million were women and more than 1 million were adolescents aged 12 to There are many reasons people do not seek treatment.

The Purpose of the 12 Steps

The most common reason is that they are unaware that they need treatment; they have never been told they have a substance use disorder or they do not consider themselves to have a problem. This is one reason why screening for substance use disorders in general health care settings is so important. In addition, among those who do perceive that they need substance use disorder treatment, many still do not seek it. For these individuals, the most common reasons given are: The costs of care and lack of insurance coverage are particularly important issues for people with substance use disorders.

The NSDUH found that among individuals who needed and made an effort to get treatment but did not receive specialty substance use treatment, However, even if an individual is insured, the payor may not cover some types or components of substance use disorder treatments, particularly medications. Strategies to reduce the harms associated with substance use have been developed as a way to engage people in treatment and to address the needs of those who are not yet ready to participate in treatment.

Harm reduction programs provide public health-oriented, evidence-based, and cost-effective services to prevent and reduce substance use-related risks among those actively using substances, 59 and substantial evidence supports their effectiveness. Outreach activities seek to identify those with active substance use disorders who are not in treatment and help them realize that treatment is available, accessible, and necessary. Outreach and engagement methods may include telephone contacts, face-to-face street outreach, community engagement, 64 or assertive outreach after a referral is made by a clinician or caseworker.

Educational campaigns are also a common strategy for reducing harms associated with substance use. Such campaigns have historically been targeted toward substance-using individuals, giving them information and guidance on risks associated with sharing medications or needles, how to access low or no-cost treatment services, and how to prevent a drug overdose death. Drugs such as heroin and other opioids, cocaine, and methamphetamine are commonly used by injection, and this route of administration has been a major source of infectious disease transmission including HIV, Hepatitis B, Hepatitis C, and other blood-borne diseases.

Data from the CDC reveal that even though HIV among people who inject drugs is declining, it is still a significant problem: 7 percent 3, of the 47, newly diagnosed cases of HIV infection in the United States in were attributable to injection drug use, and another 3 percent 1, involved male-to-male sexual contact combined with injection drug use.

New cases of Hepatitis C infection increased percent between and , and occur primarily among young White people who inject drugs. Because of these data, providing sterile needles and syringes to people who inject drugs has become an important strategy for reducing disease transmission. Opioid overdose incidents and deaths, either from prescription pain relievers or heroin, are a serious threat to public health in the United States.

Overdose deaths from opioid pain relievers and heroin have risen dramatically in the past 14 years, 80 from 5, in to 29, in , and most were preventable. Rates of opioid overdose deaths are particularly high among individuals with an opioid use disorder who have recently stopped their use as a result of detoxification or incarceration. As a result, their tolerance for the drug is reduced, making them more vulnerable to an overdose. Those who mix opioids with alcohol, benzodiazepines, or other drugs also have a high risk of overdose. Opioid overdose does not occur immediately after a person has taken the drug.

Rather, the effects develop gradually as the drug depresses a person's breathing and heart rate. This eventually leads to coma and death if the overdose is not treated. This gradual progress means that there is typically a 1- to 3-hour window of opportunity after a user has taken the drug in which bystanders can take action to prevent the user's death. Naloxone is an opioid antagonist medication approved by the FDA to reverse opioid overdose in injectable and nasal spray forms. It works by displacing opioids from receptors in the brain, thereby blocking their effects on breathing and heart rate.

The rising number of deaths from opioid overdose has led to increasing public health efforts to make naloxone available to at-risk individuals and their families, as well as to emergency medical technicians, police officers, and other first responders, or through community-based opioid overdose prevention programs. Although regulations vary by state, some states have passed laws expanding access to naloxone without a patient-specific prescription in some localities. Interventions that distribute take-home doses of naloxone along with education and training for those actively using opioids and their peers and family members, have the potential to help decrease overdose-related deaths.

Naloxone, a safe medication that can quickly restore normal breathing to a person in danger of dying from an opioid overdose, is already carried by emergency medical personnel and other first responders. But by the time an overdosing person is reached and treated, it is often too late to save them. To solve this problem, several experimental Overdose Education and Naloxone Distribution OEND programs have given naloxone directly to opioid users, their friends or loved ones, and other potential bystanders, along with brief training on how to use this medication.

These programs have been shown to be an effective, as well as cost-effective, way of saving lives. Until recently, only injectable forms of naloxone were approved by the FDA. However, in November , the FDA approved a user-friendly intranasal formulation of naloxone that matches the injectable version in terms of how much of the medication gets into the body and how rapidly. According to the CDC, more than 74 Americans die each day from an overdose involving prescription pain relievers or heroin.

To reverse these trends, it is important to do everything possible to ensure that emergency personnel, as well as at-risk opioid users and their loved ones, have access to lifesaving medications like naloxone. Withdrawal symptoms vary in intensity and duration based on the substance s used, the duration and amount of use, and the overall health of the individual. Some substances, such as alcohol, opioids, sedatives, and tranquilizers, produce significant physical withdrawal effects, while other substances, such as marijuana, stimulants, and caffeine, produce primarily emotional and cognitive withdrawal symptoms.

Most periods of withdrawal are relatively short 3 to 5 days and are managed with medications combined with vitamins, exercise, and sleep. Rapid or unmanaged withdrawal from these substances can be protracted and can produce seizures and other health complications. Withdrawal management is highly effective in preventing immediate and serious medical consequences associated with discontinuing substance use, 56 but by itself it is not an effective treatment for any substance use disorder. It is best considered stabilization: The patient is assisted through a period of acute detoxification and withdrawal to being medically stable and substance-free.

Stabilization includes preparing the individual for treatment and involving the individual's family and other significant people in the person's life, as appropriate, to support the person's treatment process. Stabilization is considered a first step toward recovery, much like acute management of a diabetic coma or a hypertensive stroke is simply the first step toward managing the underlying illness of diabetes or high blood pressure.

Similarly, acute stabilization and withdrawal management are most effective when following evidence-based standards of care. Unfortunately, many individuals who receive withdrawal management do not become engaged in treatment. Studies have found that half to three quarters of individuals with substance use disorders who receive withdrawal management services do not enter treatment.

For example, 27 percent of people who received detoxification services not followed by continuing care were readmitted within 1 year to public detoxification services in Delaware, Oklahoma, and Washington. One of the most serious consequences when individuals do not begin continuing care after withdrawal management is overdose. Because withdrawal management reduces much of an individual's acquired tolerance, those who attempt to re-use their former substance in the same amount or frequency can experience physical problems.

Individuals with opioid use disorders may be left particularly vulnerable to overdose and even death. It is critically important for health care providers to be prepared to properly assess the nature and severity of their patients' clinical problems following withdrawal so that they can facilitate engagement into the appropriate intensity of treatment.

Treatment can occur in a variety of settings but most treatment for substance use disorders has traditionally been provided in specialty substance use disorder treatment programs. For this reason, the majority of research has been performed within these specialty settings. The National Institute on Drug Abuse NIDA has detailed the evidence-based principles of effective treatment for adults and adolescents with substance use disorders that apply regardless of the particular setting of care or type of substance use disorder treatment program Table 4.

The goals of substance use disorder treatment are similar to those of treatments for other serious, often chronic, illnesses: reduce the major symptoms of the illness, improve health and social function, and teach and motivate patients to monitor their condition and manage threats of relapse. Substance use disorder treatment can be provided in inpatient or outpatient settings, depending on the needs of the patient, and typically incorporates a combination of behavioral therapies, medications, and RSS.

However, unlike treatments for most other medical illnesses, substance use disorder treatment has traditionally been provided in programs both residential and outpatient outside of the mainstream health care system. The intensity of the treatment regimens offered can vary substantially across program types. Despite differences in care delivery and differences in reimbursement, substance use disorder treatments have approximately the same rates of positive outcomes as treatment for other chronic illnesses.

Relapse rates for substance use disorders 40 to 60 percent are comparable to those for chronic diseases, such as diabetes 20 to 50 percent , hypertension 50 to 70 percent , and asthma 50 to 70 percent. Treatment varies depending on substance s used, severity of substance use disorder, comorbidities, and the individual's preferences. Treatment typically includes medications and counseling as well as other social supports such as linkage to community recovery groups depending on an individual patient's needs and level of existing family and social support.

The general process of treatment planning and delivery for individuals with severe substance use disorders is described below, along with an explanation of the evidence-based therapies, medications, and RSS shown to be effective in treatment. Among the first steps involved in substance use disorder treatment are assessment and diagnosis. The diagnosis of substance use disorders is based primarily on the results of a clinical interview. Several assessment instruments are available to help structure and elicit the information required to diagnose substance use disorders.

The diagnosis of a substance use disorder is made by a trained professional based on 11 symptoms defined in the Fifth Edition of the Diagnostic and Statistical Manual of Mental Disorders DSM These symptoms, which are generally related to loss of control over substance use, 96 are presented in Table 1. The number of diagnostic symptoms present defines the severity of the disorder, ranging from mild to severe i.

Narcotics Anonymous (NA)

Conducting a clinical assessment is essential to understanding the nature and severity of the patient's health and social problems that may have led to or resulted from the substance use. This assessment is important in determining the intensity of care that will be recommended and the composition of the treatment plan.

After a formal assessment, the information is discussed with the patient to jointly develop a personalized treatment plan designed to address the patient's needs. Such considerations are critical for understanding the individual and for tailoring the treatment to his or her specific needs. This increases the likelihood of successful treatment engagement and retention, and research shows that those who participate more fully in treatment typically have better outcomes.

Treatment plans should be personalized and include engagement and retention strategies to promote participation, motivation, and adherence to the plan. Treatment providers can improve engagement and retention in programs by building a strong therapeutic alliance with the patient, effectively using evidence-based motivational strategies, acknowledging the patient's individual barriers, making reminder phone calls, and creating a positive environment.

Engaging, effective treatment also involves culturally competent care. For example, treatment programs that provide gender-specific and gender-responsive care are more likely to enhance women's treatment outcomes. For example, American Indians or Alaska Natives may require specific elements in their treatment plan that respond to their unique cultural experiences and to intergenerational and historical trauma and trauma from violent encounters. Substance use disorder treatment programs also have an obligation to prepare for disasters within their communities that can affect the availability of services.

A disaster can disrupt a program's ability to provide treatment services or an individual's ability to maintain treatment. Individuals in recovery, for example, may relapse due to sudden discontinuation of services or stress when having to cope with effects of a disaster. Individuals receiving MAT could be at risk of serious withdrawal symptoms if medications are stopped abruptly. Others may face challenges without their treatment program's support.

As indicated above, the treatment of addiction is delivered in predominantly freestanding programs that differ in their setting hospital, residential, or outpatient ; in the frequency of care delivery daily sessions to monthly visits ; in the range of treatment components offered; and in the planned duration of care.

In general, as patients progress in treatment and begin to meet the goals of their individualized treatment plan, they transfer from clinical management in residential or intensive outpatient programs to less clinically intensive outpatient programs that promote patient self-management. A typical progression for someone who has a severe substance use disorder might start with 3 to 7 days in a medically managed withdrawal program, followed by a 1- to 3-month period of intensive rehabilitative care in a residential treatment program, followed by continuing care, first in an intensive outpatient program 2 to 5 days per week for a few months and later in a traditional outpatient program that meets 1 to 2 times per month.

For many patients whose current living situations are not conducive to recovery, outpatient services should be provided in conjunction with recovery-supportive housing. In general, patients with serious substance use disorders are recommended to stay engaged for at least 1 year in the treatment process, which may involve participation in three to four different programs or services at reduced levels of intensity, all of which are ideally designed to help the patient prepare for continued self-management after treatment ends.

Brief summaries of the major levels of the treatment continuum are discussed below. Medically monitored and managed inpatient care is an intensive service delivered in an acute, inpatient hospital setting. Residential services offer organized services, also in a hour setting but outside of a hospital. These programs typically provide support, structure, and an array of evidence-based clinical services. Partial hospitalization and intensive outpatient services range from counseling and education to clinically intensive programming.

Outpatient services provide both group and individual behavioral interventions and medications when appropriate. Typically, outpatient programs are appropriate as the initial level of care for individuals with a mild to moderate substance use disorder or as continuing care after completing more intensive treatment. Regardless of the substance for which the individual seeks treatment or the setting or level of care, all substance use disorder treatment programs are expected to offer an individualized set of evidence-based clinical components.

Alcoholics Anonymous (AA) & The 12 Steps

These components are clinical practices that research has shown to be effective in reducing substance use and improving health and functioning. These include behavioral therapies, medications, and RSS. Treatment programs that offer more of these evidence-based components have the greatest likelihood of producing better outcomes. Research continues to identify new effective components of care. Five medications, approved by the FDA, have been developed to treat alcohol and opioid use disorders.

Currently, no approved medications are available to treat marijuana, amphetamine, or cocaine use disorders. Like all other FDA-approved medications, those listed in Table 4. For these reasons, only appropriately trained health care professionals should decide whether medication is needed as part of treatment, how the medication is provided in the context of other clinical services, and under what conditions the medication should be withdrawn or terminated.

The combination of behavioral interventions and medications to treat substance use disorders is commonly referred to as MAT. Studies have repeatedly demonstrated the efficacy of MAT at reducing illicit drug use and overdose deaths, , improving retention in treatment, and reducing HIV transmission. Some medications used to treat opioid use disorders can be used to manage withdrawal and as maintenance treatment to reduce craving, lessen withdrawal symptoms, and maintain recovery. Prescribed in this fashion, medications for substance use disorders are in some ways like insulin for patients with diabetes.

Insulin reduces symptoms by normalizing glucose metabolism, but it is part of a broader disease control strategy that also employs diet change, education on healthy living, and self-monitoring. Whether treating diabetes or a substance use disorder, medications are best employed as part of a broader treatment plan involving behavioral health therapies and RSS, as well as regular monitoring. State agencies that oversee substance use disorder treatment programs use a variety of strategies to promote implementation of MAT, including education and training, financial incentives e.

These include provider, public, and client attitudes and beliefs about MAT; lack of an appropriate infrastructure for providing medications; need for staff training and development; and legislation, policies, and regulations that limit MAT implementation. MAT for patients with a chronic opioid use disorder must be delivered for an adequate duration in order to be effective.


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Patients who receive MAT for fewer than 90 days have not shown improved outcomes. Methadone is a synthetic opioid agonist that has been used to treat the symptoms of withdrawal from heroin and other opioids. A chemical substance that binds to and activates certain receptors on cells, causing a biological response.

Fentanyl and methadone are examples of opioid receptor agonists. Long-term methadone maintenance treatment for opioid use disorders has been shown to be more effective than short-term withdrawal management, and it has demonstrated improved outcomes for individuals including pregnant women and their infants with opioid use disorders. The use of methadone to treat opioid use disorders has much in common with treatments for other substance use disorders and other chronic illnesses.

However, it has one significant structural and cultural difference. Under regulations dating back to the early s, the federal government created special methadone programs for adults with opioid use disorders. The use of opioid agonist medications to treat opioid use disorders has always had its critics. Such views are not scientifically supported; the research clearly demonstrates that MAT leads to better treatment outcomes compared to behavioral treatments alone.

Moreover, withholding medications greatly increases the risk of relapse to illicit opioid use and overdose death. Decades of research have shown that the benefits of MAT greatly outweigh the risks associated with diversion. Drug diversion. A medical and legal concept involving the transfer of any legally prescribed controlled substance from the person for whom it was prescribed to another person for any illicit use. OTPs are predominantly outpatient programs approximately 95 percent that provide pharmacotherapy in combination with behavioral therapies and other RSS.

Buprenorphine and naltrexone may also be provided in OTPs. Individuals receiving medication for opioid use disorders in an OTP must initially take their doses daily under observation. Buprenorphine is available as a sublingual tablet and a sublingual or buccal film. In addition, in May , an implantable formulation of buprenorphine was approved by the FDA. For individuals who are already on a stable low to moderate dose of buprenorphine, the implant delivers a constant low dose of buprenorphine for 6 months.

Buprenorphine is associated with improved outcomes compared to placebo for individuals including pregnant women and their infants with opioid use disorders, and it is effective in reducing illegal opioid use. Buprenorphine is a partial opioid agonist, meaning that it binds to and activates opioid receptors but with less intensity than full agonists. As a result, there is an upper limit to how much euphoria, pain relief, or respiratory depression buprenorphine can produce. Clinical experience and research protocols indicate that buprenorphine initiation and stabilization during the induction period is an important part of successful treatment for individuals with opioid use disorder.

However, if the combined medication is injected, the naloxone component can precipitate an opioid withdrawal syndrome, and in this way serves as a deterrent to misuse by injection. Buprenorphine may be prescribed by physicians who have met the statutory requirements for a waiver in accordance with the Controlled Substances Act 21 U. This patient limit does not apply to OTPs that dispense buprenorphine on site because the OTP operating in this capacity is doing so under 21 U. When they first receive their waiver, physicians can provide buprenorphine treatment for only up to 30 individuals.

After the first year they can request to treat up to Although approximately , primary care physicians practice medicine in the United States, only slightly more than 30, have a buprenorphine waiver, and only about half of those are actually treating opioid use disorders.

CARA temporarily expands eligibility to prescribe buprenorphine-based drugs for MAT for substance use disorders to qualifying nurse practitioners and physician assistants through October 1, Naltrexone is an opioid antagonist that binds to opioid receptors and blocks their activation; it produces no opioid-like effects and is not abusable.

It prevents other opioids from binding to opioid receptors so that they have little to no effect. It also interrupts the effects of any opioids in a person's system, precipitating an opioid withdrawal syndrome in opioid-dependent patients, so it can be administered only after a complete detoxification from opioids. There is also no withdrawal from naltrexone when the patient stops taking it.

Because naltrexone is not a controlled substance, it can be prescribed or administered by any physician, nurse practitioner, or physician assistant with prescribing authority. Naltrexone comes in two formulations: oral and extended-release injectable. Extended-release injectable naltrexone, which is administered on a monthly basis, addresses the poor compliance associated with oral naltrexone since it provides extended protection from relapse and reduces cravings for 30 days.

A number of factors should be weighed in determining the need for medication when treating an individual for an alcohol use disorder, such as the patient's motivation for treatment, potential for relapse, and severity of co-existing conditions. Each has a distinct effectiveness and side effect profile.

Prescribing health care professionals should be familiar with these side effects and take them into consideration before prescribing. Research studies on the efficacy of medications to treat alcohol use disorders have demonstrated that most patients show benefit, although individual response can be difficult to predict. Disulfiram is a medication that inhibits normal breakdown of acetaldehyde which is produced by the metabolism of alcohol, thus rapidly increasing acetaldehyde in the blood which produces an aversive response.

Thus, once disulfiram is taken by mouth, any alcohol consumed results in rapid buildup of acetaldehyde and a negative reaction or sickness results. The intensity of this reaction is dependent on the dose of disulfiram and the amount of alcohol consumed. Disulfiram was the first medication approved by the FDA to treat alcohol use disorder and its efficacy has been widely studied.

Disulfiram is most effective when its use is supervised or observed, which has been found to increase compliance. Thus, an individual who wants to reduce, but not stop, drinking is not a candidate for disulfiram. Disulfiram should also be avoided in individuals with advanced liver disease. Naltrexone is the opioid antagonist described above that is used to treat opioid use disorder. Because it blocks some opioid receptors, naltrexone counteracts some of the pleasurable aspects of drinking. Many studies have examined the effectiveness of naltrexone in treating alcohol use disorders.

Adherence to taking the medication increases under conditions where it is administered and observed by a trusted family member or when the extended-release injectable, which requires only a single monthly injection, is used. Acamprosate is a medication that normalizes the alcohol-related neurochemical changes in the brain glutamate systems and thereby reduces the symptoms of craving that can prompt a relapse to pathological drinking. These therapies also teach and motivate patients in how to change their behaviors as a way to control their substance use disorders.

For evidence-based behavioral therapies to be delivered appropriately, they must be provided by qualified, trained providers. Despite this, many counselors and therapists working in substance use disorder treatment programs have not been trained to provide evidence-based behavioral therapies, and general group counseling remains the major form of behavioral intervention available in most treatment programs. The following sections describe behavioral therapies that have been shown to be effective in treating substance use disorders. These therapies have been studied extensively, have a well-supported evidence base indicating their effectiveness, and have been broadly applied across many types of substance use disorders and across ages, sexes, and racial and ethnic groups.

Individual counseling is delivered in structured sessions to help patients reduce substance use and improve function by developing effective coping strategies and life skills. Most studies support the use of individual counseling as an effective intervention for individuals with substance use disorders. The theoretical foundation for Cognitive-Behavioral Therapy CBT is that substance use disorders develop, in part, as a result of maladaptive behavior patterns and dysfunctional thoughts.

These sessions typically explore the positive and negative consequences of substance use, and they use self-monitoring as a mechanism to recognize cravings and other situations that may lead the individual to relapse. They also help the individual develop coping strategies. CBT may be the most researched and evaluated of all the therapies for substance use disorders. Research has shown that CBT is also an effective treatment for individuals with co-occurring mental disorders.

Individuals with a substance use disorder and co-occurring mental disorder who received CBT had significantly improved outcomes on various measures of substance use and mental health symptoms as compared to those who did not receive CBT. Behavior change involves learning new behaviors and changing old behaviors. Positive rewards or incentives for these changes can aid this process. Contingency management, which involves giving tangible rewards to individuals to support positive behavior change, 85 has been found to be effective in treating substance use disorders.

Contingency management may be combined with other therapies or treatment components. For example, contingency management has been shown to improve outcomes for adults with cocaine dependence when added to CBT. Community Reinforcement Approach CRA Plus Vouchers is an intensive week outpatient program that uses incentives and reinforcers to reward individuals who reduce their substance use. CRA without vouchers has been successfully adapted for adolescents. A-CRA, which has been implemented in outpatient and residential treatment settings, seeks to increase family, social, and educational and vocational supports to reinforce abstinence and recovery from substance use.

The effectiveness of A-CRA has been supported in multiple randomized clinical trials with adolescents from different settings, sexes, and racial groups. Motivational Enhancement Therapy MET is a counseling approach that uses motivational interviewing techniques to help individuals resolve any uncertainties they have about stopping their substance use. MET works by promoting empathy, developing patient awareness of the discrepancy between their goals and their unhealthy behavior, avoiding argument and confrontation, addressing resistance, and supporting self-efficacy 46 to encourage motivation and change.

MET has been shown to be an effective treatment in a range of populations and has demonstrated favorable outcomes such as reducing substance use and improving treatment engagement. The Matrix Model is a structured, multi-component behavioral treatment that consists of evidence-based practices, including relapse prevention, family therapy, group therapy, drug education, and self-help, delivered in a sequential and clinically coordinated manner.

Several randomized controlled trials over the past 20 years have demonstrated that the Matrix Model is effective at reducing substance misuse and associated risky behaviors. Twelve-Step Facilitation TSF , an individual therapy typically delivered in 12 weekly sessions, is designed to prepare individuals to understand, accept, and become engaged in Alcoholics Anonymous AA , Narcotics Anonymous NA , or similar step programs.

Well-supported evidence shows that TSF interventions are effective in a variety of ways:. Some substance use disorder treatment programs that employ TSF also typically encourage AA or NA participation through group counseling. A group providing mutual support and fellowship for people recovering from addictive behaviors. The first step program was Alcoholics Anonymous AA , founded in ; an array of step groups following a similar model have since emerged and are the most widely used mutual aid groups and steps for maintaining recovery from alcohol and drug use disorders.

It is not a form of treatment, and it is not to be confused with the treatment modality called TSF. TSF has been effective in reducing alcohol use during the first month of treatment for individuals with alcohol use disorders, but these effects disappeared rapidly following treatment completion. The women who received TSF and CBT over 12 weeks both had better outcomes on perceived social support from friends and on social functioning than those in the counseling group, and the differences between those receiving TSF and CBT were minimal.

In another study, a randomized controlled trial compared a CBT treatment program alone to the same treatment combined with TSF. Further, another randomized controlled trial of outpatients with severe alcohol use disorder evaluated a treatment that aimed to change people's social networks away from heavy drinkers and toward non-drinking individuals, including AA members. Again, AA participation and the number of abstinent friends in the social network were found to account for the treatment's effectiveness.

All three treatments reduced the quantity and frequency of alcohol use immediately after treatment. Further, relative to the CBT and MET treatment conditions, significantly more of the patients receiving TSF treatment maintained continuous abstinence in the year following treatment. The first clinical trial of TSF for patients in treatment for stimulant use disorder was recently completed. Individuals randomized to TSF had higher rates of attending groups such as Crystal Meth Anonymous and higher rates of abstinence at follow-up as well. Given the common group and social orientation and the similar therapeutic factors operating across different mutual aid groups, - participation in mutual aid groups other than AA might confer similar benefits at analogous levels of attendance.

Mainstream health care has long acknowledged the benefits of engaging family and social supports to improve treatment adherence and to promote behavioral changes needed to effectively treat many chronic illnesses. Studies of various family therapies have demonstrated positive findings for both adults and adolescents.

Several evidence-based family therapies have been evaluated. Family behavior therapy FBT is a therapeutic approach used for both adolescents and adults that addresses not only substance use but other issues the family may also be experiencing, such as mental disorders and family conflict. BCT also teaches communication and non-substance-associated positive activities for couples.

Findings show that BCT produces more abstinence and better functioning relationships than typical individual-based treatment and that it also reduces social costs and intimate partner violence. In a recent review of controlled studies with alcohol-dependent patients, marital and family therapy, and particularly behavioral couples therapy, was significantly more effective than individual treatments at inducing and sustaining abstinence; improving relationship functioning and reducing intimate partner violence; and reducing emotional problems of children. Research has shown that incorporating tobacco cessation programs into substance use disorder treatment does not jeopardize treatment outcomes and is associated with a 25 percent increase in the likelihood of maintaining long-term abstinence from alcohol and drug misuse.

Recovery support services RSS , provided by both substance use disorder treatment programs and community organizations, help to engage and support individuals in treatment, and provide ongoing support after treatment. Specific supports include help with navigating systems of care, removing barriers to recovery, staying engaged in the recovery process, and providing a social context for individuals to engage in community living without substance use.

Individuals who participate in substance use disorder treatment and RSS typically have better long-term recovery outcomes than individuals who receive either alone. Further, active recovery and social supports, both during and following treatment, are important in maintaining recovery. Technological advancements are changing not only the face of health care generally, but also the treatment of substance use disorders.

In this regard, approximately 20 percent of substance use disorder treatment programs have adopted electronic health record EHR systems. With the growing adoption of EHRs, individuals and their providers can more easily access and share treatment records to improve coordination of care. The use of digital technologies such as EHRs, mobile applications, telemedicine, and web-based tools to support the delivery of health care, health-related education, or other health-related services and functions.

Two-way, real-time interactive communication between a patient and a physician or other health care professional at a distant site. Telemedicine is a subcategory of telehealth. Telemedicine refers specifically to remote clinical services, whereas telehealth can include remote non-clinical services such as provider training, administrative meetings, and continuing medical education, and patient-focused technologies, in addition to clinical services.

The use of telehealth to deliver health care, provide health information or education, and monitor the effects of care, has also rapidly increased. It offers alternative, cost-effective care options for individuals living in rural or remote areas or when physically travelling to a health care facility poses significant challenges. Technology-based interventions offer many potential advantages. They can increase access to care in underserved areas and settings; free up time so that service providers can care for more clients; provide alternative care options for individuals hesitant to seek in-person treatment; increase the chances that interventions will be delivered as they were designed and intended to be delivered; and decrease costs.

Research on the effectiveness of technology-assisted care within substance use disorder treatment focuses on three main applications: 1 technology as an add-on to enhance standard care; 2 technology as a substitute for a portion of standard care; and 3 technology as a replacement for standard care.

Several studies have been conducted on technology-assisted screening, assessment, and brief intervention for substance use disorders. Many of these studies focus on Internet-based assessments and brief interventions for at-risk, college-age populations. Other studies focus on telephone-based assessments and brief interventions related to alcohol and drug use, including DIAL, and a telephone-based monitoring and brief counseling intervention. A larger pool of research studies has assessed the effectiveness of substance use disorder treatment approaches largely outpatient that incorporate Web- and telephone-based technology.

These interventions focus on a wider range of substances, including alcohol e. Many of these technology-enhanced treatment interventions are Web-based versions of evidence-based, in-person treatment components such as CBT and MET. Early research suggests the value of applying Web-based treatment approaches for moderate levels of substance misuse and for individuals who may not otherwise seek face-to-face treatment.

Recent studies of telephone-based interventions as adjuncts to or replacements for standard care interventions showed similarly promising results. For example, one study explored the effect of adding daily self-monitoring calls to an interactive voice response technology system with personalized feedback and compared it to standard motivational enhancement practice.

Study results showed that those who received the intervention reduced the number of drinks they had on the days they did drink. Several studies have examined the application of technology-assisted tools to RSS. In general, Web- and telephone-based recovery support tools focus on providing remote support to individuals following substance use disorder treatment.

Examples of e-recovery support tools include: A-CHESS , a smartphone application that provides monitoring, information, communication, and support services to patients, including ways for individuals and counselors to stay in contact; and MORE , a Web-based recovery support program that delivers assessments, clinical content, and access to recovery coaching support online.

A variety of treatment approaches have been developed to address the needs of individuals with substance use disorders. However, disparities exist in the outcomes and effectiveness of substance use treatment for different populations. A study examining a culturally sensitive substance use disorder intervention program targeted at Hispanic or Latino and Black or African American adolescents called Alcohol Treatment Targeting Adolescents in Need ATTAIN found significant reductions in alcohol and marijuana use for all racial and ethnic groups.

The study concluded that accounting for these factors when tailoring a substance use disorder intervention is critical to meeting the needs of the community it is aiming to serve. Many of the interventions developed for substance use disorder treatment services in general have been evaluated in populations that included Black or African American patients, and many of these interventions are as effective for Black or African American patients as they are for White patients.

Dialectical Behavior Therapy DBT is an evidence-based therapy that teaches a skill called mindfulness. Multiple research studies have noted that mindfulness, an attentional exercise originally developed in Buddhist cultures, is potentially useful in helping people gain mastery over substance cravings. Asian patients tend to enter treatment with less severe substance misuse problems than do members of other racial or ethnic groups, place less value on substance use disorder treatment, and are less likely to use such services.

DBT has dramatically improved the care of adolescents at our facilities. A serendipitous benefit has been the enhancement of the relationship with the multiplicity of referral sources. Our tribal partners have commented positively on the integration of DBT with those traditional, cultural, and spiritual practices that are common to the many tribal nations. Desert Visions is a federally-operated adolescent residential center whose purpose is to provide substance use and behavioral health treatment to American Indians and Alaska Natives. Desert Visions offers a multi-disciplinary treatment that includes bio-psychosocial, health, education, and cultural activities.

Lesbian, gay, bisexual, and transgender LGBT populations often enter treatment with more severe substance misuse problems, have a greater likelihood of experiencing a substance use disorder in their lifetime, and initiate alcohol consumption earlier than heterosexual clients; thus, developing effective treatment programs that address the specific needs of these populations is critical. Census Bureau, found that a higher percentage of LGBT adults, aged 18 to 64, had five or more drinks on one day in the past year compared to heterosexual adults. Research has shown that treatment providers should be knowledgeable about sexuality, sexual orientation, and unique aspects of LGBT developmental and social experiences.

Motivational interviewing, social support therapy, contingency management, and CBT have all demonstrated effectiveness specifically for gay or bisexual men with a substance use disorder. Being a veteran or an active member of the military is a unique way of life that involves experiences and sacrifices by the service member and the member's family.

Military service members, veterans, and their families have needs unlike other individuals that require culturally competent approaches to treatment and services. Veterans report high rates of substance misuse; between and , 7. For example, a large study examined improvement in substance use outcomes among 12, veterans who were diagnosed with PTSD and a substance use disorder and treated in specialized intensive veterans' treatment programs. The study found that treatment in longer-term programs, with prescribed psychiatric medication and planned participation in program reunions for post-discharge support, were all associated with improved outcomes.

The findings suggested that intensive treatment combined with proper discharge planning for veterans with severe PTSD and a substance use disorder may result in better outcomes than traditional substance use disorder treatment. A study among homeless veterans with a diagnosis of a substance use disorder as well as a mental disorder found that those who took part in a low-intensity wrap-around intervention showed improvements in a number of substance use, mental health, and behavioral health outcomes from the beginning of the study to follow-up 12 months later.

It has been estimated that half of the United States prison population has an active substance use disorder. In a randomized controlled trial of methadone maintenance for prisoners, participants were randomly assigned to counseling with passive referral to methadone maintenance treatment MMT after release, counseling with transfer to MMT, or counseling with pre-release MMT. Prisoners who received counseling and MMT in prison prior to release and continued with community-based MMT after release were significantly less likely to use opioids and engage in criminal activity post-release.

Another randomized trial assigned some participants to extended-release naltrexone treatment and others to usual treatment, consisting of brief counseling and referrals to community treatment programs. Those who received extended-release naltrexone had a lower rate of relapse 43 percent vs. Importantly, positive effects diminished after treatment with extended-release naltrexone was discontinued. Drug courts are a diverse group of specialized programs that focus on adult or juvenile offenders, as well as parents under child protective supervision who have substance use-related disorders.

By , more than 3, drug courts were in operation across the United States. Existing research, including randomized controlled trials, have found positive effects of drug courts, including high rates of treatment completion and reduced rates of recidivism, incarceration, and subsequent drug use. Despite the rapid expansion of drug courts, the number of defendants who pass through such programs remains a small proportion of the more than 1 million offenders with substance use disorders who pass through the United States criminal justice system each year.

Capacity constraints provide the most important limitation. Drug court programs require random drug tests and other monitoring measures. Required abstinence involves making sanctions certain and immediate. Promising results of a randomized trial have sparked interest in broader replication. Interventions such as HOPE do not necessarily involve substance use disorder treatment; this reflects the reality that many drug-involved offenders do not meet the criteria for substance use disorders. For many individuals, regular monitoring, alongside the adverse consequences of a failed urine test, provide powerful motivation to abstain.

It addresses problem drinking by imposing close monitoring, followed by swift, certain, yet modest sanctions when there is evidence of renewed alcohol use. As a condition of bail, participants were required to take morning and evening breathalyzer tests or wear continuous alcohol-monitoring bracelets. Similar results have been replicated in Montana. Although the field of treatment for substance use disorders has made substantial progress, additional types of research are needed.

Research involving early interventions and various components of treatment must move from rigorously controlled trials to natural delivery settings and a broader mix of patient types. Because rigorously controlled trials must focus on specific diagnoses and carefully characterized patient types, it is often the case that the samples used in these trials are not representative of the real-world populations who need treatment. Rigorously controlled trials are necessary to establish efficacy, but interventions that seem to be effective in these studies too often cannot be implemented in real-world settings because of a lack of workforce training, inadequate insurance coverage, and an inability to adequately engage the intended patient population.

As has been documented in several chapters within this Report , the great majority of patients with substance use disorders do not receive any form of treatment. Nonetheless, many of these individuals do access primary or general medical care in community clinics or school settings and research is needed to determine the availability and efficacy of treatment in these settings and to identify ways in which access to treatment in these settings could be improved. The current failure to acknowledge and address substance use disorders in these settings has reduced the quality and increased the costs of health care.

Moreover, access and referral to specialty substance use disorder care from primary care settings is neither easy nor quick. Better integration between primary care and specialty care and additional treatment options within primary care are needed. Primary care physicians need to be better prepared to identify, assist, and refer patients, when appropriate. If treatment is delivered in primary care, it should be practical for delivery within these settings and attractive, engaging, accessible and affordable for affected patients. Buprenorphine or naloxone treatment for opioid misuse should also be available in emergency departments.

Therefore, treatment research outside of traditional substance use disorder treatment programs is needed. As of June , four states, plus the District of Columbia, have legalized recreational marijuana, and many more have permitted medical marijuana use. The impact of the changes on levels of marijuana and other drug and alcohol use, simultaneous use, and related problems such as motor vehicle crashes and deaths, overdoses, hospitalizations, and poor school and work performance, must be evaluated closely.

Accurate and practical marijuana screening and early intervention procedures for use in general and primary care settings are needed. Not only must it be determined which assessment tools are appropriate for the various populations that use marijuana, but also which treatments are generalizable from research to practice, especially in primary care and general mental health care settings.


  • Alcoholics Anonymous (AA) | Step Program for Alcoholism Recovery;
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Current research suggests that it is useful to educate and train first responders, peers, and family members of those who use opioids to use naloxone to prevent and reverse potential overdose-related deaths. However, more research is needed to identify strategies to encourage the subsequent engagement of those who have recovered from overdose into appropriate treatment.

In this work, it will be important to consider contextual factors such as age, gender identity, race and ethnicity, sexual orientation, economic status, community resources, faith beliefs, co-occurring mental or physical illness, and many other personal issues that can work against the appropriateness and ultimately the usefulness of a treatment strategy. Opioid agonist therapies are effective in stabilizing the lives of individuals with severe opioid use disorders. However, many important clinical and social questions remain about whether, when, and how to discontinue medications and related services.

This is an important question for many other areas of medicine where maintenance medications are continued without significant change and often without attention to other areas of clinical progress. At the same time, it is clear from many studies over the decades that detoxification following an arbitrary maintenance time period e.

Regarding personalized medicine, research is needed on how to implement multidisciplinary, collaborative, and patient-centered care for persons with opioid use disorders and chronic pain, in a manner effectively treating both diseases together with any psychiatric comorbidities that may undermine recovery. Precision medicine research is also needed on how to individually tailor such interventions to optimize care management for patient groups in which there is overlap between pain-related psychological distress and stress-related opioid misuse.

Turn recording back on. National Center for Biotechnology Information , U. Search term. Chapter 4 Preview A substance use disorder is a medical illness characterized by clinically significant impairments in health, social function, and voluntary control over substance use. With comprehensive continuing care, recovery is now an achievable outcome.

Chapter 4 Preview

Only about 1 in 10 people with a substance use disorder receive any type of specialty treatment. The great majority of treatment has occurred in specialty substance use disorder treatment programs with little involvement by primary or general health care. However, a shift is occurring to mainstream the delivery of early intervention and treatment services into general health care practice. Well-supported scientific evidence shows that medications can be effective in treating serious substance use disorders, but they are under-used. The U. Food and Drug Administration FDA has approved three medications to treat alcohol use disorders and three others to treat opioid use disorders.

However, an insufficient number of existing treatment programs or practicing physicians offer these medications. To date, no FDA-approved medications are available to treat marijuana, cocaine, methamphetamine, or other substance use disorders, with the exception of the medications previously noted for alcohol and opioid use disorders. Supported scientific evidence indicates that substance misuse and substance use disorders can be reliably and easily identified through screening and that less severe forms of these conditions often respond to brief physician advice and other types of brief interventions.

Well-supported scientific evidence shows that these brief interventions work with mild severity alcohol use disorders, but only promising evidence suggests that they are effective with drug use disorders. Well-supported scientific evidence shows that treatment for substance use disorders—including inpatient, residential, and outpatient—are cost-effective compared with no treatment.

The primary goals and general management methods of treatment for substance use disorders are the same as those for the treatment of other chronic illnesses. The goals of treatment are to reduce key symptoms to non-problematic levels and improve health and functional status; this is equally true for those with co-occurring substance use disorders and other psychiatric disorders.

Key components of care are medications, behavioral therapies, and recovery support services RSS. Well-supported scientific evidence shows that behavioral therapies can be effective in treating substance use disorders, but most evidence-based behavioral therapies are often implemented with limited fidelity and are under-used. Treatments using these evidence-based practices have shown better results than non-evidence-based treatments and services. Promising scientific evidence suggests that several electronic technologies, like the adoption of electronic health records EHRs and the use of telehealth, could improve access, engagement, monitoring, and continuing supportive care of those with substance use disorders.

Continuum of Treatment Services Substance use disorders typically emerge during adolescence and often but not always progress in severity and complexity with continued substance misuse. Figure 4. Early Intervention , for addressing substance misuse problems or mild disorders and helping to prevent more severe substance use disorders. Treatment engagement and harm reduction interventions , for individuals who have a substance use disorder but who may not be ready to enter treatment, help engage individuals in treatment and reduce the risks and harms associated with substance misuse.

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Substance use disorder treatment , an individualized set of evidence-based clinical services designed to improve health and function, including medications and behavioral therapies. Emerging treatment technologies are increasingly being used to support the assessment, treatment, and maintenance of continuing contact with individuals with substance use disorders. SBI: Screening Ideally, substance misuse screening should occur for all individuals who present in health care settings, including primary, urgent, psychiatric, and emergency care. SBI: Brief Interventions Brief interventions or brief advice range from informal counseling to structured therapies.

Reasons for Not Seeking Treatment There are many reasons people do not seek treatment. For these individuals, the most common reasons given are: 19 Not ready to stop using A common clinical feature associated with substance use disorders is an individual's tendency to underestimate the severity of their problem and to over-estimate their ability to control it.

This is likely due to substance-induced changes in the brain circuits that control impulses, motivation, and decision making. Might have a negative effect on job Do not know where to go for treatment Do not have transportation, programs are too far away, or hours are inconvenient Strategies to Reduce Harm Strategies to reduce the harms associated with substance use have been developed as a way to engage people in treatment and to address the needs of those who are not yet ready to participate in treatment.

Outreach and Education Outreach activities seek to identify those with active substance use disorders who are not in treatment and help them realize that treatment is available, accessible, and necessary. Naloxone Opioid overdose incidents and deaths, either from prescription pain relievers or heroin, are a serious threat to public health in the United States. Principles of Effective Treatment and Treatment Planning Principles and Goals of Treatment Treatment can occur in a variety of settings but most treatment for substance use disorders has traditionally been provided in specialty substance use disorder treatment programs.

Treatment Planning Assessment and Diagnosis Among the first steps involved in substance use disorder treatment are assessment and diagnosis. Individualized Treatment Planning After a formal assessment, the information is discussed with the patient to jointly develop a personalized treatment plan designed to address the patient's needs.

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Maintaining Treatment Engagement and Retention Treatment plans should be personalized and include engagement and retention strategies to promote participation, motivation, and adherence to the plan. Treatment Setting and the Continuum of Care As indicated above, the treatment of addiction is delivered in predominantly freestanding programs that differ in their setting hospital, residential, or outpatient ; in the frequency of care delivery daily sessions to monthly visits ; in the range of treatment components offered; and in the planned duration of care.

Evidence-based Treatment: Components of Care Regardless of the substance for which the individual seeks treatment or the setting or level of care, all substance use disorder treatment programs are expected to offer an individualized set of evidence-based clinical components. Evidence-Based Practices Research continues to identify new effective components of care. Medications and Medication-Assisted Treatment Five medications, approved by the FDA, have been developed to treat alcohol and opioid use disorders. Medication-Assisted Treatment for Opioid Use Disorders MAT for patients with a chronic opioid use disorder must be delivered for an adequate duration in order to be effective.

Medication-Assisted Treatment for Alcohol Use Disorders A number of factors should be weighed in determining the need for medication when treating an individual for an alcohol use disorder, such as the patient's motivation for treatment, potential for relapse, and severity of co-existing conditions. Contingency Management Behavior change involves learning new behaviors and changing old behaviors.

Community Reinforcement Approach Community Reinforcement Approach CRA Plus Vouchers is an intensive week outpatient program that uses incentives and reinforcers to reward individuals who reduce their substance use. Motivational Enhancement Therapy Motivational Enhancement Therapy MET is a counseling approach that uses motivational interviewing techniques to help individuals resolve any uncertainties they have about stopping their substance use. The Matrix Model The Matrix Model is a structured, multi-component behavioral treatment that consists of evidence-based practices, including relapse prevention, family therapy, group therapy, drug education, and self-help, delivered in a sequential and clinically coordinated manner.

Well-supported evidence shows that TSF interventions are effective in a variety of ways: As a stand-alone intervention; - When integrated with other treatments, such as CBT; As a distinct component of a multi-treatment package; and. Acceptance - realizing that their substance use is part of a disorder, that life has become unmanageable because of alcohol or drugs, that willpower alone will not overcome the problem, and that abstinence is the best alternative;. Surrender - giving oneself to a higher power, accepting the fellowship and support structure of other recovering individuals, and following the recovery activities laid out by a step program; and.

Family Therapies Mainstream health care has long acknowledged the benefits of engaging family and social supports to improve treatment adherence and to promote behavioral changes needed to effectively treat many chronic illnesses. Recovery Support Services Recovery support services RSS , provided by both substance use disorder treatment programs and community organizations, help to engage and support individuals in treatment, and provide ongoing support after treatment.

Emerging Treatment Technologies Technological advancements are changing not only the face of health care generally, but also the treatment of substance use disorders. Electronic Assessments and Early Intervention Several studies have been conducted on technology-assisted screening, assessment, and brief intervention for substance use disorders.

Electronic Treatment Interventions A larger pool of research studies has assessed the effectiveness of substance use disorder treatment approaches largely outpatient that incorporate Web- and telephone-based technology. Considerations for Specific Populations Culturally Competent Care A variety of treatment approaches have been developed to address the needs of individuals with substance use disorders. Racial and Ethnic Groups A study examining a culturally sensitive substance use disorder intervention program targeted at Hispanic or Latino and Black or African American adolescents called Alcohol Treatment Targeting Adolescents in Need ATTAIN found significant reductions in alcohol and marijuana use for all racial and ethnic groups.

Purpose Desert Visions is a federally-operated adolescent residential center whose purpose is to provide substance use and behavioral health treatment to American Indians and Alaska Natives. Goals Provide holistic care and treatment for the physical, spiritual, and emotional needs of American Indian and Alaska Native adolescents. Utilize the DBT skill of mindfulness to allow for the introduction of cultural, spiritual, and traditional practices into treatment while still maintaining fidelity to this evidence-based approach.

Lesbian, Gay, Bisexual, and Transgender Populations Lesbian, gay, bisexual, and transgender LGBT populations often enter treatment with more severe substance misuse problems, have a greater likelihood of experiencing a substance use disorder in their lifetime, and initiate alcohol consumption earlier than heterosexual clients; thus, developing effective treatment programs that address the specific needs of these populations is critical.

Veterans Being a veteran or an active member of the military is a unique way of life that involves experiences and sacrifices by the service member and the member's family. Criminal Justice Populations It has been estimated that half of the United States prison population has an active substance use disorder. Drug Courts Drug courts are a diverse group of specialized programs that focus on adult or juvenile offenders, as well as parents under child protective supervision who have substance use-related disorders. Recommendations for Research Although the field of treatment for substance use disorders has made substantial progress, additional types of research are needed.

References 1. What is telehealth? How is telehealth different from telemedicine? Medina J. The 12 Steps were created by the founders of Alcoholics Anonymous to establish guidelines for the best way to overcome an addiction to alcohol. The program gained enough success in its early years for other addiction support groups to adapt the steps to their own needs. There are many step programs for various addictions and compulsive behaviors, ranging from Cocaine Anonymous to Debtors Anonymous—all using the same 12 Step methods.

Although the 12 Steps are heavy on spirituality, many nonreligious people have found the program immensely helpful. The language emphasizes the presence of God as each participant understands him, allowing for different interpretations and religious beliefs. Find Out How. In fact, most participants find that they will need to revisit some steps or even tackle more than one of the steps at a time. Learn What You Can Do. The 12 Traditions speak to the members of Alcoholics Anonymous as a group, unlike the steps, which are focused on the individual.

The traditions are defined in the Big Book, the main governing literature of Alcoholics Anonymous. Most step groups have also adapted the 12 traditions for their own recovery plans. Speak with an expert However, the prominence of this type of treatment as well as success stories from recovering addicts suggest it is effective. At the very least, the 12 Step model provides support, encouragement and accountability for people who genuinely want to overcome their addiction.

The sponsorship model as well as regular meeting times encourage the kind of social support that has helped countless people stay clean. Watch Jerry's Story. Are you interested in finding a 12 Step program that could help you beat your addiction? Contact us now so we can help you find a meeting. No matter where you live, there is a drug rehab center that can help you overcome your addiction. We'll help you find it. Calls to numbers on a specific treatment center will be routed to that treatment center. All calls are private and confidential. Find out more about Addiction Center.

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