Many approaches have been used to treat substance use disorders (see MediaSpeak below), including psychodynamic, behavioral, cognitive-behavioral, and biological approaches, along with several sociocultural therapies. Although these treatments sometimes meet with great success, more often they are only moderately helpful (Belendiuk & Riggs, 2014; Myrick & Wright, 2008). Today the treatments are typically used on either an outpatient or inpatient basis or a combination of the two (see Figure 12-6).

The effectiveness of treatment for substance use disorders can be difficult to determine. There are several reasons for this. First, different substance use disorders pose different problems. Second, many people with such disorders drop out of treatment very early (Radcliffe & Stevens, 2010). Third, some people recover without any intervention at all (Wilson, 2010), while many others recover and then relapse (Belendiuk & Riggs, 2014). And, fourth, different criteria are used by different clinical researchers. How long, for example, must a person refrain from substance use in order to be called a treatment success? And is total abstention the only criterion, or is a reduction of drug use acceptable?

Psychodynamic therapists first guide clients to uncover and work through the underlying needs and conflicts that they believe have led to the substance use disorder. The therapists then try to help the clients change their substance-related styles of living. Although this approach is often used, it has not been found to be particularly effective (McCrady et al., 2014). It may be that substance use disorders, regardless of their causes, eventually become stubborn independent problems that must be the direct target of treatment if people are to become drug-free. Psychodynamic therapy tends to be of more help when it is combined with other approaches in a multidimensional treatment program (Lightdale et al., 2011, 2008).

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A widely used behavioral treatment for substance use disorders is aversion therapy, an approach based on the principles of classical conditioning. Clients are repeatedly presented with an unpleasant stimulus (for example, an electric shock) at the very moment that they are taking a drug. After repeated pairings, they are expected to react negatively to the substance itself and to lose their craving for it.

Aversion therapy has been used to treat alcoholism more than it has to treat other substance use disorders. In one version of this therapy, drinking is paired with drug-induced nausea and vomiting (McCrady et al., 2014; Owen-Howard, 2001; Welsh & Liberto, 2001). The pairing of nausea with alcohol is expected to produce negative responses to alcohol itself. Another version of aversion therapy requires people with alcoholism to imagine extremely upsetting, repulsive, or frightening scenes while they are drinking. The pairing of the imagined scenes with alcohol is expected to produce negative responses to alcohol itself. Here is the kind of scene therapists may guide a client to imagine:

A behavioral approach that has been effective in the short-term treatment of people who are addicted to cocaine and several other drugs is contingency management, which makes incentives (such as cash, vouchers, prizes, or privileges) contingent on the submission of drug-free urine specimens (Godley et al., 2014; Dallery et al., 2012). In one pioneering study, 68 percent of cocaine abusers who completed a 6-month contingency training program achieved at least 8 weeks of continuous abstinence (Higgins et al., 2011, 1993).

Behavioral interventions for substance use disorders have usually had only limited success when they are the sole form of treatment (Belendiuk & Riggs, 2014; Carroll, 2008). A major problem is that the approaches can be effective only when people are motivated to continue using them despite their unpleasantness or demands. Generally, behavioral treatments work best in combination with either biological or cognitive approaches (Belendiuk & Riggs, 2014; Carroll & Kiluk, 2012).

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Cognitive-behavioral treatments for substance use disorders help clients identify and change the behaviors and cognitions that keep contributing to their patterns of substance misuse (Gregg et al., 2014; Yoon et al., 2012). Practitioners of these approaches also help the clients develop more effective coping skills—skills that can be applied during times of stress, temptation, and substance craving.

Perhaps the most prominent cognitive-behavioral approach to substance misuse is relapse-prevention training (Jhanjee, 2014; Daley et al., 2011). The overall goal of this approach is for clients to gain control over their substance-related behaviors. To help reach this goal, clients are taught to identify high-risk situations, appreciate the range of decisions that confront them in such situations, change their dysfunctional lifestyles, and learn from mistakes and lapses.

Several strategies typically are included in relapse-prevention training for alcohol use disorder: (1) Therapists have clients keep track of their drinking. By writing down the times, locations, emotions, bodily changes, and other circumstances of their drinking, people become more aware of the situations that place them at risk for excessive drinking. (2) Therapists teach clients coping strategies to use when such situations arise. Clients learn, for example, to recognize when they are approaching their drinking limits; to control their rate of drinking (perhaps by spacing their drinks or by sipping them rather than gulping); and to practice relaxation techniques, assertiveness skills, and other coping behaviors in situations in which they would otherwise be drinking. (3) Therapists teach clients to plan ahead of time. Clients may, for example, determine beforehand how many drinks are appropriate, what to drink, and under which circumstances to drink.

Relapse-prevention training has been found to lower some people’s frequency of intoxication and of binge drinking, although such gains are often made only after repeated relapse-prevention treatments (Jhanjee, 2014; Borden et al., 2011). People who are young and do not have the tolerance and withdrawal features of chronic alcohol use seem to do best with this approach (Hart & Ksir, 2014; Deas et al., 2008). Relapse-prevention training has also been used in cases of marijuana and cocaine abuse as well as with other kinds of disorders, such as sexual paraphilic disorders (see Chapter 13).

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Another form of cognitive-behavioral treatment that has been used in cases of substance use disorder is acceptance and commitment therapy (ACT). As you read in Chapters 3 and 5, ACT therapists use a mindfulness-based approach to help clients become aware of their streams of thoughts as they are occurring and to accept such thoughts as mere events of the mind. For people with substance use disorders, that means increasing their awareness and acceptance of their drug cravings, worries, and depressive thoughts. By accepting such thoughts rather than trying to eliminate them, the clients are expected to be less upset by them and less likely to act on them by seeking out drugs. Research indicates that ACT is more effective than placebo treatments and at least as effective as other cognitive-behavioral treatments for substance use disorders, and sometimes more effective (Bowen et al., 2014; Chiesa & Serretti, 2014; Lanza et al., 2014). In some cases, ACT has been combined with relapse-prevention training or other cognitive-behavioral approaches, a combination that sometimes yields more success than either approach alone (Black, 2014).

Biological treatments may be used to help people withdraw from substances, abstain from them, or simply maintain their level of use without increasing it further. As with the other forms of treatment, biological approaches alone rarely bring long-term improvement, but they can be helpful when combined with other approaches.

DetoxificationDetoxification is systematic and medically supervised withdrawal from a drug. Some detoxification programs are offered on an outpatient basis. Others are located in hospitals and clinics and may also include individual and group therapy, a “full-service” institutional approach that has become popular. One detoxification approach is to have clients withdraw gradually from the substance, taking smaller and smaller doses until they are off the drug completely. A second—often medically preferred—detoxification strategy is to give clients other drugs that reduce the symptoms of withdrawal (Day & Strang, 2011). Antianxiety drugs, for example, are sometimes used to reduce severe alcohol withdrawal reactions such as delirium tremens and seizures. Detoxification programs seem to help motivated people withdraw from drugs (Müller et al., 2010). However, relapse rates tend to be high for those who do not receive a follow-up form of treatment—psychological, biological, or sociocultural—after successfully detoxifying (Blodgett et al., 2014; Day & Strang, 2011).

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After successfully stopping a drug, people must avoid falling back into a pattern of chronic use. As an aid to resisting temptation, some people with substance use disorders are given antagonist drugs, which block or change the effects of the addictive drug (Chung et al., 2012; O’Brien & Kampman, 2008). Disulfiram (Antabuse), for example, is often given to people who are trying to stay away from alcohol. By itself, a low dose of disulfiram seems to have few negative effects, but a person who drinks alcohol while taking it will have intense nausea, vomiting, blushing, a faster heart rate, dizziness, and perhaps fainting. People taking disulfiram are less likely to drink alcohol because they know the terrible reaction that awaits them should they have even one drink. Disulfiram has proved helpful, but again only with people who are motivated to take it as prescribed (Diclemente et al., 2008). In addition to disulfiram, several other antagonist drugs are now being tested.

Antagonist DrugsFor substance use disorders centered on opioids, several narcotic antagonists, such as naloxone, are used (Alter, 2014; Harrison & Petrakis, 2011). These antagonists attach to endorphin receptor sites throughout the brain and make it impossible for the opioids to have their usual effect. Without the rush or high, continued drug use becomes pointless. Although narcotic antagonists have been helpful—particularly in emergencies, to rescue people from an overdose of opioids—they can in fact be dangerous for people who are addicted to opioids. The antagonists must be given very carefully because of their ability to throw such persons into severe withdrawal.

So-called partial antagonists, narcotic antagonists that produce less severe withdrawal symptoms, have also been developed (Hart & Ksir, 2014; Dijkstra et al., 2010). Many clinicians now prefer partial antagonists over full antagonists to help people withdraw from opioid use. The use of antagonists to help people withdraw is often called rapid detoxification because the antagonists speed things along. The full antagonists remain the treatment of choice in emergency cases of overdose.

Research indicates that narcotic antagonists may also be useful in the treatment of substance use disorders involving alcohol or cocaine (Harrison & Petrakis, 2011; Bishop, 2008). In some studies, for example, the narcotic antagonist naltrexone has helped reduce cravings for alcohol (O’Malley et al., 2000, 1996, 1992). Why should narcotic antagonists, which operate at the brain’s endorphin receptors, help with alcoholism, which has been tied largely to activity at GABA sites? The answer may lie in the reward center of the brain. If various drugs eventually stimulate the same pleasure pathway, it seems reasonable that antagonists for one drug may, in a roundabout way, affect the impact of other drugs as well.

Drug Maintenance TherapyA drug-related lifestyle may be a bigger problem than the drug’s direct effects. Much of the damage caused by heroin addiction, for example, comes from overdoses, unsterilized needles, and an accompanying life of crime. Thus clinicians were very enthusiastic when methadone maintenance programs were developed in the 1960s to treat heroin addiction (Dole & Nyswander, 1967, 1965). In these programs, people with an addiction are given the laboratory opioid methadone as a substitute, or agonist, for heroin. Although they then become dependent on methadone, their new addiction is maintained under safe medical supervision. Unlike heroin, methadone produces a moderate high, can be taken by mouth (thus eliminating the dangers of needles), and needs to be taken only once a day.

At first, methadone programs seemed very effective, and many of them were set up throughout the United States, Canada, and England. These programs became less popular during the 1980s, however, because of the dangers of methadone itself. Many clinicians came to believe that substituting one addiction for another is not an acceptable “solution” for a substance use disorder, and many people with an addiction complained that methadone addiction was creating an additional drug problem that simply complicated their original one (Winstock, Lintzeris, & Lea, 2011; McCance-Katz & Kosten, 2005). Methadone is sometimes harder to withdraw from than heroin because the withdrawal symptoms can last longer (Hart & Ksir, 2014; Day & Strang, 2011). Moreover, pregnant women maintained on methadone have the added concern of the drug’s effect on their fetus.

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Despite such concerns, maintenance treatment with methadone—or with other opioid substitute drugs—has again sparked interest among clinicians in recent years, partly because of new research support (Balhara, 2014; Fareed et al., 2011) and partly because of the rapid spread of the HIV and hepatitis C viruses among intravenous drug abusers and their sex partners and children (Lambdin et al., 2014; Galanter & Kleber, 2008). Not only is methadone treatment safer than street opioid use, but many methadone programs now include AIDS education and other health instructions in their services. Research suggests that methadone maintenance programs are most effective when they are combined with education, psychotherapy, family therapy, and employment counseling (Jhanjee, 2014; Kouimtsidis & Drummond, 2010). Today thousands of clinics provide methadone treatment across the United States.

As you have read, sociocultural theorists—both family-social and multicultural theorists—believe that psychological problems emerge in a social setting and are best treated in a social context. Three sociocultural approaches have been used to help people overcome substance use disorders: (1) self-help programs, (2) culture- and gender-sensitive programs, and (3) community prevention programs.

Self-Help and Residential Treatment ProgramsMany people with substance use disorders have organized among themselves to help one another recover without professional assistance. The drug self-help movement dates back to 1935, when two Ohio men suffering from alcoholism met and wound up discussing alternative treatment possibilities. The first discussion led to others and to the eventual formation of a self-help group whose members discussed alcohol-related problems, traded ideas, and provided support. The organization became known as Alcoholics Anonymous (AA).

Today AA has more than 2 million members in 114,000 groups across the world (AA World Services, 2014). It offers peer support along with moral and spiritual guidelines to help people overcome alcoholism. Different members apparently find different aspects of AA helpful. For some it is the peer support; for others it is the spiritual dimension (Tusa & Burgholzer, 2013). Meetings take place regularly, and members are available to help each other 24 hours a day.

By offering guidelines for living, the organization helps members abstain “one day at a time,” urging them to accept as “fact” the idea that they are powerless over alcohol and that they must stop drinking entirely and permanently if they are to live normal lives (Nace, 2011, 2008). AA views alcoholism as a disease and takes the position that “Once an alcoholic, always an alcoholic” (Rosenthal, 2011; Rosenthal & Levounis, 2011, 2005; Pendery et al., 1982). Related self-help organizations, Al-Anon and Alateen, offer support for people who live with and care about people with alcoholism. Self-help programs such as Narcotics Anonymous and Cocaine Anonymous have been developed for other substance use disorders (Jaffe & Kelly, 2011).

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It is worth noting that the abstinence goal of AA is in direct opposition to the controlled-drinking goal of relapse-prevention training and several other interventions for substance misuse (see pages 413–414). In fact, this issue—abstinence versus controlled drinking—has been debated for years (Hart & Ksir, 2014; Rosenthal, 2011, 2005). Feelings about it have run so strongly that in the 1980s the people on one side challenged the motives and honesty of those on the other (Sobell & Sobell, 1984, 1973; Pendery et al., 1982).

Research indicates, however, that both controlled drinking and abstinence may be useful treatment goals, depending on the nature of the particular drinking problem. Studies suggest that abstinence may be a more appropriate goal for people who have a long-standing alcohol use disorder, whereas controlled drinking can be helpful to younger drinkers whose pattern does not include tolerance and withdrawal reactions. Those in the latter group may indeed need to be taught a nonabusive form of drinking (Hart & Ksir, 2014; Witkiewitz & Marlatt, 2007, 2004). Studies also suggest that abstinence is appropriate for people who believe that it is the only answer for them, as they are more likely to relapse after having just one drink (Rosenthal, 2011, 2005; Carbonari & DiClemente, 2000).

Many self-help programs have expanded into residential treatment centers, or therapeutic communities—such as Daytop Village and Phoenix House—where people formerly addicted to drugs live, work, and socialize in a drug-free environment while undergoing individual, group, and family therapies and making a transition back to community life (O’Brien et al., 2011; Bonetta, 2010).

The evidence that keeps self-help and residential treatment programs going comes largely in the form of individual testimonials. Many tens of thousands of people have revealed that they are members of these programs and credit them with turning their lives around. Studies of the programs have also had favorable findings, but their numbers have been limited (Galanter, 2014; Moos & Timko, 2008).

Culture- and Gender-Sensitive ProgramsMany people with substance use disorders live in a poor and perhaps violent setting. A growing number of today’s treatment programs try to be sensitive to the special sociocultural pressures and problems faced by drug abusers who are poor, homeless, or members of minority groups (Hadland & Baer, 2014; Hurd et al., 2014; Lawson et al., 2011). Therapists who are sensitive to their clients’ life challenges can do more to address the stresses that often lead to relapse.

Similarly, therapists have become more aware that women often require treatment methods different from those designed for men (Lund, Brendryen, & Ravndal, 2014; Greenfield et al., 2011). Women and men often have different physical and psychological reactions to drugs, for example. In addition, treatment of women with substance use disorders may be complicated by the impact of sexual abuse, the possibility that they may be or may become pregnant while taking drugs, the stresses of raising children, and the fear of criminal prosecution for abusing drugs during pregnancy (Finnegan & Kandall, 2008). Thus many women with such disorders feel more comfortable seeking help at gender-sensitive clinics or residential programs; some such programs also allow children to live with their recovering mothers.

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Community Prevention ProgramsPerhaps the most effective approach to substance use disorders is to prevent them (Sandler et al., 2014; Whitesell et al., 2014). The first drug-prevention programs were conducted in schools. Today such programs are also offered in workplaces, activity centers, and other community settings and even through the media (NSDUH, 2013). Around 12 percent of adolescents report that they have participated in drug prevention programs outside school within the past year. Around 75 percent have seen or heard a substance use–prevention message. And almost 60 percent have talked to their parents in the past year about the dangers of alcohol and other drugs.

Some prevention programs are based on a total abstinence model, while others teach responsible use. Some seek to interrupt drug use; others try to delay the age at which people first experiment with drugs. Programs may also differ in whether they offer drug education, teach alternatives to drug use, try to change the psychological state of the potential user, help people change their peer relationships, or combine these techniques.

Prevention programs may focus on the individual (for example, by providing education about unpleasant drug effects), the family (by teaching parenting skills), the peer group (by teaching resistance to peer pressure), the school (by setting up firm enforcement of drug policies), or the community at large. The most effective prevention efforts focus on several of these areas to provide a consistent message about drug misuse in all areas of people’s lives (Hansen et al., 2010). Some prevention programs have even been developed for preschool children.

Two of today’s leading community-based prevention programs are TheTruth.com and Above the Influence. The Truth is an anti-smoking campaign, aimed at young people in particular, that has “edgy” ads on the Web (on YouTube, for instance), on television, and in magazines and newspapers. Above the Influence is a similar advertising campaign that focuses on a range of substances abused by teenagers. Originally created by the U.S. Office of National Drug Control Policy, Above the Influence became a private, not-for-profit program in 2014.

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Community-based prevention programs are not always effective, no matter how powerful and clever their ads may be. For example, after a 5-year study, the Government Accountability Office concluded in 2006 that the highly regarded My Anti-Drug campaign of the late 1990s and early 2000s had been largely ineffective. Thus, it is encouraging that a recent nationwide survey of 3,000 students suggests that watching Above the Influence ads may help reduce marijuana use by teenagers (Slater et al., 2011). The survey found that 8 percent of eighth-graders familiar with the campaign have taken up marijuana use, in contrast to 12 percent of students who have never seen the ads.